By Debra Wood, RN, contributor
Taking a break rejuvenates the spirit and improves performance, yet nurses enjoyed a respite from patient-care responsibilities on fewer than half of their shifts, according to a recent study. Amazingly, the University of Pennsylvania research found no sign working nonstop increased errors.
“This has been going on for years,” said lead author Ann E. Rogers, Ph.D., RN, FAAN, associate professor at the University of Pennsylvania School of Nursing, in Philadelphia. “I’d like to see nurses’ working conditions improve. It’s very hard to continue to function over long periods of time without some sort of break.”
Rogers asked a cohort of full-time nurses belonging to the American Nurses Association to complete a 28-day logbook, detailing their work hours, errors or near misses, and whether they sat down for a break, if it was free of patient demands and its duration. Nearly 400 nurses responded.
On 10 percent of the shifts, nurses reported no opportunity to sit down or eat a meal; on 43 percent of the shifts, nurses grabbed something to eat while responding to call lights or other patient needs.
Rogers found nearly 40 percent of nurses surveyed worked shifts longer than 12 hours, but the long workdays were not associated with an ability to enjoy a rest period. In fact, the numbers went down.
Forty-nine percent of nurses working shifts of 8.5 or fewer hours were able to escape patient-care duties during a break, compared with 46.7 percent working shifts of 12.5 hours or more. And the percentage of shifts free of patient-care duties decreased to 30 percent when nurses worked 20 or more consecutive hours.
Claire M. Young, RN, MBA, chief nursing officer and chair of the division of nursing at The Cleveland Clinic Foundation in Ohio, has set a firm rule that nurses cannot work longer than 12 hours in any day. She also wants nurses at her facility to escape call lights during breaks, perhaps by going outside for some fresh air.
“It’s a great recharger,” Young said. “Our campus has green space with trees and benches. We feel it’s better to get off the floor.”
Cleveland Clinic’s parent shift lets nurses work shorter periods, which frequently are used to cover meal periods. The hospital also has added to each unit an assistant nurse manager, who helps care for patients so staff nurses can leave the unit.
Mary Beth Reardon, RN, MS, OCN, CNAA, vice president for nursing administration at H. Lee Moffitt Cancer Center & Research Institute in Tampa, Florida, and her nurse managers have found that having the right staffing does more for ensuring nurses receive meal breaks than anything else.
Reardon tries to keep units fully staffed. For those days when it is difficult to get off the floor, the hospital has placed a refrigerator on each unit for nurses to stow lunches. It also has established a quiet area. Sometimes a nurse manager will go down to the cafeteria to pick up food for staff. Other managers will care for patients during breaks or even postpone surgeries, to ensure staff members assisting have time to eat between cases.
Many states require rest or break periods, and in those states, Rogers did not find compliance with the laws. However, some managers and nursing leaders have adopted procedures to ensure their nurses receive rest periods.
“It’s a high priority for us,” said Chris Boothe, RN, CCRN, administrative director of critical care services at Memorial Regional Hospital in Hollywood, Florida, a level 1 trauma center. “It’s essential that we’re constantly working to ensure that nurses get breaks, so they can operate at their optimal level.”
Units at Memorial have developed different plans to guarantee everyone enjoys time off the floor. Some units designate break times at the start of a shift, and the nurse manager covers for nurses leaving the unit. Other units use a buddy system, with each duo of nurses determining an appropriate time for a break and covering for each other.
Nurse managers at Mount Carmel West in Columbus, Ohio, assign nurses to one of three specific break times, post it on the unit and monitor their compliance. Nurses are expected to trade with a peer if they cannot leave the floor at the scheduled time, said Ruth McFarland, RN, CCRN, unit director.
Denise Mansfield, RN, BSN, ONC, nurse manager of a medical-surgical floor at North Broward Medical Center in Deerfield Beach, Florida, cannot imagine going 12 hours nonstop and has read that efficiency drops after six hours. She and the clinical nurse specialist assigned to the unit take over so nurses on the floor can enjoy breakfast and lunch breaks. Even so, some nurses resist.
“They don’t want to be stuck late,” Mansfield said. “That half-hour to eat will not cost them at the end. They will fade away to nothing before it’s over, and it will take longer to do everything once they pass that point.”
Danielle Orr, RN, MHA, ONC, nurse manager of the orthopedic, trauma and neurology unit at North Broward Medical Center, monitors whether nurses clock out for lunch on the computer, and if they don’t, she tells them they cannot stay the whole day without eating.
“[Nurses] lose concentration and don’t have normal cognitive abilities, and they become irritable,” said Orr, who covers for them. “Nurses feel like they are neglecting their patients if they go to lunch. Sometimes, it’s tough to get them to go, but I push them.”
Concern about nurses’ capabilities flag when trying to work nonstop motivates many of the managers.
“Nurse and patient safety are most important issues,” said Elizabeth Albers, RN, MSN, director of nursing services at Doctors Hospital in Coral Gables, Florida, which encourages nurses to leave the floor for meal periods. “When someone works eight or 12 hours, and they don’t take a break, it can be detrimental to the patient. They are tired and don’t think as clearly.”
Thirty percent of the nurses Rogers surveyed reported making errors, with more than half of them classified as medication errors, during the 28-day survey. Although Rogers found no increased error risk associated with missed lunch breaks, longer rest periods seemed to offer a protective effect. Breaks and meal periods averaged 23.8 minutes on mistake-free shifts vs. 16.2 minutes on shifts when nurses made errors.
“Even if we don’t see a change in the errors, we all need breaks and meals,” Rogers said. “The cost of replacing an RN is very substantial. Covering and making sure people get breaks might be cheaper than someone getting tired and fed up.”
Some nursing leaders have learned that encouraging breaks improves nurses’ performance. Often leaders try to ensure units are staffed so the nurses feel their patients will fair well while leaving the unit. Rogers suggests nurses working on units where breaks are not the norm discuss the issue with their managers to resolve the situation.
“If nurses don’t take a break, it will be so stressful, and it will build up,” Orr said. “It’s not going to be as good for them or the patients.”
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