Raj rajaratnam clorox

International Journal of Nursing Studies 67 (2017) 20–28

Fatigue in hospital nurses — ‘Supernurse’ culture is a barrier to addressing problems: A qualitative interview study

Linsey M. Steege*, Jessica G. Rainbow School of Nursing, University of Wisconsin � Madison, Madison, WI, United States

A R T I C L E I N F O

Article history: Received 13 November 2015 Received in revised form 30 September 2016 Accepted 19 November 2016

Keywords: Culture Fatigue Hospital nursing staff Nursing workforce

A B S T R A C T

Background: Fatigue in hospital nurses is associated with decreased nurse satisfaction, increased turnover and negative patient outcomes. Addressing fatigue in nurses has been identified as a priority by many organizations worldwide in an effort to promote both a culture of patient safety and a healthy nursing workforce. Objectives: The overall aim of this study was to explore barriers and facilitators within the hospital nurse work system to nurse coping and fatigue. The purpose of this paper is to describe emergent themes that offer new insight describing the relationships among nurse perceptions of fatigue, nursing professional culture, and implications for the nursing workforce. Design: A qualitative exploratory study was used to explore nurse identified sources, barriers to addressing, and consequences of fatigue. Participants and setting: Twenty-two nurses working in intensive care and medical-surgical units within a large academic medical center in the United States participated in the interviews. Method: Interviews with the participants followed a semi-structured interview guide that included questions eliciting participants' views on nurse fatigue levels, consequences of fatigue, and barriers to addressing fatigue. The interview transcripts were analyzed using directed content analysis guided by the Systems Engineering Initiative for Patient Safety (SEIPS) model. Additional themes that did not directly align with the SEIPS model were also identified. Results: All nurses in the current study experienced fatigue; yet they had varying perspectives on the importance of addressing fatigue in relation to other health systems challenges. A new construct related to nursing professional culture was identified and defined as “Supernurse”. Identified subthemes of Supernurse include: extraordinary powers used for good; cloak of invulnerability; no sidekick; Kryptonite, and an alterego. These values, beliefs, and behaviors define the specific aspects of nursing professional culture that can act as barriers to fatigue risk management programs and achieving safety culture in hospital organizations. Nurse fatigue and attributes of nurse professional culture also have implications for nurse satisfaction and retention. Conclusions: Findings from this study further support the role of nursing professional culture as an important barrier to effectively addressing fatigue in nursing work systems. Future work is needed to identify and evaluate innovative culture change models and strategies to target these barriers.

ã 2016 Elsevier Ltd. All rights reserved.

Contents lists available at ScienceDirect

International Journal of Nursing Studies

journal homepage: www.elsevier.com/ijns

What is already known about this topic? � Fatigue in nursing is associated with negative patient outcomes as well as decreased satisfaction and increased turnover in nurses.

� There is a growing emphasis on addressing nurse fatigue in order to achieve a culture of safety in hospital organizations.

�

* Corresponding author at: School of Nursing, University of Wisconsin � Madison, 701 Highland Avenue, Madison, WI, 53705, United States.

E-mail address: lsteege@wisc.edu (L.M. Steege).

http://dx.doi.org/10.1016/j.ijnurstu.2016.11.014 0020-7489/ã 2016 Elsevier Ltd. All rights reserved.

Nursing culture is a barrier to implementing fatigue counter- measures and management programs.

What this paper adds � Nurses report experiencing fatigue, yet have varying perspec- tives on how important addressing fatigue is in relation to other health systems challenges.

� A new multidimensional construct characterizing the specific aspects of nursing professional culture that act as barriers to addressing fatigue is identified and defined as “Supernurse”.

http://crossmark.crossref.org/dialog/?doi=10.1016/j.ijnurstu.2016.11.014&domain=pdf
mailto:lsteege@wisc.edu
http://dx.doi.org/10.1016/j.ijnurstu.2016.11.014
http://dx.doi.org/10.1016/j.ijnurstu.2016.11.014
http://www.sciencedirect.com/science/journal/00207489
www.elsevier.com/ijns
L.M. Steege, J.G. Rainbow / International Journal of Nursing Studies 67 (2017) 20–28 21

� Fatigue negatively impacts nurse satisfaction, and may act as a mediator between practice conditions and negative nursing workforce outcomes.

1. Introduction

Worldwide, the important role of the nurse in patient outcomes is well established (Aiken et al., 2002a, 2002b; Needleman et al., 2002; Tzeng et al., 2002). Nurse staffing levels, nurse education, and perceptions of work all influence the quality of care that nurses are able to provide to their patients. Addressing patient outcomes and creating a culture of safety is therefore the priority of many international organizations (IOM, 2006; Organization, 2015). A culture of safety is defined by several key characteristics including: an established, timely and anonymous reporting culture; a just culture regarding disciplinary action; diversity in employees; and a learning culture surrounding incidents (Gander et al., 2011).

Improving patient care quality through nursing care and creating a culture of safety is made more difficult due to a nursing workforce shortage internationally (Buchan and Aiken, 2008). The shortage is attributed to not only a deficit in qualified nurses, but also the deficit in nurses willing to work in the present practice conditions (Buchan and Aiken, 2008). Addressing nurse workforce issues through better nursing work system design may be a critical mechanism for improving both nurse and patient outcomes.

One modifiable factor in the nursing work system, which affects patient and nursing outcomes, is fatigue. Fatigue arises in workers in response to excessive demands from work tasks, environment, and organization, and can interfere with workers’ physical and cognitive abilities and performance (Barker Steege and Nussbaum, 2012; Rogers, 2008). As defined, fatigue is a consequence of sub- optimal system design. High demands, such as those related to long work hours, circadian disruption, increasingly complex and high acuity patients, and insufficient staffing ratios, are associated with nurse fatigue (Smith-Miller et al., 2014; Steege et al., 2015).

Previous studies have shown high prevalence of fatigue among hospital nurses (Barker and Nussbaum, 2011b; Smith-Miller et al., 2014). Nurses who are fatigued may have decreased reaction time, attention to detail, and problem-solving ability, which contributes to increased risk for errors and injury (Barker and Nussbaum, 2011a; Rogers, 2008). Given this definition, prevalence, and associated consequences, it is important to address fatigue. Nursing organizations around the world have released position statements and guidelines to address nurse fatigue and promote a safety culture through a joint responsibility shared between the healthcare organization and individual nurses (American Nurses Association, 2014; Registered Nurses’ Association of Ontario, 2011).