Pages 1, 3, 4 Pages 9-10 Pages 14-17...E-mail: [email protected] District 22: Toni McDonald...

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Princeton, MN55371

Inside this IssueWho and How to Contact

TNA Districts and Presidents . . . . . . . . . . 2

Quarterly Report: Texas Immunization

Stakeholder Working Group . . . . . . . . . . . 6

Commentary: Allaying Vaccine Fears with

Historical Context . . . . . . . . . . . . . . . . . . . 8

Mandatory Overtime: What Nurses Need

to Know . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Continuing Nursing Education Credit:

Fitness for Duty Includes Getting

Your ZZZZs . . . . . . . . . . . . . . . . . . . .14-17

Membership Application . . . . . . . . . . . . . . 18

State of Nursing Education: 2010Quarterly circulation approximately 274,000 to all RNs, LVNs, and Student Nurses in Texas.

Join theTexas Nurses Association

Today!

Applicationon page 18.

The amount of interest and energy aimed at solving the nursing workforce shortage in Texas surely by now rivals that of health care reform. Ever since 1999, when Texas Nurses Association and partners conducted initial research to answer the question – is yet another nursing shortage looming? – increasing the production of qualified nurses has been a priority for a number of groups in Texas.

In 2001, the Nursing Shortage Reduction Act was passed by the Texas Legislature. It began a series of biennium investments by the Legislature in nursing education in Texas. Educate more nurses and you’ll have more nurses and less shortage was the thinking. Having more nurses at practice could influence in a positive way the workplace environment and the quality of patient care.

The Nursing Shortage Reduction Act of 2001 was effective because it established the first program to increase enrollments in nursing education, and promoted innovation in recruitment and retention of nursing students. It also established the Texas Center for Nursing

Workforce Studies (CNWS), a resource for data and research on the nursing workforce in Texas.

Since 2001, approximately $100 million of funding has been appropriated by the Texas Legislature to address the nursing shortage – both for increasing nursing student enrollments and for funding of schools. In 2007, Texas nursing schools graduated 7,031 new registered nurses; a 55 percent increase over the 4,500 produced in 2001.

Interestingly – and sadly – 7,765 qualified applicants were not admitted to Texas nursing schools in 2007. The number in 2008 grew to 8,964 qualified applicants who were denied admission to Texas’ 86 initial RN licensure programs. Even though Texas had been brilliantly successful in promoting nursing as a great career choice and thus increasing applications to nursing schools, the lack of budgeted faculty positions and available clinical space became obstacles in meeting the demand for nursing school slots that could increase the production of nurses.

Add to the nursing demand numbers some recent data from CNWS: the projected number of nursing graduates needed to meet demand will reach 9,700 in 2010; 13,000 in 2013; and 25,000 in 2020. That’s an 86 percent rise in demand by 2020; a 53 percent supply at current rates. If projections are accurate, the question obviously becomes: How do we continue to produce enough initial RN licensed graduates to meet demand?

Questions. Answers. Solutions. Fortunately, for Texans, the number of

stakeholders addressing the nursing shortage and the nurse supply/demand gap is impressive. The list is a virtual who’s who in health care and health care policy development: Texas Nurses Association, Texas Hospital Association, Institute of Medicine, Robert Wood Johnson Foundation, American Association of Retired Persons (AARP) – Texas, Texas Board of Nursing, Texas Higher Education Coordinating Board, Texas Health

State of Nursing continued on page 3

Pages 1, 3, 4 Pages 9-10 Pages 14-17

• Texas Nursing Voice January, February, March 2010

8” Ads OPEN

Texas Nurses Association Districts and Presidents

District 1: Patricia Shanaberger Phone: 915.831-4495 E-mail: [email protected]

District 2: Heidi Taylor Phone: 806.651-3500 E-mail: [email protected]

District 3: Lygia Dunsworth Phone: 817.452-7866

E-mail: [email protected]

District Address: Renee James PO Box 16958 Ft. Worth, TX 76162 Office: 817.249-5071 E-mail: [email protected].

Web site: www.tna3.org

District 4: Colleen Hines Phone: 972.348-1614 E-mail: [email protected] District Address: Pat Pollock PO Box 35503 Dallas, TX 75235 Office: 972.435-2216 E-mail: [email protected] Web site: www.tnad4.org

District 5: Serena Bumpus Phone: 512.324-7183 E-mail: [email protected] Web site: www.tna5.org

District 6: Ellarene Duis Sanders Phone: 409.740-4056 E-mail: [email protected] Web site: www.tna6.org

District 7: Charlotte Sedillos Phone: 254.760-4344 E-mail: [email protected] Web site: www.tnadistrict7.org

District 8: Gayle Dasher Phone: 210.705-6266 E-mail: [email protected] Web site: www.texasnurses.

org/districts/08/

District 9: Brenda Binder Phone: 281.395-3734 E-mail: [email protected]

District Office: Melanie Truong 2370 Rice Blvd., #109 Houston, TX 77005 Office: 713.523-3619 E-mail: [email protected] Web site: www.tnadistrict9.org

District 10: Lillian Sifuentes Phone: 254.698-6434 E-mail: [email protected]

District 11: Vacant

District 12: Patricia Morrell Phone: 936.212-7222 E-mail: [email protected]

District 13: Vacant

District 14: Joe Lacher Phone: 956.882-5072 E-mail: [email protected]

District 15: Andrea Kerley Phone: 325.670-4230 E-mail: akerley@

hendrickhealth.org Web site: www.texasnurses.

org/districts/15/

District 16: Martha Sleutel Phone: 325.942-2224 E-mail: [email protected]

District 17: Nancy Goodman Phone: 361.825-2607 E-mail: nancy.goodman@

tamucc.edu Web site: www.texasnurses.

org/districts/17/

District 18: Patty Freier Phone: 806.797-8120 E-mail: [email protected] Web site: www.texasnurses.

org/districts/18/

District 19: Nina Wallace Gross Phone: 903.877-5102 E-mail: [email protected] Web site: www.texasnurses.

org/districts/19/

District 20: Denise Neill Phone: 361.570-4277 E-mail: [email protected]

District 21: Sherrie Harris Phone: 432.640-1138 E-mail: [email protected]

District 22: Toni McDonald E-mail: tmcdonald@

hcecwildblue.com

District 25: Inger Zerucha Phone: 903.315-2632 E-mail: [email protected]

District 26: Cecilia Hinojosa Phone: 956.454-0330 E-mail: [email protected]

District 28: Jenny Wilder Phone: 903.826-2712 E-mail: [email protected]

District 29: Beverly Howard Phone: 281.756-5616 E-mail: [email protected]

District 35: Kim Gatlin Phone: 903.466-6982 E-mail: [email protected]

District 40: Contact TNA Phone 800.862-2022 ext. 129 E-mail: [email protected]

TEXAS NURSING VoiceA publication of Texas Nurses Association

January, February, March 2010Volume 4, Number 1

Editor-in-Chief – Clair B. Jordan, MSN, RNManaging Editor – Joyce Cunningham

Creative Communications – Deborah TaylorCirculation Manager – Belinda Richey

Editorial Contributors

Joyce Cunningham; Toni Inglis, MSN, RN; Clair Jordan, MSN, RN; Laura Lerma, MSN, RN; Debora Simmons,

PhD(c), RN, CCRN, CCNS; Lisa Watson; James H. Willmann, JD; Cindy Zolnierek, MSN, RN

Editorial Advisory Board

Stephanie Woods, PhD, RN, Dallas, (Chair)Jose Alejandro, MSN, RN, MBA, CCM, DallasPatricia Allen, EdD, RN, CNE, ANEF, Lubbock

Sandra Kay Cesario, PhD, RN, C, PearlandJennifer D.M. Cook, PhD, MSN, RN, San Antonio

Anita J. Coyle, PhD, RN, CHES, SangerThelma L. Davis, LVN, Giddings

Anita T. Farrish, RN, MHSM, NE-BC, WacoPatricia Goodpastor, RN, The Woodlands

Patricia Holden-Huchton, RN, DSN, DentonTara A. Patton, BSN, RN, Palestine

Dianna Lipp Rivers, RN, CNAA, BC, Beaumont

Executive Officers

Susan Sportsman, PhD, RN, PresidentMargie Dorman-O’Donnell, MSN, RN,

Vice PresidentClaudia Turner, MSN, RN, Secretary-Treasurer

Regional Directors of Texas Nurses Association

Kleanthe Caruso, MSN, RN, CNAA, BC, CCHP – North

Jennifer Cook, PhD, MSN, RN – SouthDana Danaher, MSN, RN, CPHQ – Central

Viola Hebert, MA, BSN, RN – EastJo Rake, MSN, RN – West

Executive Director

Clair B. Jordan, MSN, RN

TEXAS NURSING Voice is published quarterly – January, February, March; April, May, June; July, August,

September; and October, November, December by – Texas Nurses Association, 7600 Burnet Road, Suite 440,

Austin, TX 78757-1292.

Editorial Office

TEXAS NURSING Voice, 7600 Burnet Road, Suite 440, Austin, TX 78757-1292

512.452-0645, e-mail [email protected]

Address Changes

Send address changes to Texas Nurses Association, 7600 Burnet Road,

Suite 440, Austin, TX 78757-1292, e-mail: [email protected]

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Texas Nurses Association and the Arthur L. Davis Publishing Agency, Inc. reserve the right to reject any advertisement. Responsibility for errors in advertising is limited to corrections in the next issue or refund of price of advertisement.

Acceptance of advertising does not imply endorsement or approval by Texas Nurses Association (TNA) of products advertised, the advertisers, or the claims made. Rejection of an advertisement does not imply a product offered for advertising is without merit, or that the manufacturer lacks integrity, or that this association disapproves of the product or its use. TNA and the Arthur L. Davis Publishing Agency, Inc. shall not be held liable for any consequences resulting from purchase or use of an advertiser’s product. Articles appearing in this publication express the opinions of the authors; they do not necessarily reflect the views of the staff, board, or membership of TNA or those of the national or local associations.

Copyright © 2010 by Texas Nurses Association.

Presidents of the 29 state-wide Districts of Texas Nurses Association, as well as some District offices, are listed below. They invite you to contact them with questions or comments about TNA District membership and involvement.

January, February, March 2010 Texas Nursing Voice •

Care Policy Council of the Governor’s Office, to mention but a few. All of these groups are unified in their understanding that demand for nurses will outpace supply if nothing is done. Their approaches vary somewhat but contain common threads of innovation, collaboration, accountability and improved efficiencies as solution ingredients.

Nursing Workforce Shortage Coalition

The Nursing Workforce Shortage Coalition – a diverse partnership of over 100 health care organizations, business groups and education leaders – worked tirelessly this past legislative session to increase the funding for nursing education in order to address the shortage. The solutions the coalition proposed are increasing nursing school capacity, improving efficiencies, assisting nursing students with financial aid and incentives in order to encourage enrollment and graduation, and holding schools accountable for producing more graduates.

Texas Team – Center to Champion Nursing in America

In the spring of 2008, the newly established Center to Champion Nursing in America – a joint initiative of AARP, Robert Wood Johnson Foundation, U.S. Health Resources and Services Administration, and the U.S. Department of Labor – issued a call inviting states to join a nationwide effort to develop more local strategies to prepare and retain nurses. Texas answered the call and was one of only 18 states selected to participate. By December 2008, Texas Nursing: Our Future Depends on It was released. It is the strategic plan developed by the Texas Team to address nursing education capacity. To meet demand, Texas needs to hire 265 additional full-time and 159 part-time faculty statewide.

“Texas must strive for synergies, partnerships, disruptions and innovation in order to meet the goal of producing sufficient initial RN licensure graduates,” states the report. The plan supports growth, regionalization and partnerships as the primary framework. The Texas Team recommends regionalization and sharing of

State of Nursing continued from page 1

State of Nursing continued on page 4


recommendations for improving the health care system in Texas. In early December, Beth Mancinci, PhD, RN, NE-BC, FAHA, FAAN, professor and associate dean, Undergraduate Nursing Programs, University of Texas at Arlington, provided testimony on behalf of Texas Nurses Association before the Council’s Partnership Workforce Subcommittee. The main topic: faculty and nursing education capacity. The key question became: to expand capacity in nursing schools, is there a faculty shortage, a compensation problem (i.e., a financial disincentive to work in education), or a combination of both? In other words, if experienced nursing faculty is available, how does Texas attract it and what kind of funding would be needed?

The answers – at least the possibilities – according to Mancini again come down to innovation and collaboration. Faculty could be shared. So could resources. Educational innovations such as use of BSN-prepared nurses as part of faculty or flexible clinical rotations that allow more MSN-prepared nurses to participate in education could also be options for expanding capacity.

Outside InfluencesBesides a Texas Team in the Center to

Champion Nursing in America, there’s a team from Oregon. Named the Oregon Consortium for Nursing Education (OCNE), it launched what’s referred to as “a groundbreaking program” to increase the number of BSN-prepared nurses. Through collaboration, nursing faculty from associate degree and baccalaureate nursing programs have agreed to new nursing competencies, shared curriculum and academic standards. The results so far: a significant increase in nurses pursuing bachelor’s degrees. Like in the testimony of Mancini, use of BSN-prepared nurses as part of faculty could be some of the reform of nursing education needed for 21st century health care.

There is also urgency in strengthening the nursing workforce claims renowned researcher

resources to expand capacity and maximize use of limited resources. In short, “With a critical shortage of nurse educators, schools of nursing must change or the state risks being left behind.”

Collaborative members of Texas Team include representatives of nursing education and practice, state workforce offices, state departments of labor, consumers, local business, philanthropies and others.

Texas Health Care Policy Council By the end of each even-numbered year,

the Texas Health Care Policy Council (THCPC) must report to the Governor, Lieutenant Governor, and Speaker on its findings and

and nurse economist Peter I. Buerhaus, PhD, RN, FAAN. In his and colleagues’ recent research published online in a June 2009 Health Affairs Web exclusive, The Recent Surge In Nurse Employment: Causes and Implications, a recent surge in nurse employment it is proposed should not give employers and policy makers any comfort or illusion that the nursing shortage has been reversed. Rather Buerhaus, et al., claim , relief from the shortage is temporary and driven by the latest U.S. recession that began in December 2007. In times of recession, reveals Buerhaus, real or anticipated loss of family income drives nurses to return to or stay in the workforce.

With an easing of the current nursing shortage, Buerhaus suggests, it’s time to focus on “addressing the implications of the changing composition of the RN workforce.” That means the demographics are changing and employers and policymakers need to take notice. • Older RNs (over the age of 50) account

for most of the employment increase and most of the growth in non-hospital environments.

• RNs aged 23-25 years account for 28percent of the total increase in employment suggesting nursing is growing in attraction as a career.

• Increased employment of foreign-bornRNs (i.e., country of birth outside the U.S.). Shortage projections for 2020 make it likely that the demand for RNs educated in other countries will increase.

With these demographic trends, suggests Buerhaus, adaptations must occur in the workplace and an easement in the current shortage is an ideal time to investigate the potential of change. For instance, to retain the older RN in the workforce, efforts should be focused on improving the ergonomic environment of the clinical workplace. For foreign-born RNs, communication skills due to language or cultural differences should be considered and improved.

“Until nursing education capacity is increased,” notes Buerhaus, “future imbalances in the nurse labor market will be unavoidable.”

The recommendation: preserve budgets for nursing education and remove barriers to expanding the size of the future RN workforce. ★

State of Nursing continued from page 3

January, February, March 2010 Texas Nursing Voice •

Nurses Rated Highest in Ethics

In Gallup’s 2009 annual Honesty and Ethics of Professions poll, nurses are the undisputed leaders of people in a list of 22 professions that a majority of Americans – 83% in fact – consider to have the highest of ethical standards. Other professionals following nurses in the top five most highly rated professions include: druggists/pharmacists, 66% rating; medical doctors, 65%; police officers, 63%; and engineers, 62%.

At the other end of the list sits Members of Congress. A 55% majority of Americans in the poll rated them as having low or very low ethics and standards. Car salespeople, senators, stockbrokers and HMO managers were also at the bottom of the 2009 rankings of professions.

Nurses continue to top Gallup’s honesty and ethics poll since 1999 when nursing was first included in the list of professions. The exception was 2001 when firefighters – included on a one-time basis following Sept. 11 – took the top spot. Get all the details at gallup.com. ★

Texas Center for Nursing Workforce Studies

Concern about the nursing shortage and the lack of nursing workforce data lead to passage of House Bill 3126 in the 78th Legislative Session which established the Texas Center for Nursing Workforce Studies (CNWS) within the Statewide Health Coordinating

Council. The CNWS collects and analyzes data on nurses in Texas concerning: • Educationalandemploymenttrends

• Supplyanddemandtrends

• Nursingworkforcedemographics

• Migrationofnurses.

Every two years since 2004, the CNWS has surveyed Texas hospitals to assess the size and effects of the nursing shortage in Texas’ largest employer of nurses. Information from these surveys has been instrumental in obtaining funding to increase the number of nurse graduates in Texas, such as the unprecedented $50 million appropriated for nursing education earlier this year.

The biennial survey will be sent to Texas hospitals in March 2010. Completion is voluntary and confidential. All hospitals are strongly encouraged to respond. The more complete and accurate the data obtained, the more useful the projections and policy recommendations will be. If you are a chief nursing officer, look for the survey in March!

For more information about the Center for Nursing Workforce Studies, and reports from previous surveys, go to http://www.dshs.state.tx.us/chs/cnws/default.shtm. ★

Hospital Safe Staffing Law…

In June 2009, Texas Governor Perry signed into law Senate Bill 476 which established requirements for hospital governing boards to adopt nurse staffing policies. The new law also requires hospitals to establish nurse staffing committees, who recommend a staffing plan and who monitor, evaluate, and report to the hospital governing board the effectiveness of the nurse staffing plan. The law also prohibits hospitals from requiring mandatory overtime. On September 1, 2009, the Hospital Safe Staffing Law became effective.

What’s New?In its last issue (October/November/December

2009), TEXAS NURSING Voice reported that the Texas Department of State Health Services (DSHS) was expected to issue by January 1, 2010, revised licensing rules that incorporated provisions of the new law. DSHS held a preliminary meeting on November 13, 2009 for stakeholders to discuss development of the new rules. DSHS has indicated that the timeline for the adoption of new rules will now most likely be late summer or early fall of 2010.

From communications that Texas Nurses Association (TNA) has received, it appears that the new requirements for hospital board policies and staffing committees are being implemented by hospitals without much difficulty. Most of the concerns about implementation of the new law center on mandatory overtime. There are some very specific hospital practices, particularly in surgical and interventional areas and involving the use of on-call time, that may not easily be distinguished from mandatory overtime. The rules may be able to clarify some of these issues.

Stay tuned… ★

by Susy Sportsman, PhD, RN, President, and Clair Jordan, MSN, RN, Executive Director,

Texas Nurses Association

Widespread interest in the highly anticipated, state criminal trial of two nurses – Anne Mitchell and Vicki Galle – indicted in Winkler County, West Texas for advocating for patients increased in early January the phone calls and e-mails to Texas Nurses Association from nurses following the case. Callers displeased by the messaging in a recent mail piece wanted to know, what’s up with this mailer from the California Nurses Association /NNOC?

Apparently, CNA /NNOC dropped mail to nurses across Texas declaring that the criminally indicted, West Texas RNs need help and that help should come in the form of nurses supporting the state and national legislation agendas of CNA /NNOC. Callers to TNA were asking, what’s that legislative agenda got to do with helping the nurses in Winkler County?

The state criminal case facing Mitchell and Galle has nothing to do with Texas’ Safe Harbor law, as the mailer pretends. The Safe Harbor law is a unique protection for nurses who are trying to determine what their duty to their patients is. Mitchell and Galle knew what their duty to their patients was – it was to report the physician who they were concerned was providing substandard care to their patients. It is precisely because they knew what their duty was and had the courage to carry out that duty, that they now face criminal charges.

There are no Identified laws – not in Texas, Washington, D.C. or California – that limit the discretion of a local prosecutor to pursue criminal action against any individual, as the Winkler County attorneys have done by abusing the discretion of their office. A federal civil lawsuit for malicious prosecution filed by Mitchell and Galle may provide

OpinionYou Can’t Believe Everything You Read

remedies in this situation, but not until the criminal trial – set for February 8, 2010 – is resolved.

It is against the law in Texas to retaliate against nurses who advocate for their patients. If retaliation occurs – such as the job termination in the “Winkler County” situation – Texas nurses have the ability to seek remedies through civil action, just as Mitchell and Galle are doing with their federal civil lawsuit. Put another way, even though there are laws in our country against murder, murders still unfortunately happen. Laws cannot prevent murder, but when it occurs, there can be justice delivered in our courtrooms through our judicial system. By the same token, no law can totally protect whistleblowers from retaliation but the Texas whistleblower laws do provide for legal remedies should retaliation occur.

As of early January 2010, state and national organizations and over 375 individuals have sent donations of support – both financial and in-kind services – to the TNA Legal Defense Fund, established by Texas Nurses Association as a way to support the legal rights of practicing nurses in advocating for their patients. Just prior to Thanksgiving 2009, the TNA Legal Defense Fund made a $20,000 distribution to Mitchell and Galle’s defense costs – double the original goal of $10,000 which included the $5000 matching contribution by Texas Nurses Association. The “West Texas RNs” have been truly helped by the generous and sincere support of nurses across the country, that have provided the means for Mitchell and Galle to aggressively defend their criminal indictments and maximize their access to the legal protections that exist under Texas law for nurses who advocate for their patients.

The state’s criminal trial date is set for February 8. Texas Nurses Association provides updates at texasnurses.org. Donations to the TNA Legal Defense Fund continue to be accepted at the same Web site. ★


by Laura Lerma, MSN, RN, Texas Nurses Association Representative to TISWG

During its November 5 meeting, Texas Immunization Stakeholder Working Group attendees focused on: H1N1; an Immunization Branch update; an update on the CDC stimulus projects; and the current media and education campaign.

Because of the immediate concerns related to H1N1 in Texas, time was spent discussing the H1N1 vaccine allocation and distribution process. The allocation process is a partnership between the public and private sectors across the state at all levels. As is known, the demand for the vaccine far outweighs the supply currently being allocated weekly from the Centers of Disease Control and Prevention (CDC).

In response to the need to coordinate allocation and distribution within the state, the Vaccine Allocation Approval Committee (VAAC) was established. The VAAC decides where the H1N1 vaccine is allocated within the state based on the current disease trends within the state, CDC requirements, and what formulation and amount of the vaccine will be received from the CDC into the state that week. The VAAC does take into consideration the priority populations and the needs of the providers of the vaccine. The VAAC is seeing a gradual increase in the availability of vaccine doses and has seen significant coverage throughout the state. However, there is still concern regarding the number of doses being allocated to Texas, and whether there is enough in the manufacturing pipeline to cover everyone especially with the new recommendation of a second vaccine dose for children under the age of 10 years. Texas seems to be experiencing H1N1 in waves with it now showing up more and more in adult populations. As of November 2, 2009, 2,394,400 doses of the H1N1 vaccine had been made available to Texas by the CDC. 2,009,300 had been received and distributed to the over 10,000 providers in the state who are eligible to administer the vaccine.

Casey Blass, director of the Infectious Disease Prevention Section, reported that valuable lessons have been learned through this process and will be addressed in a strategic plan for the future. Two immediate concerns he addressed were the lack of resources available to deal with the crisis and the lack of systems in place to deal with the intensity of the capacity surge in hospitals throughout the state. He encouraged health care professionals to continue to access

Quarterly Report: Texas Immunization Stakeholder Working Group

The Texas Immunization Stakeholder Working Group (TISWG) was established by the 78th Texas Legislature in 2003 to focus on improving the state immunization rates, particularly for children. Under the Department of State Health Services (DSHS), TISWG establishes a partnership of various state agencies for the purpose of developing a road map to assist the DSHS Immunization Division in setting priorities and implementing plans to increase the vaccination rates in the state. Members of the work group represent federal, state and local agencies and programs; schools; health care providers; employers; insurance/health plans; vaccine manufactures; and those from the private sector.

the information resources that are available – the 211 help desk and texasflu.org

Between April and November, there had been 990 hospitalizations statewide associated with H1N1; 220 ICU admissions. There had been 113 deaths of which 25 were pediatric deaths. The median age of those who died was 33 years. Eighty-six per cent of the deaths were of people who did have an underlying medical condition.

Public Awareness CampaignBesides the allocation and distribution process,

there has been a very intense public awareness campaign in progress. The goal of the campaign is threefold: 1. Inform and educate Texas about the flu; 2. Find and use innovative ways to get /share the information; and 3. Develop tools and resources that can be used to promote the message of prevention and mitigation.

Activities will focus on the big picture – of trying to find the balance between concern and panic. A multimedia campaign is planned including TV, radio, webinars, podcasts, social media and printed materials.

Although H1N1 is a major focus of the Immunization Branch, they do have other activities that they must attend to. Jack Sims, Immunization Branch Manager reported the following:

1. Based on 2008 data, immunization coverage levels in Texas continue to improve. Currently, based on a 77.8 per cent coverage level, Texas is ranked 12th in the nation. Thanks to the concerted effort of everyone involved, there has been a steady trend of improvement since 2002.

2. The Adult Safety Net Program has been expanded to cover all vaccines recommended for adults and includes where adults can access those vaccines.

3. Texas has seen a significant decrease in the number of annually reported Hepatitis B cases. On average, Texas usually has between 700 and 800 reported Hepatitis B cases in adults per year. If current statistics hold true, 2009 will see less than 300.

4. Out of the 81st Texas Legislature came several new laws or law changes that impacted the Immunization Branch. All of those projects are in development and will be presented at a later meeting.

5. Lack of compliance with new 7th grade immunization requirements lead to an emergency rule to extend the due date by 30 days. It was of concern that some clinics required security in the form of the local police to maintain control and to provide a safe environment for both staff and patients.

6. The 2009-2010 flu season is upon us. The vaccine is very similar to the 2008-2009 vaccine. The age and risk groups previously recommended for annual vaccination against influenza have not changed. All children aged 6 months through 18 years are recommended to receive vaccination against the flu. There is not expected to be a shortage, but supplies may be tight due to the increase in demand and the decrease in production from manufacturers that are focusing on the H1N1 vaccine. We are

still early in flu season, so get vaccinated to protect yourself from becoming ill.

As reported last quarter, the Immunization Branch was awarded stimulus money from the CDC to develop four projects:

1. First Responder Feasibility Study: Will determine the feasibility of providing vaccines to first responders deployed to a disaster area.

2. School-based Influenza Study: Will evaluate already existing school-based influenza vaccination programs for their effectiveness, issues/barriers, and possible statewide implementation.

3. Cocooning Concept: Will develop and implement a pilot to introduce the concept of cocooning – encouraging immediate family members of newborn infants and children too young to be fully immunized against pertussis to be immunized thus creating a protective “cocoon” of immunity around the child – to hospitals and pediatric and OB/GYN practice settings.

4. EMR-ImmTrac Reporting: Will evaluate the many electronic medical record (EMR) software systems in an effort to increase and enhance access of ImmTrac registrants who utilize those systems.

The Public Information, Education, and Training Group within the Immunization Branch has been actively developing and distributing videos and brochures addressing the need for first responders to register in ImmTrac and the barriers new moms experience to getting their children immunized. The focus has been to get parents to go to the Web site for information in an effort to keep their children on their immunization schedule.

These are interesting times for TISWG and its collaborative members with ongoing concerns on the horizon surrounding H1N1 and seasonal flu. These are exciting times for TISWG as new and important projects are being developed. The Texas Nurses Association is proud to be part of TISWG and the work it is doing to improve the health of all the citizens of Texas. ★


by Toni Inglis, MSN, RN

One Saturday, Rondah Kentch and I cared for eight premature babies in our neonatal intensive care bay. All of them were adorable, nearing discharge and had blank immunization consents on the fronts of their charts, waiting for signature. With 65 years of neonatal nursing experience between us, we could handle the babies. What wasn't so easy was getting consent from their parents to protect them from communicable, deadly diseases.

Jason's parents arrived, and I knew within minutes that they were intelligent, highly educated and empowered with all of the information in the world at their fingertips. After warming to them, I brought up the consents.

"We just don't know," they said. "The government is telling us that children need so many shots, yet there's that link with autism and the dangerous substances they put into the vaccines. And hepatitis B — how in the world would Jason get that? By injecting street drugs with shared needles? We're leaning toward not getting them at this time."

Two other sets of parents in the room who were listening intently expressed the same impassioned concerns. The parents turned to me and asked my take on the vaccines. After taking a deep breath, I told them:

Commentary: Allaying Vaccine Fears with Historical Context

I can see that you all love your babies very much and that you want to do the right thing for them. You're young, though, and these diseases are not real to you.

Rondah here was stricken with polio at the tender age of four. It was 1953, a year after Jonas Salk developed the polio vaccine, but two years before it was available. She was separated from her family and hospitalized for six months of gruelingly painful therapy administered every four to six hours around the clock. But Rondah was one of the lucky ones. She survived with only a limp in her left leg.

I remember waiting in a mile-long line at the local elementary school with my family to get our polio vaccines. Polio had killed and permanently paralyzed many people in our community and all around the world. Think President Franklin Roosevelt. Everyone standing in that long line felt a symphony of emotions — fear bordering on fright, feeling blessed, exhilarated by the promise and the triumph of human achievement over disease.

A nurse friend of mine contracted hepatitis B in the 1960s from a needlestick at work and was left sick and mostly bedridden for seven irretrievable years when her five children were young — an unimaginable torture.

Sixty years ago, leading research facilities began developing vaccines to protect us from

horrific diseases that can sicken and kill us — diphtheria, polio, pertussis, tetanus, hepatitis B and more. These diseases are communicable, and they are preventable. Many have become dormant because of vaccines. In the absence of population immunity, however, they will come back. There's an alarming pertussis outbreak right now in Williamson County.

Your babies' chances of harm by disease are real and far greater than harm by vaccine. I can back that statement with the best science from the World Health Organization, the U.S. Centers for Disease Control and Prevention, the U.S. Department of Health and Human Services and the U.S. Food and Drug Administration. If Jason were mine, I would opt to protect him — and his community — from the real threat of disease.

The parents signed the consents. But I felt like I had just run a marathon. I learned professional nursing by mastering the sciences. I was in no way prepared to fight a large and growing grassroots movement contemptuous of science and government that opposes the systematic vaccination of children against deadly diseases. Children are already dying in this war against science. It won't end, I guess, until enough children die.

About the Author: Toni Inglis, MSN, RN, is a neonatal intensive care nurse in Austin and a clinical nurse specialist in community health. She is a long-time member of Texas Nurses Association who is also a frequent, local contributor of commentary to the Austin American-Statesman. The commentary printed in this issue of TEXAS NURSING Voice was also published by the Statesman on November 30, 2009 under the title, Taking on doubt over vaccinations against disease. ★

January, February, March 2010 Texas Nursing Voice • Page 9

3. When is mandatory overtime not prohibited? Or what are the exceptions?

• Theprohibitionsonmandatoryovertimedo not apply if:

i. A health care disaster, such as a natural or other type of disaster that increases the need for health care personnel unexpectedly affects the county in which the nurse is employed or affects a contiguous county; or

ii. A federal, state, or county declaration of emergency is in effect in the county in which the nurse is employed or is in effect in a contiguous county; or

iii. There is an emergency or unforeseen event of a kind that:

a. Does not regularly occur

b. Increases the need for health care personnel at the hospital to provide safe patient care; and

c. Could not prudently be anticipated by the hospital.

If a hospital determines that an exception exists under an unforeseen emergency (iii), the hospital can mandate a nurse to work overtime only after making a good faith effort to meet the staffing need through voluntary overtime, including calling per diems and agency nurses, assigning floats, or requesting an additional day of work from off-duty employees.

by Cindy Zolnierek, MSN, RN, Director of Practice, Texas Nurses Association

After “Mandatory Overtime Prohibited” appeared in the October/November/December 2009 issue of TEXAS NURSING Voice, the Texas Nurses Association (TNA) received a number of phone calls and e-mails from nurses around Texas with questions about their particular situations. This follow-up article intends to clarify requirements of the new law in an attempt to share many of the questions we received from nurses.

The Texas Department of State Health Services (DSHS) will be revising the Hospital Licensing Rules for consistency with SB 476, and further clarification of the Hospital Safe Staffing Law which includes mandatory overtime prohibition. These rules are not expected to be adopted until late summer or early fall of 2010.

1. What do nurses need to know about the new mandatory overtime law?

• It applies to hospitals.

• It prohibits hospitals from requiringnurses to work hours or days in addition to hours or days scheduled.

• It is not related to the total number of hours or days scheduled.

• It isnot related to how time is paid (e.g. overtime pay).

• There are exceptions in certainemergency or disaster situations.

• It is illegal for a hospital to retaliateagainst a nurse who refuses to work prohibited mandatory overtime.

• Refusing to work prohibited mandatoryovertime is not patient abandonment.

2. What is mandatory overtime?

• ‘Mandatory overtime’ means a requirement that a nurse work hours or days that are in addition to the hours or days scheduled, regardless of the length of a scheduled shift or the number of scheduled shifts each week.”

• Mandatoryovertimedoesnot include:

• Prescheduledon-calltime

• Time immediately before or after ascheduled shift necessary to document or communicate patient status to ensure patient safety (e.g., end-of-shift report)

• While many of us may have our ownunderstanding of “mandatory overtime,” the definition provided in the statute is the one used to determine whether a particular practice is prohibited by law. Being required to work more than 40 hours per week is not necessarily prohibited mandatory overtime if the shift had been prescheduled. Yet, being required to come in for an unscheduled shift might be prohibited mandatory overtime, even if total hours worked are under 40 for that week.

Mandatory Overtime: What Nurses Need to Know

• Theprohibitionsonmandatoryovertimealso do not apply if the nurse is actively engaged in an ongoing medical or surgical procedure and the continued presence of the nurse through completion of the procedure is necessary to ensure the health and safety of the patient.

4. How does on-call time fit in?

Prescheduled on-call time is not considered mandatory overtime. However, a hospital may not use on-call time as a substitute for mandatory overtime. Exactly what hospital practices would constitute using on-call as a substitute for mandatory overtime is not clear. While hospitals traditionally schedule on-call to meet unanticipated staffing needs, it is possible that hospitals could attempt to avoid mandatory overtime by placing nurses on call every day. The Department of State Health Services hospital licensing rules may provide further clarification about what on-call practices would be considered a substitute for mandatory overtime.

5. What if I believe my hospital is using prohibited mandatory overtime?

You have several options to raise your concerns within your organization and have them addressed. It is illegal for a hospital to retaliate against you for raising patient safety concerns.

• Speak directly to your manager about the practice you identify as mandatory overtime. Share your perception that it constitutes mandatory overtime and is not allowed by the Hospital Safe

Mandatory Overtime continued on page 10


Staffing Law. Attempt to understand your manager’s rationale for the work requirements and see if together you are able to identify mutually acceptable alternatives.

• Share your concern with your staffing committee representative. Overtime, and mandatory overtime in particular, is often the result of scheduling and staffing problems – areas the staffing committee is responsible for monitoring and addressing. By bringing your concern to this group, it raises it out of your department into a larger arena where many minds can evaluate the situation and work on a solution.

• If you believe the mandatory overtime request places you at risk due to fatigue, request Safe Harbor. A request for Safe Harbor Nursing Peer Review brings the situation up for review by your peers who can provide an objective perspective

The Practice Committee of the Texas Nurses Association (TNA) has worked to increase nurses’ understanding of the effect of human factors, such as fatigue, on their fitness for duty. Because of nurse leaders’ unique role in establishing safe practice environments that promote patient safety, the committee considered how they could support this role. A survey of Texas chief nursing officers (CNOs) conducted by the Committee revealed that, while most CNOs were aware that fatigue negatively affected nurse performance and safety, only 4% had developed any kind of approach to address fatigue as a safety risk.

To assist more nurse leaders (managers, directors, risk managers, etc.) meet their obligation to maintain safe environments, the Committee developed a resource guide, Tired is Trouble: A Nurse Leader’s Guide to Managing Fatigue in the Workplace. This resource guides nurse leaders through a comprehensive organizational assessment to identify practices that may contribute to fatigue in the workplace. Specific tools to prevent, manage, and mitigate fatigue are provided. This publication is available from TNA at www.texasnurses.org.

on the practices in your department. The Safe Harbor Nursing Peer Review Committee must report their findings to the chief nursing officer who must act on their findings.

• Consider sharing your concerns with your Human Resources Director or Hospital Compliance Officer. These individuals are vested in ensuring the hospital is following workplace regulations and often have confidential procedures in place for employees to register concerns or complaints.

• If you have been unsuccessful in raising concerns within your organization, you may report outside the organization to the Department of State Health Services who are is responsible for licensing hospitals. You may file a complaint online at www.dshs.state.tx.us/HFP/complain.shtm.

Questions and comments are welcomed at [email protected]. ★

Mandatory Overtime continued from page 9

Tired is Trouble: A Nurse Leader’s Guide to Managing Fatigue in the Workplace

Surveyed CNOs also said that they needed resources for staff education on human performance factors such as fatigue. This edition of the Texas Nursing Voice contains an article on just that topic: Fitness for Duty Includes Getting Your ZZZZs. If CNE credit is desired, the article and post-test may be accessed online www.texasnurses.org.

Members of TNA’s Practice Committee wanted to make themselves available to the readership regarding the issue of fatigue in the workplace and the importance of addressing it from both an organizational and individual perspective. Contact information is listed below.

Bob Dent, MBA, RN, NEA-BC, FACHE, Committee [email protected]

Connie Barker, PhD, RN, [email protected]

Courtney Huntsman, BSN, [email protected]

Robin Fleschler, PhD, RNC

Sandi McDermott, MSN, RN, [email protected]

Debora Simmons, PhD(c), RN, CCRN, CCNS

Maria Talamo, MA, RN, NEA-BC, [email protected]

Mary Viney, MSN, RN, [email protected]

Julie Withaeger, MSN, [email protected]

Cindy Zolnierek, MSN, RN (TNA Staff)[email protected] ★


The above photo first appeared in the last issue of TEXAS NURSING Voice, within the coverage of TNA’s Annual Nursing Leadership Conference. The editors apologize; we inadvertently failed to recognize Regina Jones Johnson (fourth from left) among the TNA leadership and members of the TNA Governmental Affairs Committee (GAC).

Correctly now, the photo includes (from left): Denise Jackson, GAC member; Margie Dorman-O’Donnell, TNA vice president and Board of Directors liaison to GAC; Victoria England, GAC member; Regina Jones Johnson, GAC member; Rep. Kolkhorst; Susy Sportsman, TNA president; Jo Rake, TNA director, West Region; Viola Hebert, TNA director, East Region; Nancy Goodman,

GAC member; Teresa Oehler, TNA District 9 alternate GAC member; and TNA Director of Governmental Affairs Jim Willmann.

Regina Jones Johnson, DrPH, MSN, RN, is a long-standing member of the TNA Governmental Affairs Committee. She is also associate professor, Family and Public Health Nursing, Co-PI Institute on Domestic Violence & Sexual Assault, The University of Texas at Austin School of Nursing. A personal goal of hers has been to get more faculty involved in the state-level activities of Texas Nurses Association. Editors hope that now that she’s been properly identified as a valuable contributor to the governmental affairs efforts of Texas Nurses Association, her goal can be more easily accomplished. ★

Ooooops!


How to Earn Continuing Nursing Education Credit1. The article, Fitness for Duty Includes

Getting Your ZZZZs, is presented as information only in this issue of TEXAS NURSING Voice. It is also presented online with an opportunity to earn continuing nursing education credit. To receive a certificate of successful completion for 1.0 contact hour, visit www.texasnurses.org and follow the online prompts.

2. Once you complete the registration form, you may use your Visa® or MasterCard® to pay the processing fee.

• $10forTNAmembers

• $15fornon-members

3. Once payment is made, you will receive a confirmation that will allow access to the online activity.

4. Read the article.

5. Take the post-test. To successfully

complete the post-test, you must achieve a score of 80% or better.

6. Complete the evaluation tool.

7. You will then be able to print your

Certificate of Successful Completion for 1.0 contact hour.

Accreditation StatementThe Texas Nurses Association/Foundation

Provider Unit is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Disclosure to Participants1. Requirements for successful completion:

To receive credit for this continuing nursing education activity, the reader must:

• Read the activity (either in TEXAS NURSING Voice or online at texasnurses.org).

• Completetheregistrationformonline.

• Pay the appropriate processing feeonline.

• Complete the activity evaluation toolonline.

• Achieveascoreof80%onthepost-test.

• Once successful completion has beenverified, a “Certificate of Successful Completion” will be awarded for 1.0 contact hours

2. Conflict of interest: A conflict of interest occurs when an individual has an

opportunity to affect or impact educational contents with which he or she may have a commercial interest or financial relationship. All planning committee members and the author(s) are required to disclose any potential or actual conflict of interest with any commercial entity that may have an interest in the activity’s educational contents. The planners and the one author (Zolnierek) of this CNE activity would like to disclose that they are employed by the Texas Nurses Association.

3. Commercial support: This educational activity did not receive any commercial support.

4. Non-endorsement of products: TNA/F’s ANCC accreditation status refers to the continuing nursing education activity only, and does not imply either TNA/F’s or ANCC’s real or implied endorsement of any product, service or company referred to in this educational activity.

5. Off-label product use: This education activity does not include any information about off-label use of a product for a purpose other than that for which it is approved by the U.S. Food and Drug Administration (FDA).

6. Expiration date: This activity expires January 19, 2012.

QuestionsE-mail any questions to: CNE@texasnurses.

org or phone 512-452-0645 extension 3. (If you experience technical difficulty, please use extension “0” to get help.)

Educational learning goal/purpose statement

The purpose of this educational activity is to enhance the knowledge base and practice of the registered nurse by outlining the limitations of human performance as it influences fitness for duty and the nurse’s ability to practice safely.

Learning objectives1. Explain the “anatomy of an error” in health

care.

2. Identify human performance limitations, such as emotional, cognitive and physical factors, that can contribute to errors.

3. Relate fatigue to a nurse’s fitness for duty and risk for error.

4. Review the nurse’s responsibility for

ensuring fitness for duty under the Standards for Nursing Practice. [include whose standards? Is this Texas Standards for Nursing Practice or BON?]

About the authorsDebora Simmons, PhD(c), RN, CCRN,

CCNS is associate director, Patient Safety Education Project, and research scientist at Texas A&M University Health Science Center Rural and Community Health Institute.

Cindy Zolnierek, MSN, RN, is director of practice for Texas Nurses Association, a frequent contributor to TEXAS NURSING Voice.

IntroductionIn 2006, Wisconsin registered nurse Julie

Thao faced criminal prosecution for "neglect of a patient causing great bodily harm" following a medication error that resulted in a patient’s death. Nurse Thao had slept at the hospital the night before after a 16-hour shift. It was the July 4th holiday, and she had agreed to work a double shift (7:00 a.m. to midnight) in order to help provide adequate staff coverage for the Labor and Delivery unit in which she was employed. Nurse Thao mistakenly infused an epidural anesthetic intravenously, thinking the drug was an antibiotic prescribed for a strep infection the patient had. Both infusion bags had been placed next to each other on a counter in the patient’s room. The patient died within the hour, although her newborn son survived (Error, 2006).

Was nurse Thao guilty as charged? Or was nurse Thao, who had an impeccable record prior to this incident, a good nurse who made a mistake with disastrous consequences? Most nurses will make medication errors at some point in their careers, and most of their patients will be “lucky” enough not to suffer serious consequences from their mistakes. How does the fact that nurse Thao had worked a double shift the day before and slept at the hospital play into the error equation?

Nurses are frequently asked to “work over” to cover an unexpected absence of a co-worker or to cover a chronically short-staffed area. Despite the availability of extra hours and the temptation of additional income, the professional accountability of nursing carries a responsibility to be in a safe condition to care for patients. “Fitness for duty” is used to describe this condition. Nurses may not be aware of what factors influence fitness for duty and how easily human performance limitations – emotional, cognitive, and physical components – can contribute to errors. This article reviews the limitations of human performance as it influences fitness for duty and impacts the nurse’s ability to practice safely.

Anatomy of an ErrorAnatomy is the science of structure. We all

completed an anatomy course early in our nursing education to learn about the structure of the human body, but most of us have probably not considered the anatomy of an error until we are faced with the consequences of an error. It’s at that point that we ask, “How did this happen? I was so careful!” The obvious

Fitness for Duty Includes Getting Your ZZZZs

Error: those occasions when a planned activity fails to achieve the intended outcome (Reason, 1990).

Fitness for Duty continued on page 15

by Debora Simmons, PhD(c), RN, CCRN, CCNS and Cindy Zolnierek, MSN, RN


answer is that we are human and ‘to err is human.’ But, there’s more…

Errors can be broken down into two types. Active errors occur by the person doing the activity, for example, when a nurse gives the patient a wrong medication. Latent errors occur farther away from the action, that is, away from the bedside. An example might be look-alike medications stored in adjacent bins in the medication cart or new equipment to which staff have not been oriented. Essentially, these are errors waiting to happen.

Because human error is inevitable, prevention is directed at the design of systems that can

prevent errors – mechanisms that don’t allow you to make a mistake. For instance, you cannot fill your

car’s unleaded gas tank with leaded gasoline because the gas receptacle for no-lead gasoline tanks has been designed smaller than a leaded nozzle. The two don’t fit, thus preventing an error.

There are many examples of this approach in health care as well: pre-filled syringes prevent dosage errors, programmed infusion pumps prevent certain infusion errors, and bar coding has prevented some identification errors. However, health care is extremely complex and it is impossible to design potential errors out of all processes. Consider the design of the work environment, staffing and scheduling practices, and communication processes – has any health care system perfected these designs to eliminate error? Though improvements have been made, nurses continue to be left at the “sharp end” where latent errors become active. Therefore, the nurse often represents the final opportunity to prevent a latent error from becoming an active error – the last safety net so to speak.

Human Performance FactorsHumans are imperfect. Human factors

confound performance and risk for error (see sidebar, Some Human Factors Affecting Performance). Many of these factors involve our interaction with the environment, for example, when we’re faced with unfamiliar e q u i p m e n t , poor lighting in a patient’s room, a noisy nurses’ station, or a difficult physician. E n v i r o n m e n t a l distractions are a well documented factor in medical e r r o r s . W h e n reduced, performance improves. Recently, several San Francisco hospitals were successful in reducing their medication errors by 88 per cent by reducing the interruptions (distractions) nurses experienced when administering medications (San Francisco Chronicle, 10/28/09).

Other human factors are internal. Fatigue is an internal human factor that crosses both our emotional state and physical abilities. Performance ability considers the relationship of the nurse’s work capacity to workplace demands and can be referred to as “fitness for duty.” We often think of impaired practice due to alcohol or other substance use when we hear the term “fitness for duty,” but fitness for duty is actually a broader concept that encompasses

any factor that may affect the nurse’s ability to perform competently and safely. Fatigue is one such factor that has been studied thoroughly in other industries, but only recently applied to health care.

Fatigue as a Factor in Fitness for Duty

Fatigue is defined as “an overwhelming sense of tiredness, lack of energy, and a feeling of exhaustion associated with impaired physical and/or cognitive functioning. Sleepiness and f a t igue of ten co-exist as a c o n s e q u e n c e o f s l e e p d e p r i v a t i o n . ” (Rogers, 20 08, p.2-509). Fatigue may result from circadian rhythm effects, sleep deprivation and continuous fatigue effects, and “time-on-task” effects.

Our sleep-wake cycle is regulated biologically by two factors and their interaction: a homeostatic system and circadian rhythm. Circadian rhythm is a “biological clock” which regulates our periods of sleepiness and wakefulness during the day. It functions in response to light signals which stimulate the release of hormones such as cortisol in the morning light and melatonin in evening. We respond with fluctuations in attentiveness during the day. Most of us experience our greatest sleepiness in the early morning hours (2:00-4:00 a.m.) and a lesser period in the early afternoon (1:00-3:00 p.m.). Circadian rhythms can only be shifted one to two hours in either direction and can be influenced by our sleeping and waking behaviors. For example, if we normally work early in the morning, but stay up late and sleep in over the weekend, we experience greater than usual sleepiness on Monday morning as our body adjusts to the change in sleep pattern. Disturbances in circadian rhythm, such as when traveling across time zones, also interrupt our normal sleep patterns and force our body to adjust – we experience this as “jet lag”. Night shift workers are especially challenged to manage disruptions to circadian rhythms.

Sleep/wake homeostasis is a second biological component that interacts with our circadian rhythm to help us to maintain adequate sleep. While circadian rhythm regulates the timing of sleepiness, sleep-wake homeostasis is concerned with the duration and intensity of sleep. While awake, we accumulate a need for sleep. When we get adequate quality sleep, we are able to replenish this sleep deficit. When we don’t, our homeostasis or balance is upset and we become sleep deprived.

Most adults require seven to eight hours of sleep per day. Sleep deprivation occurs when we don’t get required sleep or when we are awake longer than 16 hours. Lack of an uninterrupted sleep interval, such as when breaking up sleep into several naps, can also contribute to sleep deprivation (as any mother of an infant can attest!). A sleep deficit is cumulative over time and may require more than one replenishing normal sleep cycle to remedy.

Time-on-task is an industrial concept that refers to fatigue that accumulates during the work period. Prolonged concentration while reviewing and noting physician orders may be an example of time-on-task that may result in fatigue. Generally, fatigue increases and performance diminishes with sustained task effort.

How Fatigue Affects Fitness for Duty

Imagine… you are on your way to Hawaii to begin your dream vacation. As you board your airplane you are greeted by a red-eyed pilot carrying a large “energy drink” and overhear her comments to the flight attendant that she only had time for a four-hour nap between flights so was feeling a bit tired. Sound frightening? Would you board the plane?

What if you knew that in a safety study conducted by the National Transportation Safety Board (NTSB) of U.S. major carrier accidents from 1978 to 1990, it was concluded: Half the captains for whom data were

available had been awake for more than 12 hours prior to their accidents. Half of the first officers had been awake for more than 11 hours. Crews comprising captains and first officers whose time since awake was above the others made more errors overall and significantly more procedural and tactical decision errors (1994).

How confident are you of the pilot’s fitness for duty?

Insufficient sleep is associated with cognitive problems, mood alteration, reduced job performance, reduced motivation, i n c r e a s e d safety risks, and p h y s i o l o g i c a l changes (Rogers, 2 0 0 8 ) . F e d e r a l regulators recognize t h e a d v e r s e effects of fatigue on s a fe t y a n d require the airline industr y (a long with trucking and nuclear industries) to directly manage fitness for duty of airline crew members – specifically the number of consecutive hours that can be worked and the number of hours required between work periods for adequate rest.

Any factor affecting the nurse’s ability to perform competently and safely influences the nurse’s fitness for duty.

Some Human Factors Affecting Performance

DistractionFatigue

Pressure/StressNorms

Lack of communicationLack of knowledge/skills

Lack of teamworkLack of resources

To reduce error-producing fatigue, state regulatory bodies s h o u l d p r o h i b i t nursing staff from providing patient care in any combination of scheduled shifts, mandatory overtime, or voluntary overtime in excess of 12 hours in any given 24-hour period and in excess of 60 hours per 7-day period.

IOM, 2004

Sleep deprivation may result in:

* lapses in attention and inability to stay focused

* reduced motivation* compromised problem-solving

* confusion or bewilderment

* irritability or hostility

* unusual tenseness or anxiety

* memory lapses (particularly in short-term memory)

* impaired communication

* faulty information processing and judgment

* diminished ability to detect and recognize the significance of subtle changes in a patient’s health

* diminished reaction time

* slowed information processing

* inability to deal with the unexpected

* indifference and loss of empathy

“We cannot change the human condition, but we can change the conditions under which humans work.”

James Reason


Fitness for Duty continued from page 14


Patients in hospital beds are more likely to be greeted by a sleepy nurse than airline passengers are a sleepy pilot. Knowing that this sleepy nurse has a significantly greater risk of making an error that will affect your care, and perhaps your recovery, how safe do you feel now?

Despite recommendations from the Institute of Medicine in 2004, and recent attention to hours worked by medical residents, hours worked by nurses remain, for the most part, unchallenged. In a recent survey conducted by the Texas Nurses Association, 60 per cent of hospital chief nursing officers reported having a fitness for duty policy, yet only 4 percent of those reported considering fatigue as a component of this policy.

Nurses are not immune to fatigue or related effects on performance. A landmark study of 393 staff nurses over 5317 work shifts documented the significant effects of work duration, overtime, and number of hours worked on errors:

• Thelikelihoodof making an error increased with longer work hours and was three times higher when nurses worked shifts lasting 12.5 hours or more.

• Working overtime increased the odds ofmaking at least one error, regardless of how long the shift was originally scheduled.

• There(was)atrendforincreasingriskswhennurses work overtime after longer shifts, with the risks being significantly elevated for overtime following a 12-hour shift.

• Workingmore than 40 hours per week and more than fifty hours per week significantly increased the risk of making an error.

• Results were somewhat similar for nearerrors (Rogers et al., 2004, p. 207).

Why are nurses at risk for fatigue?There are a number of professional and

personal factors that contribute to nurse fatigue. The unpredictable nature of the health care environment – emergencies, fluctuating census patterns, changes in patient conditions, physician practice patterns – contributes to changing needs for nursing staff. Although organizations have strategies for anticipating patient care needs and scheduling staff appropriately to meet those needs, it is often a “best guess” and must be adjusted. This creates gaps in staffing needs – some days more nurses than those scheduled will be needed, requiring additional work hours and possible o v e r t i m e . A n organization that h a s v a c a n c i e s faces even greater c h a l l e n g e s i n meeting its staffing n e e d s w i t h o u t requiring additional hours from nurses.

Characteristics of a 24-hour, 7-day-a-week operation also contribute

to a nurse’s risk for fatigue. Night shift hours predispose individuals to sleep deprivation due to their circadian rhythm and likely interruption in sleeping schedule on days off. Twelve-hour shifts are popular with nurses, but they easily lead to fatigue at the end of the work day, or at the completion of a few shifts in a row. On-call often interrupts sleep as well as requires nurses to work hours exceeding the recommended daily limit.

As human beings, nurses will have personal factors affecting risk for fatigue. Nurses who report social duties and caretaking roles outside of work often report higher levels of stress both at work and at home. A nurse may be the caretaker for elderly family, young children, or ill partners. Concerns about one setting (e.g., the home) are frequently reported to interfere with performance in the second arena (work) (Scott et al., 2006). Our physical and mental health – aging, dehydration, depression, anxiety and stress – also affects our experience of fatigue and related performance.

Nurse’s responsibility for fitness for duty

Just as you wouldn’t go to work under the influence of alcohol, you shouldn’t go to work under the influence of fatigue – whatever the reason (personal or professional factors). Vigilance is not enough. Individuals are poor judges of their impairment from fatigue or sleep deprivation and alertness cannot be willed.

The nurse has a primary duty to his/her patient that supersedes any facility policy or physician order. The Code of Ethics for Nurses (ANA, 2001) clearly outlines the nurse’s responsibility for safe patient care:

• “Thenurse’sprimarycommitmentistothe…patient…” (Provision 2)

• “The nurse is responsible and accountablefor individual nursing practice… “(Provision 4)

Further, the Texas Board of Nursing Standards of Practice state that the nurse shall:

• “Implement measures to promote a safeenvironment for clients and others” (Rule 217.11(1)(B)); and

• “Accept only those nursing assignmentsthat take into consideration client safety and that are commensurate with the nurse’s educational preparation, experience, knowledge, and physical and emotional ability” (Rule 217.11(1)(T)).

The nurse has a duty to always act in the best interest of the patient. This duty to the patient includes being physically and emotionally “fit” to provide safe patient care. Therefore, nurses providing direct patient care have a professional responsibility to ensure they are adequately rested and not fatigued when accepting a

patient assignment. Likewise, a nurse making an assignment (or staffing a unit) must consider the “physical and emotional ability of the person to whom the assignment is made” [Rule 217(1)(S)] and is therefore responsible for considering the nurse’s fatigue and patient’s safety in making an assignment, a work schedule, or setting policies (e.g. on-call hours).

Sleep Hygiene

Individual Safety PracticesDespite the evidence, nurses are frequently

faced with either voluntary or required work schedules that may put them at risk for fatigue. How can nurses protect themselves and their patients when they may be at risk for fatigue? A number of countermeasures, preventative and operational strategies (Rosekind et al., 1996), can

assist in maintaining alertness and on-the-job performance. However, these strategies should be applied with caution – they do not eliminate the safety risks of working when fatigued.

Factors Related to Nurse Fatigue

ProfessionalOn-call hours

Required overtime hours

Total # hours worked per week

Length and sequencing of shifts

Rotating shiftsChronic short staffing

Working when sick

PersonalWorking extra jobsVoluntary overtime

Additional home/family responsibilities

Overall physical/mental health

(Nursing Organizations Alliance, 2006)

Evidence-Based Practice Recommendations

• Get7-8hoursofsleepper24-hourperiod

• Donotwork>48hoursina7-dayperiod

• Donotschedule/work12-hourshifts

• Ifyoumustwork12-hour shifts:

• Do not work more than 3 shiftswithout a day off

• Take breaks free from patient careresponsibilities (10 minutes/2 hours and a 30 minute meal break)

• Take10-12hoursoffbetweenshiftstoobtain adequate sleep

• Usecaffeine therapeutically

• Do not consume caffeine outside ofwork hours

• Only consume caffeine at thebeginning of the shift or between 3:00 a.m. and 5:00 a.m.

• Ifyouworknights,takeanappriortoyourshift

• Takeanapduring theshift (allowawakeup period after the nap before resuming patient care)

Rogers, 2008

DO

• Establisharegularschedule: wake up and go to bed at the same time every day

• Practicearelaxingbedtime routine

• Create asleep friendly environment

• Exercise!Butnotright before bed.

DON’T

• Gotobedifyouaren’t sleepy

• Consumealcohol,caffeine, heavy/spicy/sugary food 4-6 hours before bed

• Gotobedhungry

• Exercisevigorously before bed

• Read,write,eat,watch TV, etc. in bed




Jennie began her day of scheduled on-call at 3:30 p.m. when her 8-hour OR shift concluded. After arriving home at 4:30 p.m., she had something to eat and then took a 2-hour nap. At 10:30 p.m. she was called in for a trauma. She completed two emergency cases that night and was particularly disturbed by one patient, a young woman who died during surgery.

She returned home at 4:30 a.m. but had difficulty falling asleep. Feeling exhausted, she called the charge nurse at 5:00 a.m. to let her know that she felt too tired to work after taking call that night. The charge nurse told her she was expected to come in to work and coming in on-call was no excuse for missing work. Despite grabbing a double Expresso on the way to work, Jennie found herself having difficulty staying awake while driving. When she arrived at work, she told her manager that she felt too tired to practice safely, could not

American Nurses Association (2001). Code of Ethics for Nurses with Interpretive Statements. Washington D. C.: Author.

Hughes, R. G. & Rogers, A. E. (2004). First do no harm. American Journal of Nursing. 104(3), 36-38.

Institute of Medicine. (2004). Keeping patients safe: Transforming the work environment of nurses. Washington, DC: Author.

Nursing Organizations Alliance (2006). Principles of fatigue that impact safe nursing practice. Retrieved 12/03/09 from http://www.nursing-alliance.org/

Reason, J. (1990). Human Error. Cambridge: Cambridge University Press.

Rogers, A. E. (2008). Chapter 40: the effects of fatigue and

A primary, preventative countermeasure is to minimize sleep loss by using days off to “catch up” or “stock up” in anticipation of sleep debt. Good sleep habits, or sleep hygiene (see inset), can improve sleep quality. However, despite the quality of sleep, several sleep cycles are required to fully recover from a sleep deficit and sleep cannot be effectively “stored” to accommodate for a future lack of sleep.

Operational strategies include those things you can do while on the job to mitigate fatigue. Social interaction and conversation can assist in maintaining alertness; physical exercise combats sleepiness, however may leave one more fatigued later. Strategic use of caffeine can improve alertness. Nutritional snacks and planned breaks, including naps, can assist the nurse in maintaining energy (see inset: Evidence-Based Practice Recommendations).

The nurse has a primary duty to the patient. Texas nurses who believe that this duty may be violated by accepting an assignment when too tired to work safely, have the option of evoking Safe Harbor Nursing Peer Review. Safe Harbor is a process that protects the nurse when the nurse makes a good faith request for nursing peer review of an assignment because the nurse believes that accepting the assignment would violate the nurse’s duty to the patient. The nurse has the right to refuse the assignment while awaiting the Nursing Peer Review Committee’s determination. The decision to refuse the assignment must be based upon the belief that no reasonable nurse would accept the assignment. A nurse requesting Safe Harbor is protected from retaliation.

Organizational Safety PracticesHealth care has traditionally valued nurses

who never call in, who pick up extra shifts when needed, and who never seem to need a break – yet, this valuing allows fatigue and its dangers to permeate the organizational culture. Current evidence and recommendations challenge organizations to shift their culture toward one respectful of the deleterious effects of fatigue on the patient, the nurse, and the organization. A number of organizational practices can be implemented to fight fatigue in the workplace. First, organizations can work to understand current practices that may contribute to fatigue by conducting an assessment of staffing and scheduling, use of overtime and breaks, nurse satisfaction measures, and patient incident and employee accident reports. This information can assist organizations in identifying their risks related to potential fatigue, prioritizing issues, and developing a fatigue management plan to incorporate evidence-based recommendations. Recent legislation passed in Texas, the Hospital Safe Staffing Law, prohibits hospitals from requiring nurses to work hours or shifts in addition to hours or shifts previously scheduled. This prohibition on mandatory overtime is a first step in supporting nurses’ efforts to ensure they are rested prior to accepting additional shifts.

Conclusion The fallibility of human beings, limitations

of human performance, and importance of fitness for duty are well established. The health care industry has not yet incorporated this knowledge into its systems to effectively design out errors or “mistake proof” care. It is incumbent on the nurse to assume responsibility for safe patient care. That responsibility includes ensuring personal fitness for duty when accepting an assignment.

Evoking Safe Harbor Nursing Peer ReviewThis process applies for LVNs when an entity employs, hires or contracts for the services of 10 or

more nurses, and for RNs when at least 5 of those 10 or more nurses are RNs.

A nurse may evoke safe harbor by making a written initial request to the supervisor. The initial request must include:• Thenurse’snameandhis/hersignature

• Thedateandtimeofrequest

• Thelocationofwheretheassignmentistobecompleted

• Thenameofthepersonmakingtheassignment

• Abriefexplanationofwhysafeharborisbeingrequested

The initial request must be followed by a comprehensive request, completed in writing before leaving the work setting at the end of the work period. The comprehensive written request must include:• Theconductassignedorrequested,includingthenameandthetitleofthepersonmaking

the assignment;

• A description of the practice setting (the nurse’s responsibilities, resources available,extenuating or contributing circumstances impacting the situation);

• Adetaileddescriptionofhowtherequestedconductorassignmentwouldhaveviolatedthenurse’s duty to the patient (specific section of the Texas Nursing Practice Act or Board of Nursing rules if possible);

• Ifapplicable,thenurse’srationalefornotengagingintherequestedconductorassignmentawaiting the nursing peer review committee’s determination

• Copiesofanyotherpertinentdocumentation

• Thenurse’sname,title,andrelationshiptothesupervisormakingtheassignmentorrequest.★

References

sleepiness on nurse performance and patient safety. In Hughes, R. G., editor, Patient Safety and Quality: An Evidence-Based Handbook for Nurses (Volume 2). Rockville, MD: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services.

Rogers, A., Hwang, W., Scott, L., Aiken, L. & Dinges, D. (2004). The working hours of hospital staff nurses and patient safety. Health Affairs, 23(4), 202-212.

Rosekind, M. R.; Gander, P. H.; Gregory, K. B.; Smith, R. M.; Miller, D. L.; Oyung, R.; Webbon, L. L.; Johnson, J. M. (1996). Managing fatigue in operational settings 1: physiological considerations and countermeasures. Behavioral Medicine, 21, 157-165.

Error and Punishment. Retrieved on 12/03/09 from http://www.nursingadvocacy.org/news/2006/nov/20_captimes.html

accept the assignment, and requested safe harbor (completed the quick request form).

Jennie’s manager then met with her to see if they could collaborate and reach agreement on an acceptable assignment. Jennie thought that if she could use the sleep room until noon, she would be rested enough to assist with afternoon cases. The manager arranged for this and asked Jennie if she would withdraw her Safe Harbor request. Even though the immediate situation was remedied, Jennie elected to have the Nursing Peer Review Committee consider her request because scheduled shifts immediately following an on-call shift was not an unusual practice at her facility. She completed the comprehensive form, and gave it to her manager before going to the sleep room.

Jennie also voiced her concerns about fatigue, on-call, and scheduled shifts to the nurse representing perioperative services on the Nurse Staffing Committee so that they could evaluate the issue.

When duty to keep patients safe is threatened by fatigue…


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