N483 Transition to professional nursing practice

Here is my Capstone Research Paper:

Nursing Fatigue: Dangerous For Nurses and Patients

Darah M. Daskalakis

Adelphi University

NUR 483-600: Transition Into Professional Practice

Dr. Deborah Ambrosio Mawhirter, EdD, RN

May 7, 2022

Abstract

Fatigue can be physical or psychological—or a combination of the two—and can lead to compromised decision-making, reaction time, and critical thinking; it can also negatively influence general health. It is important that a nurse is not fatigued, this way the nurse will not make any errors in the clinical setting that will jeopardize them or the patient. In addition, continuous understaffing may negatively impact nurses’ wellbeing and patient care (Shang et al., 2019). It is best practice for all facilities to implement self-care techniques for nurses during their orientation at the facility to eliminate poor patient outcomes, errors, and burnouts.

Keywords: fatigue, understaffing, quality of care, patient safety, infection control, nurse to patient ratios, patient care

Nursing Fatigue: Dangerous for Nurses and Patients

Nurses have many responsibilities when it comes to their career, with one of the biggest being to keep their patients safe. Over the last few years, Covid-19 has impacted the lives of everybody worldwide- especially nurses and those in the healthcare field. Between nursing shortages, short staffing, and an increase in the number of hospitalizations due to Covid-19, nurses have been working harder than ever to deliver quality care to their patients daily. However, it seems that these nurses are taking care of everybody except the one person who truly needs it- themselves. Many nurses experience high levels of stress which can lead to burnout. Not only does it affect nurses and their health, but also, their patients are at risk too. Nurse burnout has a positive correlation to nurses leaving the profession, decreased job performance, and to patient care being hindered/worsened; thus, ultimately leading to poor patient outcomes (Crane & Ward, 2016). It is important to identify the top stressors within the nursing field to determine what interventions can be placed to prevent burnout, stress, and fatigue within the nursing profession and enhance patient safety.

One of the top stressors identified in the nursing field is the issue of understaffing. Nurse Staffing and Healthcare-Associated Infection, Unit-Level Analysis is an experiment that had been conducted using cross sectional data between 2017 to 2012 to see the correlation between healthcare associated infections and nurse staffing (Shang et al., 2019). According to the study, it had been determined that understaffing is associated with increased risk of hospital acquired infections, stating: “When a unit is understaffed, in our study, meaning staffing was below 80% of unit median, nurses in the unit experienced excessive workloads. These heavy workloads may compromise infection prevention practices and surveillance activities for early recognition of signs and symptoms of infection.” (Shang et al., 2019). This study points out the fact that overworked nurses tend to make mistakes throughout their shift, due to fatigue, leading to having job-related stress and negatively affecting patient care. An action that can be implemented by the nurse/institution to improve patient outcomes in the long run can be to hire more nurses so that short staffing won’t be as much of an issue, as presented in this study. In summary, when addressing the understaffing issue, hospital administrators need to pay close attention to the units with continuous understaffing (Shang et. al., 2019).

Comparing to the study previously spoken about, Safety implications of different forms of understaffing among nurses during the COVID-19 pandemic (Andel et. al., 2022) also follows the issue of decreased safety due to understaffed units. In this study, Covid-19 plays a huge role in the reason for inadequate staffing in the nursing profession. The design of this study includes having 120 nurses complete three surveys across a six-week period during the Covid-19 pandemic, asking the participating nurses to respond on a 5-point scale, ranging from strongly agree to strongly disagree. To obtain results, this study utilized survey questions related to measuring personnel understaffing, safety workarounds, cognitive failures, and near misses, which is described as “an unplanned event that did not result in injury, illness, or damage- but had the potential to do so” (National Safety Council, 2013, p.1) (Andel et. al., 2022). As a result of this study, it was determined that personnel and expertise understaffing influences experiences of near misses through safety workarounds and cognitive failures (Andel et. al., 2022). Even though this study only utilized 120 participants, the results were clear and seem to be consistent to this day as the pandemic continues worldwide. Other studies performed, such as the one in Chronic hospital nurse understaffing meets COVID-19: an observational study (Lasater et. al., 2021), supports the finding that hospital nurses were burned out and working in understaffed conditions in the weeks prior to the first wave of COVID-19 cases, posing risks to the public’s health. Understaffing of nurses has always been an issue in the healthcare field, however now with Covid-19, it has only gotten worse. Hospitals and other healthcare facilities need to address safe nurse staffing policies, as the American Nurses Association “has continued working to address unsafe nurse staffing levels to improve working conditions for nurses and achieve optimal patient outcomes” (American Nurses Association, 2021).

One of the most important factors when it comes to preventing nurse burnout is for nurses to practice health promoting behaviors. One article that discusses this topic is Nurses and Health Promoting Behaviors: Knowledge may not Translate into Self Care, where the authors discuss the barriers nurses face using Pender's Model of Self Promotion. The connection made within the Pender’s Model of Self Promotion is how intrinsic factors and extrinsic factors affect health promotion behaviors such as nutrition, physical activity, stress management, sleep hygiene and healthy relationships (Ross et al., 2017). This article discusses health promoting behaviors and how often nurses practice them. Although nurses are very knowledgeable in ways to promote health, many would be surprised to find that most nurses do not partake in these behaviors that they teach others about on a daily basis. Some of these behaviors that are discussed are improper nutrition, poor sleeping patterns, lack of physical activity and long hours (Ross et al., 2017). The authors examine the possible factors, both intrinsic and extrinsic, that may contribute to this lack of participation in these activities. It was found that many night nurses have a disadvantage regarding healthy eating because they tend to get their meals from vending machines or just simply snack. Also, the disruption in their circadian rhythm has been linked to increased emotional eating on shift for night nurses compared to day shift nurses and less exercising (Ross et al., 2017). This article relates to this research paper because this paper involves identifying ways to enhance patient safety through implementing strategies to reduce nursing fatigue and burnout. By thoroughly covering health promoting behaviors, especially sleep hygiene and stress management, that can give an inside view of ways to prevent these things and help implement good practices, this article directly relates to the issue of nursing fatigue (Ross et al., 2017). An action that can be implemented by the nurse/institution to improve patient safety/outcomes in the long run can be to implement learning programs for new nurses that teach about self-care related to anxiety, fatigue, and job stressors.

In conclusion, there is an abundance of research supporting the fact that understaffing of nurses leads to nurse burnout, and in turn, a safety deficit for patients. This is a process problem, as understaffing is one of the leading causes of nurse burnout. Regarding this concern, the best nursing practices to reduce nurse burnout includes setting wellness goals, such as improved nutrition, increased physical strength and flexibility training, and stress reduction. One of the most important things that nurse leaders can do is to maintain their own health and well-being, thereby encouraging staff members to do the same (Ross et. al., 2017). Doing so has been proven to enhance the quality of care given by the nurses who practice self-care implementations, having a decrease in work-related incidents and negative outcomes. As far as changes to be implemented, hospitals and healthcare facilities need to better adhere to safe nurse staffing policies. Since understaffing is the root cause of nurse fatigue, hospital administrators need to make sure that they are keeping enough nurses on the floor during the typical work shift, making sure that they have extra nurses on call during emergency situations, such as the Covid-19 pandemic. To do this, the institution would need to make it known that they need nurses. A way to do this would be to create advertisements on websites, such as Indeed.com, to attract nurses. The institutions can entice nurses to join their team by offering sign on incentive bonuses, thus making it more likely for nurses to want to take on the position even more. As far as education and furthering research goes on the topic of decreasing nurse burnout to enhance patient safety, it is a widely known phenomenon and there are no specific guidelines to follow. The guidelines that need to be followed are related to staffing, where institutions need to pick up on, as previously mentioned. There are, however, many tips and research articles to follow that are written by nurses themselves, sharing their experience and helping others avoid the issue of nurse burnout in order to improve patient safety outcomes. It is recommended that, when possible, nurses should take advantage of any therapeutic or counseling services offered by their institution or anywhere outside of work. Rita Trofino, a registered nurse and associate dean of the School of Health Sciences at St. Francis University, suggests that nursing professionals talk to their human resources department to locate employee assistance programs or individual/group therapy options (Kaple, 2022) in order to combat the stress and avoid nurse burnout. Even though Covid-19 is still an active issue in the world, with research continuing to be carried out daily, nurses have the ability to educate themselves and implement interventions necessary to not only properly care for their patients, but for themselves as well.

References

American Nurses Association. (2021). Nurse Staffing. ANA. https://www.nursingworld.org/practice-policy/nurse-staffing/

Andel, S. A., Tedone, A. M., Shen, W., & Arvan, M. L. (2021). Safety implications of different forms of understaffing among nurses during the COVID‐19 pandemic. Journal of Advanced Nursing, 78(1). https://doi.org/10.1111/jan.14952

Crane, P. J., & Ward, S. F. (2016). Self-Healing and Self-Care for Nurses. AORN Journal, 104(5), 386–400. https://doi.org/10.1016/j.aorn.2016.09.007

Kaple, T. (2020, July 27). Top Tips From Nurses on Dealing With Burnout | NurseJournal.org. NurseJournal. https://nursejournal.org/resources/tips-for-avoiding-nurse-burnout/

Lasater, K. B., Aiken, L. H., Sloane, D. M., French, R., Martin, B., Reneau, K., Alexander, M., & McHugh, M. D. (2020). Chronic hospital nurse understaffing meets COVID-19: an observational study. BMJ Quality & Safety, 30(8), 1–9. https://doi.org/10.1136/bmjqs-2020-011512

National Safety Council. (2013). Near miss reporting systems. In Alliance an OSHA Cooperative Program. OSHA Safety and Health. https://nsccdn.azureedge.net/nsc.org/media/site-media/docs/workplace/near-miss-reporting-systems.pdf?

Ross, A., Bevans, M., Brooks, A. T., Gibbons, S., & Wallen, G. R. (2017). Nurses and Health-Promoting Behaviors: Knowledge May Not Translate into Self-Care. AORN Journal, 105(3), 267–275. https://doi.org/10.1016/j.aorn.2016.12.018

Shang, J., Needleman, J., Liu, J., Larson, E., & Stone, P. W. (2019). Nurse Staffing and Healthcare-Associated Infection, Unit-Level Analysis. JONA: The Journal of Nursing Administration, 49(5), 260–265. https://doi.org/10.1097/nna.0000000000000748

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Your topic

Self care strategies for nurses to prevent burnout.

I chose to write and research about this topic because it is one of the number one contributing factors to the decline in patient safety. Especially with the recent Covid-19 outbreak across the world, the past 3 years have been especially stressful for nurses. The workplaces are short staffed and nurses are under an unbelievable amount of stress. This contributes to their lack of self-care, and in turn, contributes to the decreased level of patient safety.

Search process and Source(s) used

The first library subscription I chose was CINAHL Complete because they also have evidence-based articles, care sheets, and book chapters, which are specific to nursing and health. Also, it has a wide range of articles from 1937 to present day.

The second library database I chose was ProQuest Central because it is a large database that has many versatile articles, with over 19,000 of them being full text articles. Also, it includes scholarly journals, and full text dissertations that date back to 1921 until present day.

Search terms:

- Concept: self-care and strategies

Terms: wellness or mental health or maintenance or techniques or tactics or stress management.

- Concept: nurse

Terms: healthcare professional or medical staff or caregiver.

- Concept: burnout

Terms: exhaustion or breakdown or depression or fatigue or stress.

Citation:

American Nurses Association. (2021). Nurse Staffing. ANA. https://www.nursingworld.org/practice-policy/nurse-staffing/

Crane, P. J., & Ward, S. F. (2016). Self-Healing and Self-Care for Nurses. AORN Journal, 104(5), 386–400. https://doi.org/10.1016/j.aorn.2016.09.007

Kaple, T. (2020, July 27). Top Tips From Nurses on Dealing With Burnout | NurseJournal.org. NurseJournal. https://nursejournal.org/resources/tips-for-avoiding-nurse-burnout/

Information found:

The information that I had found was both primary and secondary research. I chose to use these articles/studies because they all include information and data involving nursing fatigue and what causes it in the clinical setting. These studies raise important points that need to be addressed, now making it apparent that hospital administrators, nurse managers, and health leaders urgently need to create favorable work environments supporting nursing practice to reduce burnout and improve quality of care.

These articles also discuss health promoting behaviors and how often nurses practice them. Although nurses are very knowledgeable in ways to promote health, many would be surprised to find that most nurses do not partake in these behaviors, that they teach others about on a daily basis, themselves. Some of these behaviors that are discussed are improper nutrition, bad sleeping patterns, lack of physical activity, long hours, etc. The authors examine the possible factors, both intrinsic and extrinsic, that may contribute to this lack of participation in these activities.

Critique of information:

These articles relate to my research paper because they thoroughly cover health promoting behaviors, especially sleep hygiene and stress management, that can give an inside view of ways to prevent these things and help implement good practices, thus decreasing nursing fatigue and promoting patient safety in the workplace.

Time spent:

I spent roughly 5 hours trying to find articles/research data that I could utilize to support my research paper.

Feelings:

I found the research experience to be very time consuming. Although there are many articles out there relating to nursing fatigue and the impact that it may have on patient safety, it was difficult for me to find credible sources that were within the time frame of 5 years. There are many sources out there, such as blogs written by nurses, that are very helpful for learning about this kind of information. However, those blogs are not credible sources so I could not use them for my research purposes.

Here is my Capstone Clinical Patient Scenario that I had created during my time in N483:

Capstone Clinical Assignment: Case Study

Darah M. Daskalakis

Adelphi University

NUR 483-225: Capstone

Professor Engel

May 2, 2022

Abstract

In this patient scenario, Robert Burch is a patient who has been diagnosed with heart failure upon his visit to the ER. Heart disease, the most common type being coronary artery disease, is the leading cause of death for men, women, and people of most ethnic and racial groups in the United States (Centers for Disease Control and Prevention, 2018). Although a very serious and potentially life-threatening condition to have, the use of proper treatment can improve signs and symptoms of heart failure and may help some people live longer. Some treatments, such as lifestyle changes, can improve the quality of life. Prevention of heart failure can occur by controlling conditions that can cause it, such as coronary artery disease, high blood pressure, and obesity (Mayo Clinic, 2021).

Key words: Coronary artery disease, Heart Failure, Treatment, Life-Style Changes, High Blood Pressure, Diabetes, Obesity.

Capstone Patient Scenario

Mr. Burch, a 74-year-old white male, presents to the Emergency Department following a visit to his primary care provider complaining of shortness of breath, ongoing four-day fatigue, and abdominal discomfort. Mr. Burch’s past medical history includes smoking cigarettes, coronary artery disease, and hypertension. Previously, Mr. Burch also had two stents placed: one in his left anterior descending artery (91% blockage) and one in his right coronary artery (52% blockage).

In the emergency department, the initial assessments preformed on Mr. Burch include having a full set of vitals taken, auscultating heart and lung sounds, assessing pulses, and assessing the condition of his skin. Additionally, the patient’s provider orders a chest X-ray, 12-lead EKG, cardiac enzymes, BNP, and an echocardiogram to be completed. Upon further assessment, the nurse finds that Mr. Burch has yellow, cloudy urine, bilateral crackles in the lungs and tachycardia. The ECG revealed atrial fibrillation and the chest x-ray revealed cardiomegaly and bilateral pulmonary edema. Mr. Burch’s vital signs and other pertinent data/lab values are as follows:

BP: 152/73 Height: 176cm (5’9”) BUN: 18 mg/dL

HR: 103-130bpm and irregular Weight : 80kg (176lb) Creatinine: 1.3 g/dL

RR: 24-34 LDH: 708 U/L LDH: 709 U/L

Temperature: 99.14° H/H: 11.9g/dL / 37.1% BNP: 842 pg/mL

Mr. Burch now has been admitted to the cardiac telemetry unit, where he then tells the nurse that his weight is approximately 3.5kg more than it had been 3 days ago. This is significant information that the nurse needs to consider, being that this means in just 3 days, Mr. Burch has gained 3 liters of fluid as volume excess. This most likely means that Mr. Burch has a new onset or exacerbation of heart failure (Melander, 2004). Based on this finding, it would be essential to anticipate that Mr. Burch will be prescribed diuretics and beta blockers by his provider. Relating Mr. Burch’s comment about gaining 3kg in the last 3 days and auscultating bilateral crackles in the lungs, this patient is experiencing fluid volume overload. Diuretics can help relieve fluid retention by promoting excretion of water from the kidneys, hence, fixing his issue of fluid volume overload. Because Mr. Burch’s blood pressure is high and he is tachycardic, the beta blocker can help slow down his heart rate and relieve some of the workload on his heart, thus decreasing his blood pressure as well (Melander, 2004).

After approximately 4 hours after admission to the telemetry unit, Mr. Burch’s skin becomes cool and clammy. His respirations are labored, and he complains of abdominal pain. Upon physical examination, it is found that Mr. Burch is diaphoretic, gasping for air, has jugular vein distention, expiratory wheeze, and bilateral crackles. His SpO2 is 87% on room air, his blood pressure is 192/102mmHg, his heart rate is 135bpm and irregular, respiratory rate is 43bpm, and it is noted that since admission he has only urinated approximately 25mL/hr. Because Mr. Burch’s heart cannot pump blood efficiently throughout his body, the blood is backing up into the lungs, causing pulmonary edema. This is the reason as to why he is struggling to breathe and why his oxygen levels are so low. In addition to this, his heart is working very hard to compensate for the decreased cardiac output, hence why his blood pressure and heart rate are so elevated. As far as his abdominal discomfort, this could be the result from his kidneys not being perfused, as his urine output is significantly decreased. Right away, Mr. Burch should be placed into high fowler’s position so that he can have optimal lung expansion. He should also be placed on oxygen and have any PRN medications for blood pressure, such as metoprolol or hydralazine given. The nurse should then notify the healthcare provider using SBAR communication.

Patients, like Mr. Burch, are admitted into healthcare facilities every day for heart failure. Factors such as being a smoker, having a poor diet, being overweight, and living a sedentary lifestyle can all lead to cardiovascular disease and heart failure. With proper treatment, the signs and symptoms of heart failure and may improve and help some people live longer. Taking prescribed medications and making lifestyle changes, such as losing weight, exercising, reducing salt (sodium) in your diet, and managing stress can improve a patient’s quality of life. In the case of Mr. Burch, he should be advised to quit smoking and should be educated on the health risks that come along with a history of smoking, such as the development of heart disease over years and how it can progressively worsen his pre-existing conditions. Since Mr. Burch is also slightly overweight and has a history of coronary artery disease, he should be educated on the importance of proper diet (low sodium, low fat, heart healthy) and regular exercise (Mayo Clinic, 2021).

References

Centers for Disease Control and Prevention. Underlying Cause of Death, 1999–2018. CDC WONDER Online Database. Atlanta, GA: Centers for Disease Control and Prevention; 2018. Accessed May 2, 2022.

Mayo Clinic. (2021, December 10). Heart failure. Mayo Clinic. Retrieved May 2, 2022, from https://www.mayoclinic.org/diseases-conditions/heart-failure/symptoms-causes/syc-20373142

Melander, S. D. (2004). Case studies in critical care nursing: A guide for application and Review (3rd ed.). Saunders.

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