1. Leap, Edwin MD, FACEP


How to use the evidence to influence change.


Article Content

Our fatigue doesn't require a study. But studies have been done.

Figure. Edwin Leap, ... - Click to enlarge in new windowFigure. Edwin Leap, MD, FACEP

The telephone held loosely against my ear, I dictated the following slurred words: "The patient is awake, alert, and sleeping quietly at discharge." Something shook inside me and I corrected myself: "awake, alert, and ambulatory."


After 14 years practicing emergency medicine, I have seen how fatigue changes more than dictations. I wonder how often my decisions have been affected by working night shift and alternating shifts&-going from days to evenings, evenings to days, nights to evenings, all in the span of a week. There were times when I was "awake, alert, and sleeping quietly" myself. Working nights allowed me extra time with my wife and four small children, which was a blessing. It also gave me extra money, thanks to a shift differential (a difference in pay based on the shift worked). However, it left me anxious and melancholy from inadequate sleep: not surprising, as depression has been found to be more common among shift workers. Health care workers' fatigue is a reality that doesn't require a double-blind study. But studies have been done.


It has been well documented that working alternating shifts can lead to desynchronosis, which means that one's internal circadian cues are disrupted, and that can affect one's judgment.


Long-term shift workers may have a higher mortality rate from coronary disease and diabetes than day workers, according to Karlsson and colleagues in a 2005 study in the Scandinavian Journal of Work, Environment and Health. According to several studies, physicians and nurses driving home from night shifts appear to have elevated rates of motor vehicle accidents.


Our patients suffer the effects of shift work as well. In research cited by the National Institutes of Occupational Safety and Health (done outside the health care field), the risk of errors increased dramatically on the 12th hour relative to the eighth, on the afternoon and night shift relative to the morning, and on each successive night worked. Daytime sleep is also less restorative than nighttime sleep.


Research aside, the fact remains that most health care workers try to leave night and rotating shifts as quickly as possible. Consequently, EDs and other units are often staffed in the late evening and night by entry-level nurses who haven't yet "earned" a better schedule.


Patients aren't going to stop needing care, so what else can be done besides a shift differential? Maybe we could base the length of the shift on how tiring it is, with 10-hour days, eight-hour evenings, and six-hour nights. It might help just to take some naps, according to a study published in the November 2006 issue of the Annals of Emergency Medicine. (Editor's note: For more on this study, see Editorial, page 11.) And the best way to put these and other solutions into action is to convince administrators that a problem exists, maybe by having them work a month or two of nights again.


There is no easy answer. But we need to come up with solutions. A 2003 Business Week article suggests that 24-hour operations cost U.S. industries $206 billion annually. The article also predicts increases in liability lawsuits related to worker fatigue, such as the New Jersey suit some years ago that found Consolidated Rail Corporation "liable for $52.4 million in damages [paid] to the family of an employee killed in an accident caused by another employee who said he was operating on only three to four hours of sleep." That information might be powerful enough to influence hospital administrators and policymakers.


Working these shifts often leaves us demoralized, bitter, and too fatigued to enjoy the normal social interactions and hobbies that give us the connections and sanity we need. We have to start paying attention to fatigue. Maybe then we'll be able to keep nurses and physicians in the same jobs, happy and healthy, for a very long time. And maybe we'll save some lives along the way&-like our own.