Improving nurse working conditions: towards safer models of hospital care.

O ver the past decade, an emerging body of literature established a link between nurses’ working conditions and their ability to provide safe care. Nurses who are not at their best are both prone to making errors themselves, and less able to serve as effective ‘‘safety nets’’ for their patients, intercepting errors made by physicians and others. Excessive nurse workloads predict an increased rate of adverse events, and, by their own reports, nurses working shifts of >12 hours are at greatly increased risk of making medical errors. On the basis of these and related findings, the Institute of Medicine has recommended: a) that efforts be made to assure appropriate nurse workloads and b) that nurses work no more than 12 hours per day and 60 hours per week; but these recommendations have not been broadly enforced. Two articles in the current issue of the Journal of Hospital Medicine add to our understanding of the relationship between nurse working conditions and safety, and substantiate the need to improve nurses’ working conditions. In the first, Surani et al. conducted a pilot study of 20 night nurses working 12-hour shifts in which well-validated, objective tools revealed that ICU nurses were suffering from pathologic levels of drowsiness on the job. The topic is of importance as recent survey work demonstrated that nurses working >12 hours and resident-physicians working shifts of 24 of more hours make significantly more medical errors and suffer many more occupational injuries than those working less exhausting schedules. Objective data on resident-physicians has corroborated these findings, but objective data measuring sleepiness in nurses has been lacking. Surani et al.’s study helps to fill this need. Further, this study suggests that hospitals should not be complacent about the safety of 12-hour shifts, which may still be associated with dangerous levels of drowsiness-induced impairment. Careful management of the number of consecutive night shifts, or further reductions in nursing work hours even beyond the 12-hour limit endorsed by the IOM may be in order—particularly in high-risk critical care environments—though further research substantiating Surani et al.’s findings and comparing alternative scheduling options would be valuable. The second study by Conway et al. analyzed data for acute care hospitals in California from 1993 to 2004, and found that