More evidence: Exhaustion of risk of error: Critical care nurses

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Critical care nurses (CCNs) across the country reported high levels of stress, depression, and anxiety even before the onset of the COVID-19 pandemic, and these factors correlated with an increase in self-reported medical errors, a cross-sectional study of American NCCs found.

The study based on national surveys, conducted by the Ohio State University College of Nursing in Columbus, was published online May 1 at American Journal of Critical Care.

The survey, conducted between August 2018 and August 2019, reveals that 39.8% of NCCs reported depressive symptoms and 53.2% reported symptoms of anxiety. In addition, 61% of CCNs surveyed rated their physical health at 5 or less on a scale of 1 to 10 and 51% rated their mental health at 5 or less. Only 39.8% reported experiencing a high quality of professional life.


Bernadette J. Mazurek Melnyk, Ph.D.

Bernadette J. Mazurek Melnyk, PhD, APRN-CN, director of welfare at Ohio State University and dean of the College of Nursing, led the study of members of the American Association of Critical-Care Nurses. Among the 771 respondents, 92% were women and the average age was 39.9 years, with 57.8% in the age range of 25 to 44 years. Ethnically, the cohort was 83.4% non-Hispanic whites and 91.4% reported working more than 8 hours a day. The days worked lasted 12 hours or more for 68.2%, and an additional 22.3% worked from 9 to 12 hours.

“They are exhausted after three weekly 12-hour shifts and some even go out to work at other centers as well,” Melnyk said. Medscape Medical News. “This interferes with concentration and judgment.”

“These are hours of work that are not allowed in the aviation industry or the railroad industry,” added Nancy Blake, PhD, RN, FAANP, head of nursing at Harbor-UCLA Medical Center in Torrance, California. “And when there is a shortage of nursing staff, someone will get a call the next day after a shift.”

In the current study, the physical and mental well-being of nurses was assessed using validated instruments, including the Generalized anxiety disorder Questionnaire-2, patient health questionnaire-2, professional quality of life scale, and perceived stress scale-4.

According to Melnyk, her nurses often report physical health problems such as musculoskeletal disability resulting from lifting and changing patients, as well as high blood pressure and cholesterol, poor nutrition and alcoholism, unconditioning for lack of recreational exercise and sleep disorder. “We believe that, as nurses, they should meet nutritional and activity guidelines, but they are not,” she said.

On a positive note, nurses who perceived their job as very favorable to their well-being (score of 6 or higher out of 10) were twice as likely to have better physical health (probability of establishing). [OR], 2.16; 95% CI, 1.33 – 3.52). The observed relationship between increased perceived support for staff well-being and better health was maintained after adjusting for age, sex, race / ethnicity, marital status, education, and hours of work per day or shift of the nurse. .

Unwanted error recipe

Overall, 61% of respondents admitted to having made medical mistakes in the last 5 years. Nurses with poor physical and mental health reported having made significantly more errors than those in better health, with ORs of 1.31 (95% CI, 0.96 – 1.78) for physical health and of 1.62 (95% CI, 1.17 – 2.29) for depression.

This resulted in errors for 67% of nurses with higher stress scores compared to 56.5% of people who reported no or little stress. “These errors may include errors in dosing or in dosing scheduling and erroneous steps when procedures are performed,” Melnyk said. Blake added: “Under stress, nurses can even mix patients.”

The findings of the study confirm those of one previous national study of the general nursing population by the Melnyk group, which showed that nurses in poorer health were 26% to 71% more likely to make medical mistakes. Here, too, there was a significant relationship between greater perceived well-being in the workplace and better health. And among doctors, this similar depletion has been linked to double the rate of medical errors.

The pandemic effect

Although the survey conducted by Melnyk and colleagues was conducted before the COVID-19 pandemic, depletion has only worsened since then. According to UCLA’s Blake, the pandemic peak increased the workloads of already stressed CCNs by requiring higher patient-nurse relationships.

“I think it’s fair to say that some nurses are reaching their breaking point. The worst thing has been caring for dying patients whose families can’t visit them and being the nurse in the room watching family members cry in the living room. ‘the other end of the iPad can’t say goodbye to their loved ones,’ ”he said.

With the goal of resolving this situation, the Blake center recently implemented a program called Helping Healers Heal, in which someone checks nurses and participates in one-on-one debrief sessions and discussions. “We also have a psychologist who usually treats medical residents, but has developed some programs for the well-being of nurses,” she said.

Despite these measures, the center has experienced a small rise in nurse turnover, which is expected to increase with the imminent retirement of the baby boomer cohort. “But the turnover has been much higher in hospitals across the country. Some nurses say they can’t go back to the hospital, they’ll try to get a job at a pharmaceutical company, or they’re leaving nursing altogether. We anticipate a future shortage of nurses. Blake said.

For Jessica Curtisi, RN, PCCN, who works in the intensive care unit at Wexner Medical Center, similar support has allowed her to manage the intense emotions evoked by her work. “At the lowest point last year, leaving the profession briefly crossed my mind. What keeps me here is my sense of duty. If I don’t stay and care for these patients, who will?” she said.

Continuing has been easier by enlisting the help of employees with counseling, awareness training and even pet therapy. “The advice has allowed it [me] “Ventilate my emotions without fear to someone who really wants to listen,” Curtisi said. “It helped me understand my own natural mechanism of adjustment, which was to bottle my emotions. Mindfulness training helped me feel the intense emotions of my work without burning me and preventing me from follow the day to day “.

Call to action

The study’s researchers warn:[H]Hospital and health care leaders must prioritize the health of their nurses by solving system problems, building wellness cultures, and providing evidence-based wellness support and programming, which will ultimately increase the quality of patient care and reduce incidence of preventable medical errors. “

Melnyk herself said it more clearly. “We need to correct these things and do more than we are doing about the conditions that contribute to exhaustion and depression. The health of our doctors has a big impact on health quality, safety, staff turnover and cost. “.

The authors have not disclosed any relevant financial relationship.

I am J Crit Care. 2021; 30: 176-84. Summary

Diana Swift is a Toronto-based medical journalist. You can contact her at [email protected].

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