Managing Fatigue: a

new ACORN guideline

Presenter: Sue Ireland

2nd August 2014

Is This A Sign?

Warnings?

The Scale of the Problem

If fatigue can crash a car, run
aground an oil tanker, melt down a
nuclear power plant and blow up a
space shuttle...
...imagine what it is doing to our
patients.

The Scale of the Problem

In Australia, landmark Quality in
Australian Healthcare Study (1995)
found that
16% of hospitalised patients suffered an
adverse event
50% were preventable
10% of these resulted in death or permanent
disability13

Overview

Fatigue: a definition
Process of ACORN review
Guideline statements
ACORN recommendation
Where to from here

The Definition:
Fatigue is the state of tiredness
that is associated with long hours of
work, prolonged periods without
sleep, or requirements to work at
times that are out of synch with
the bodys biological or circadian
rhythm 1

The Research:
Dawson and Reid2:
17 hours of wakefulness equates to a
performance equivalent of a blood
alcohol reading of 0.05g/dL

Rogers et al3:
Longer than 12.5 hours of work
increases the probability of error by
200-300%
Other research: low level

Other Seminal Documents:

To Err is Human (1999)4

Crossing the Quality Chasm(2001)5
Workplace Health & Safety Act(2011)6
AORN Standards (2013)7
Canadian Nurses Association &
Registered Nurses' Association of
Ontario Nurse Fatigue & Patient
Safety: research report(2010)8

Who Else is Doing This?

Entire Transport Industry
Trucks, trains, planes, ships & automobiles

The Military
Aerospace Industry
Mining & Energy
Nuclear Industry

Who Else is Doing This?

Existing Guidelines:
Safework Australia (2013)9
ANMF(2010)10
AMA (2008)11
Emergency Services SA (2012)12
RACS (2007)13
ANZCA(2007)14

Process of ACORN Review

Our team
Searching for the evidence
Guideline statements
The healthcare organisation
The unit
The individual nurse

Key Recommendations
The Healthcare Organisation:
Guideline Statement 1
Health care facilities shall promote a
culture of safety by having written
policies, procedures and guidelines
relating to fatigue management for the
delivery of safe and effective nursing
care.

Rationale
Promote change in cultural
attitudes
The organisation has safety
obligations

What can be done?

Rostering
Budgets
Reviewing overtime/ call backs
Education on fatigue
Sleep facilities and alternate
transport arrangements
Guidelines for hospital
coordinators

Key Recommendations
The Unit:
Guidance Statement 2
To enable clinicians to function safely
and efficiently within their work roles, the
manager at the unit level should
recognise the potential of fatigue when
considering staffing allocations, rostering
and work load utilisation.

Rationale
Nurse leaders at a unit level are responsible
for the effective management for the
perioperative nursing team and their work
environment.
They are responsible for ensuring that
clinicians perform competently, safely and
free from fatigue thereby providing a safe
work culture and encompassing staff and
patient wellbeing

What can be done?

Rosters
Breaks
Skill mix
Allocation
Education
Foster culture change

Key Recommendations
The Individual Nurse:
Guidance Statement 3
The perioperative nurse shall be aware
of the patient and individual safety risks
in relation to fatigue

Rationale
Perioperative nurses in all roles
have a professional
responsibility to manage their
own fatigue to provide safe
patient care.

What can be done?

Arrive at work in a fit state
Communicate
Recognise signs and symptoms
of fatigue in self and others
Collaborative rostering
Support cultural change
Complete training

ACORN Recommendation
Develop a fatigue management
program including:
Identification: fatigue risks
Management: risk assessment
Prevention: controlling the risks
within the perioperative setting.

Where to From Here?

Meeting requirements of:
ACORN Standards
Environment management
Positioning patient for surgery
Risk management
Staffing requirements
Budget preparation and monitoring
Planning and design of the perioperative environment
Emotional support for personnel
Surgical safety
Safe patient and manual handling

Where to From Here?

Meeting requirements of:

National Standards
Accreditation Standards
Work Health and Safety Act 2011
State and Territory Regulations

Where to From Here?

Development / modification of
existing tools for:
Monitoring and audit
Fatigue prevention

The Review Team

Sue Ireland (Team leader)

Tracey Nicholls
Scott Mitchell
Peter Smith
Rachel Short

Thank you to Dr Sonya Osborne, Dr

Zaneta Smith, Joy Jensen and the
ACORN Board

Fatigue is
Everyones
responsibility

visit our new

website

www.acorn.org.au
TO ORDER YOUR COPY
OF THE
ACORN STANDARDS

References
. Caldwell and Caldwell, 2003, p.15 as cited in World Health Organization (WHO). Human Factors in Patient Safety: Review of
topics and tools, 2009. Available from
http://www.who.int/patientsafety/research/methods_measures/human_factors/human_factors_review.pdf?ua=1
Accessed Feb 18, 2014. [A]
2..Dawson, D., K. Reid, Fatigue, alcohol and performance impairment. Nature, 1997. 388(6639): 235-237. [D]
3. Rogers, A.E. et al, The working hours of hospital staff nurses and patient safety. Health Affairs 2004, 23 (4): 202-212. doi
10.1377/hlthaff.23.4.202. [D]
4. Kohn, L, Corrigan, J., M Donaldson. To Err Is Human: Building a Safer Health System. 1999. INSTITUTE OF MEDICINE,
NATIONAL ACADEMY PRESS Washington, D.C.
5. Institute of Medicine, CROSSING THE QUALITY CHASM: A New Health System for the 21st Century 2001 INSTITUTE OF
MEDICINE, NATIONAL ACADEMY PRESS Washington, D.C.
6. Australian Government. Work, Health and Safety Act 2011, No. 137, 2011. Available from
www.comlaw.gov.au/Details/C2011A00137. Accessed Feb 18, 2014
7. Association of periOperative Registered Nurses, 2013 Perioperative Standards and Recommended Practices, in AORN
Guidance Statement: Safe On-Call Practices in Perioperative Practice Settings 2013. 549-552. [O]
8. Canadian Nurses Association and Registered Nurses' Association of Ontario Nurse fatigue and patient safety: research
report. 2010. Available from www.cna-aiic.ca Accessed Feb 18, 2014. [D]
9. Safe Work Australia, Guide for Managing the Risk of Fatigue at Work, S.W. Australia, Editor 2013: Canberra. Available from
http://www.safeworkaustralia.gov.au/sites/swa/about/publications/pages/guide-fatigue-at-work Accessed Feb 18, 2014.
[O]
10. Australian Nursing Federation Fatigue Prevention Policy. 2013. Available from
http://anmf.org.au/documents/policies/P_Fatigue_prevention.pdf [O]
11. Managing the Risks of Fatigue in General Practice - For GPs and GP Registrars. 2008. Available from
https://ama.com.au/managing-risks-fatigue-general-practice-gps-and-gp-registrars
12. Emergency Services Guideline for Risk Managing Fatigue. 2012.) Available from
http://www.safecom.sa.gov.au/site/home.jsp
13. RACS . 2007 Standards For Safe Working Hours And Conditions For Fellows, Surgical Trainees And
International Medical Graduates. Available from www.surgeons.org/publications
14. ANZCA. 2007. Statement On Fatigue And The Anaesthetist. Available from www.anzca.edu.au.