High Risk Fatigue Levels of

ICU Nurses
Presented by: Alyssa Benefield, Brigid Clark, Danika Acosta, Elizabeth Goetz,
Jamie Wientjes, Julia Suerth, Kristin Cabatingan, Sanisa Mendoza, & Shelby
Welsh
High fatigue levels in ICU nurses
- High fatigue levels are an issue in nursing because it:
- Impairs memory
- Decreases cognitive function
- Results in poor decision making
- Decreases psychomotor performance
- Increases the occurrence of errors
- Unsafe practice!
- Medical errors
- Increased infection rates
- Increased morbidity

(Ramadan & Al-Saleh, 2014)

Burke, C. (2019). ICU Nurse yawning [Photograph]. Retrieved from

https://www.nursingreview.com.au/2019/03/nurse-fatigue-and-its-effect-on-
patient-safety/
Fatigue Levels vs. Errors
- 19% of the sample were sleep
deprived
- 89.2% of the nurses received 5 hour or less
of sleep
- The means of medical errors in
fatigued ICU nurses were significantly
higher than the means of non-fatigued
ICU nurses
- The longer the duration of the nurses
shift, the more likely a medical error
will occur Figure 1. Table 3. Adapted from "The association of sleep deprivation on the occurrence of
errors by nurses who work the night shift." by Mohamed Ramadani & Khalid Al-Saleh,
2014, retrieved from Current health sciences journal, (20)2, 97-103.
(Ramadan & Al-Saleh, 2014) doi:10.12865/CHSJ.40.02.03
PICOT Question:

For night shift nurses in the ICU (P), how

does light therapy (I) affect fatigue level (O)
during a 12-hour shift (T) compared to
nurses that use Vitamin D supplementation
(C)?
 Summary of Current Practice - LED Lights
Arizona
- Tucson: TEP Energy Star Lighting Program
- Offer discounted LED lights to promote use
- Phoenix: LED street light Program
- Flagstaff: Street lights
Nationally
- The shift to LED light bulbs from incandescent light
bulbs has shifted dramatically nationwide.
- US Department of Energy Solid State Lighting
Portfolio
- Only one thus far has been initiated in a hospital
to improve sleep, health, alertness, performance
and quality of life in night shift workers
(U.S. Department of energy, 2018)
(LED Street Light Program, 2016) Vava. (2017). Why make the switch to LED? [poster]. Retrieved from
http://blog.vava.com/top-5-reasons-to-make-the-switch-to-an-all-led-
(LED Light Bulbs: the Benefits and Drawbacks, 2016) home/
 Summary of Current Practice: Vitamin D Supplementation
Current practice: People who live in either low sun Symptoms associated with vitamin D deficiency:
exposure or high sun exposure regions currently - Fatigue
take vitamin D supplements to help combat the - Depression
symptoms associated with vitamin D deficiency

However, it has NOT been implemented in hospitals Arizona:

- Tucson/Phoenix: longer summers, short
winters high sun exposure & vitamin D
deficiency
- Flagstaff: Traditional four seasons, high sun
exposure, less likely to have Vitamin D
deficiency
Nationally:
- Northern, midwestern, and eastern regions:
longer winters, shorter summers

Chow, Z. (2019). Sunlight exposure in the United States [poster]. Retrieved from (Schramm, Lahner, Jöckel, Erbel, Führer, Moebus & Heinz,
https://examine.com/nutrition/vitamin-d-and-depression/ 2017)
Synopsis of Current Literature

● Fatigue in nurses is a serious and ongoing problem

● Disrupted light exposure can have adverse health effects

● Vitamin D has a significant effect on fatigue levels

● Light therapy has beneficial effects on both cognitive and non-cognitive function

in patients and nurses

● How we came to our issue

 Strengths:
Randomised control trials
Accurate measurements of illuminance in LUX
levels
Peer reviewed journals
Abundance of supporting evidence on the use
and effects of LED and Vitamin D outside of
hospitals
Specific population of night shift nurses
Strengths &
Weaknesses:
○ Single center studies
■ Decreases generalizability for all ICU’s
Weaknesses
○ Lack of research and implementation involving

○
both practices
Studies didn’t correct for other variables
associated with fatigue
of Research
○ Majority are a level IV of evidence
■ The higher the levels help guide practice
decisions
■ We want more diversity in the levels of
research
 EBP Recommendations & Application
Recommendation: Implement LED lights in ICU units

● A brighter work environment allowed for more effective sleep + decreased fatigue
■ (Jensen et al., 2016)
○ LED lights > fluorescents

● Light exposure shifts circadian rhythms

○ (Stone et al., 2018)

● Easier to implement and enforce than Vitamin D

● LED lights with high LUX can increase production of Vitamin D in body
○ (Kalajian et al., 2017)
Cost-Analysis - LED Lighting
● Cost to implement
○ Approximately 70% reduction in lighting-related expenses
compared to fluorescent lighting
○ $5 per LED bulb vs $1 per fluorescent bulb
○ Depends on how many bulbs per hospital- how big the hospital is
and how many patients utilizing rooms/units in use
● How much has it cost other hospitals to implement
○ No exact values, $5 per LED bulb (estimate) and square
footage/numbers of bulbs factors in
● Background on Cost of Lighting in Hospitals Currently
○ Hospitals in the U.S. spend, $1.67 on electricity per square
foot (average) - 15% of budget
○ In an average-size hospital building (75,000 square feet):
$18,000 for just lighting
○ For a large hospital building (650,000 square feet):
$160,000 for lighting (Energy Focus Inc, 2016)
Cost-Analysis - LED Lighting (Continued)
● Pros of LED lights
○ Total cost - (energy, maintenance, replacement costs) is far less than fluorescents,
○ Can last up to 10 years at 24/7 operation- reducing replacement costs
○ Reduced toxic-waste (greenhouse gases)
○ LED lights function much cooler
● Cons of LED lights
○ Higher initial cost - LEDs are currently more expensive, price per lumen, on an initial capital cost basis
than fluorescents
● Why this would be important to implement despite cost
○ Despite a higher initial cost, ends up reducing hospital bill because of decreased energy usage, decrease in
maintenance needs, and decrease amount of replacements (lasts longer at 24/7 operation)
○ Important for nurses to maintain awareness and agility in a 12-hour shift for the safety of all patients and
themselves

(National Institutes of
Health, 2014)
Cost-Analysis - Vitamin D

● Cost to Implement (to facility or nurse)

○ 17 cents per pill roughly (max)
○ 3 month duration (90 day supply and one tablet
per day)
○ $61.20 annually per nurse (max)

● How much has it cost other hospitals to implement

○ No research could be found on if this study has
been implemented by a hospital before

(Masoudi et al., 2015)

Cost-Analysis - Vitamin D (Continued)
● Why this would be important to implement despite
cost
■ Prevents med errors, improper
documentation, improved concentration,
able to catch change of conditions
■ Fatigue connected with 3x the risk of
making med error in nurses
■ Safer for nurses who commute- less risk
of falling asleep on drive in or out
■ Fatigue can cause depression, irritability,
weight gain, reduced motivation in nurses
LED lights more effective to cost and less
(Masoudi et al., 2015) responsibility for the nurse compared to
vitamin D
Risks vs. Benefits - The Institution
RISKS
● Lighting: Extra cost to the institution -
specialized lighting can cost more to
implement (Perdahci, 2018)
○ Paying workers and specialists
○ Possible delays in care from
construction - therapeutic
environment halted
● Vitamin D: Extra cost to the institution
~$61 per nurse (Masoudi et al., 2015)
○ Staff refusal or adherence
○ Cannot be forced - staff must be
willing
BENEFITS
● Lighting:
○ Decreased cost long-term - energy savings
○ Better rankings and patient satisfaction
from improved care and decreased fatigue
in nurses (Ramadan & Al-Saleh, 2014)
○ Less lawsuits from error
● Vitamin D:
○ Similar benefits to those discussed above
with lighting -better rankings, patient
satisfaction, and less fatigue (Ramadan &
Al-Saleh, 2014)
○ Promotes integrative therapy and
functional medicine
Risks vs. Benefits - Nursing
RISKS BENEFITS

● Lighting: ● Both lighting & vitamin D:

○ Risks are r/t interruption of patient sleep with ○ Decreased fatigue amongst nurses - this means:
prolonged light exposure ■ Better patient care
■ Disruption in the nurse-patient ■ Reduced medication errors
relationship ■ Improvement of patient satisfaction
○ Disrupted circadian-rhythm for nurse (Jensen, ■ Increased productivity
2016) ■ More fulfillment and job satisfaction
○ Mortality and delirium rates in the ICU
decrease as light lux decreased (>2000 lux) (Ramadan & Al-Saleh, 2014)
■ Accusations against nurses (Ramadan &
Al-Saleh, 2014)
● Vitamin D: ● Vitamin D:
○ Vitamin D toxicity (rare - ~1%) ○ Overall better health and better calcium
○ Interactions with other medications the nurses
absorption
are taking
○ Cannot force the nurse to start taking vitamin
D3 - will be hard to track effectiveness
Risks vs. Benefits - The Patient
RISKS:
● Lighting:
○ Higher incidence of patient mortality
and delirium (Simons et al., 2016)
○ Disruption of sleep
○ Excessive stimulation + ICU noises
and non-clustered care (61% of ICU
patients have disrupted sleep cycles)
■ Inability to heal properly,
distress, delirium (Durrington,
2017)
● Vitamin D:
○ No effectiveness/change if nurse
decides not to participate
BENEFITS:
● Lighting:
○ More productive nursing staff! Alert and awake
nurses can provide their best care without the
presence of fatigue
○ Risk of nursing-related injuries to the patient
(such as medication errors) are reduced when
fatigue is reduced (Ramadan & Al-Saleh,
2014
● Vitamin D:
○ Similar to lighting benefits - if nurses are
adherent to taking vitamin D it will decrease
fatigue levels
 Evaluation
Outcomes:

The night shift nurses will show decreased reaction speed times on the PVT by
February 10th.

The night shift nurses will verbalize and state decreased fatigue after the
implementation of LED lights by February 10th.
 Summary
Introduction
jaa Application to
Facility

Cost
Description of Light
Issue Therapy vs.
Vitamin D

Best Practice
Risk vs. Benefit
 References
Burke, C. (2019). ICU Nurse Yawning [Photograph]. Retrieved from https://www.nursingreview.com.au/2019/03/nurse-

fatigue-and-its-effect-on-patient-safety/

Chow, Z. (2019). Sunlight exposure in the United States [poster]. Retrieved from https://examine.com/nutrition/vitamin-d-

and-depression/

City of Phoenix. (2016). LED Street Light Program. Retrieved from https://www.phoenix.gov/led

Durrington, H. (2017). Light intensity on intensive care units - a short review. Journal of intensive and critical care 3(2),

105. doi: 10.21767/2471-8505.1000082

Energy Focus Inc. (2016). Energy focus sets the new standard in healthcare lighting. Retrieved from

https://www.energyfocus.com/wp-content/uploads/2018/03/HealthcareBrochure_031618.pdf.
 References (Continued)

Jensen, H. I., Markvart, J., Holst, R., Thomsen, T. D., Larsen, J. W., Eg, D. M., & Nielsen. L. S. (2016). Shiftwork and

quality of sleep: effect of working in designed dynamic light. Internal archives of occupational and environmental health,

89(1), 49-61. doi: 10.1007/s00420-015-1051-0

Energy Focus Inc. (2016). Energy focus sets the new standard in healthcare lighting. Retrieved from

https://www.energyfocus.com/wp-content/uploads/2018/03/HealthcareBrochure_031618.pdf.

Jensen, H. I., Markvart, J., Holst, R., Thomsen, T. D., Larsen, J. W., Eg, D. M., & Nielsen. L. S. (2016). Shiftwork and

quality of sleep: effect of working in designed dynamic light. Internal archives of occupational and environmental health,

89(1), 49-61. doi: 10.1007/s00420-015-1051-0

 References (Continued)
Kalajian, T. A., Aldoukhi, A., Veronikis, A. J., Persons, K.,, Holick, M.F. Ultraviolet B light emitting diodes (LEDs) are more

efficient and effective in producing vitamin D3 in human skin compared to natural sunlight. Scientific Reports, 7(1). doi:

10.1038/s41598-017-11362-2

Masoudi Alavi, N., Madani, M., Sadat, Z., Haddad Kashani, H., & Reza Sharif, M. (2015). Fatigue and vitamin d status in

iranian female nurses. Global journal of health science, 8(6), 196–202. doi:10.5539/gjhs.v8n6p196

National Institutes of Health. (2014). LED lighting in Healthcare Facilities. Division of Technical Resources. Retrieved from

https://www.orf.od.nih.gov/TechnicalResources/Documents/Technical

Bulletins/LEDlightinginHealthcareFacilitiesMay2013TechnicalBulletin.pdf
 References (Continued)
Ramadan, M., & Al-Saleh, K. (2014). The association of sleep deprivation on the occurrence of errors by nurses who work the

night shift. Current health sciences journal, (20)2, 97-103. doi:10.12865/CHSJ.40.02.03

Simons, K., Laheij R., Van den Boogaard, M., Moviat, M., Paling, A., Polderman, F., Rozendaal, F., Salet, G., Van der

Hoeven, J., Prof, P., & Jager, C. (2016) Dynamic light application therapy to reduce the incidence and duration of

delirium in intensive-care patients: a randomised controlled trial. Lancet respiratory medicine 4(3), 194-202. doi:

10.1016/S2213-2600(16)00025

Schramm, S., Lahner, H., Jöckel, K. H., Erbel, R., Führer, D., Moebus, S., & Heinz Nixdorf. (2017). Impact of season and

different vitamin D thresholds on prevalence of vitamin D deficiency in epidemiological cohorts—a note of caution.

Endocrine, 56(3), 658-666.

 References (Continued)
Tucson Electric Company. (2016). LED Light Bulbs: the Benefits and Drawbacks. Retrieved from

https://www.tep.com/news/led

U.S. Department of Energy, Office of Energy Efficiency & Renewable Energy. (2018). 2018 Solid-State Lighting Project

Portfolio. (No. 1732). Retrieved from http://energy.gov/eere/ssl/solid-state-lighting.

Vava. (2017). Why make the switch to LED? [poster]. Retrieved from http://blog.vava.com/top-5-reasons-to-make-the-

switch-to-an-all-led-home/

Stone, J. E., Sletten, T. L., Magee, M., Ganesan, S., Mulhall, M. D., Collins, A., … Rajaratnam, S. (2018). Temporal dynamics

of circadian phase shifting response to consecutive night shifts in healthcare workers: role of light-dark exposure. The

Journal of physiology, 596(12), 2381–2395. doi:10.1113/JP275589