Fatigue and Alarm Fatigue in Critical Care Nurses

Purpose:  The purpose of the descriptive, correlational research study of fatigue and alarm fatigue in critical care nurses was to understanding the levels of fatigue and which demographic characteristics were assocoated with higher levels of fatigue.  The sources of loading, of the task of responding to cardiac monitoring alarms was subjectively assessed to evaluate the nurse’s perception of the dimensions of workload.  Additionally, critical care nurse’s concern surrounding cardiac monitoring alarms and a culture of safety were investigated.

Methods:   A non-probability convenience sample of critical care nurses was obtained at the national critical care conference over a three day period in May 2014.  Inclusion criteria:  registered nurses currently engaged in full time work (>36hr/week), provider of direct patient care, employed in inpatient critical care unit which provides cardiac monitoring.  Exclusion criteria:  advanced practice nurses, managers, supervisors, part time employment, non-critical care unit or do not have cardiac monitors.

The sample of 195 nurses completed the demographic tool, two study instruments and the survey tool.  Occupational Fatigue Exhaustion Recovery Scale (OFER) was used to assess chronic fatigue, acute fatigue and intershift recovery.  This 15-item scale distinguishes between the three fatigue levels. The National Aeronautics and Space Administration-Task Load Index (NASA-TLX), was used to evaluate subjective workload of responding to cardiac monitoring alarms.  NASA-TLX evaluates the task on the following dimensions:  mental demands, physical demands, temporal demands, own performance, effort, and frustration.  The Healthcare Technology Foundation (HTF) survey was utilized to examined issues surrounding clinical alarms and priorities for future actions related to alarms. 

Results: An exploratory, univarate analysis was done to assess associations of 26 demographic and work environment variables between chronic, acute, intershift fatigue and total workload of responding to cardiac alarms.  Significant sample characteristics were: 167 (85.6%) female, mean age 42.6 years (SD ± 11.5, range 24-65), length of time as a registered nurse 15.9 yrs. (SD ± 10.9, range 1-43), length of time in critical care 13.2 yrs. (SD ± 9.7, range 1-42), education and:  BSN 112 (57.4%), Associate Degree 42 (21.5%), Master’s Degree, 40 (20.5%), and Doctoral Degree 1 (.5%). Area of practice:  Intensive care 176 (90.3%), telemetry 19 (9.7%).  Teaching or non-teaching hospital, 150 (77%), Community Hospital, 43 (22%), Not for Profit, 146 (75%), For Profit 37 (19%), Units with monitor watchers or telemetry technicians, 104 (53%), areas with secondary alarm systems, 65 (33%).  Living situation:  married/living with partner, 117 (60%), single, 54 (28%), living with others have the following breakdown by age group:  0-5 years, 28 (14%), 6-12 years, 40 (21%), 13-18 years, 38 (19%), 19-24 years, 33 (17%), 25-60 years, 135 (69%), 61 or older, 30 (15%).  Numbers of people in household that need looking after by the nurse:  0 people in house hold, 108 (35%), 1 person, 34 (17%), 2 people, 35 (18%), 3 or more people, 35 (10%). Shift:  dayshift no rotation, 110 (56%), night shift no rotation, 59 (30%), dayshift with rotation, 16 (8%), night shift with rotation, 7 (4%).  Hours worked/week, 39.2 (SD ± 6.8, range 24-72), paid overtime, 7.4 (SD ± 3, range 0-76), non-paid overtime, 3.1 (SD ± 9, range 0-75), second job, 45 (23%), average number of successive shifts 3.1 (SD ± 1.9, range 0-14), maximum number of shifts of worked between days off, 4.1 (SD ± 2.8, range 0-25), number of days off in succession 2.8 (SD± 1.8, range 0-18)  Reasons for working shifts:  part of the job, 102 (52%), higher rate of pay, 44 (23%), convenient for domestic responsibilities, 43 (22%).

Main advantages of a shift system, groups were not mutually exclusive,  more flexibility, 90 (25%), more time with family/friends, 40 (11%), more time to sleep, 39 (11%), no rotation, 8 (10%), better pay, 36 (10%), less commuting, 28 (8%), second job/more overtime, 26 (7%), school, 21 (6%), continuity of care, 12 (3%), autonomy, 11(3%), job satisfaction, 10 (3%).  Main disadvantages, long hours/not enough recovery time 68 (21%), lack of family time/missed events, 60 (18%), alteration in sleep pattern, 56 (17%), abnormal eating patterns, 36 (11%), exhaustion/fatigue, 35 (11%), lack of a social life, 24 (7%), too much rotation, 24 (7%), stressful 14 (4%).

The mean chronic fatigue levels, (N=195) was, 49.35 (SD ± 24.83), mean acute fatigue levels, was, 63.86 (SD ± 20.06), the mean intershift recovery levels, was, 50.68 (SD ± 19.55) and overall fatigue level 54.63 (± 10.78).  Fatigue scoring:  Low: 0-25, Low/Moderate: 26-50, Moderate/High: 51-75, High: 76-100.

The interrelationships among chronic fatigue, acute fatigue, and intershift recovery: chronic fatigue and acute fatigue positive moderate correlation (r_p  = 0.55, p < .0001), nurses with higher chronic fatigue have higher rates of acute fatigue, chronic fatigue and intershift recovery have a negative moderate correlation (r_p  = -0.52,  p  < .0001), those with higher chronic fatigue have lower intershift recovery, and acute fatigue and intershift recovery have a negative moderate correlation (r_p = -0.50, p  < .0001), those with higher acute fatigue have lower intershift recovery.  Levels of chronic fatigue, acute fatigue and intershift recovery were statistically significant (p  <  .0001). 

The workload of responding to cardiac monitoring alarms on the NASA-TLX multidimensional scale:  mental workload mean 11.30 (SD ± 5.25, range 1-20), physical workload 8.81 (SD ± 5.98, range 0-20), temporal workload 13.89 (SD ± 4.35, range 1-20), performance workload  7.64 (SD ± 4.87, range 0-20), effort workload 11.85 (SD ± 4.90, range 1-20), frustration workload 12.55 (SD ± 5.25, range 1-20) and total workload  66.03 (SD ± 20.29, range 6-114).  To date the workload of responding to cardiac monitoring alarms has not been evaluated.

Issues of importance to monitoring alarms: alarm sounds should be distinct, nuisance alarms, confusion among alarms and sounds, missed alarms, background noise interference, difficulty setting, hearing, and prioritizing alarms.

Significant univarate associations were found with the study variables and the following:  a weak positive correlation was found between age and chronic fatigue (r_p= 0.143) and is statistically significant (p = 0.047), the mean intershift fatigue in those with an associate degree was significantly lower than the mean of those with a bachelor’s degree or higher, (45.3968 ± 20.90049 vs. 52.1351 ± 18.97834, p = .048), the mean acute fatigue level of nurses working in telemetry units as compared to all other units was  higher, (62.8977 ± 20.12657 vs. 72.8070  ± 17.50708, p = .030), mean chronic fatigue levels in single nurses was significantly lower than the mean of those married (43.3951 ± 26.10646 vs. 51.6312 ± 24.02253, p = .047) and mean acute fatigue levels in single nurses was significantly lower than the mean of those married (56.9753 ± 21.39053 vs. 66.5012 ± 18.95411, p = .005), there was significantly higher chronic fatigue in nurses who lived with at least one person, age 19-24 years versus none, (61.62 ± 23.62 vs. 46.85 ± 24.39, p = .0017) and nurses who lived with at least one person age 25-60 years versus none (51.68 ± 24.88 vs. 44.11 ± 24.09, p = .049), there was significantly lower acute fatigue in nurses who lived with at least one person over 60 years compared to none (59.68 ± 18.22 vs. 64.76 ± 20.3, p = .018), there was a significant higher intershift fatigue in nurses who had people ages 6-12 years (50.77 ± 20.78 vs. 50.32 ± 13.88, p = 0.043), there was a weak positive correlations between the number of people living in the household in chronic fatigue (r_p = 0.171, p = .017) and acute fatigue (r_p = 0.161, p = 0.025), there was a difference in nurses who worked the day shift and increase in chronic fatigue (53.1624 ± 24.83218 vs. 43.7778 ± 23.62961, p =.009), nurses who worked over 40 hours/week had higher chronic fatigue (47.7711 ± 23.74213 vs. 58.3908 ± 29.13598, p = .003), working non-flex shifts had a higher chronic fatigue (47.2878 ± 23.66492 vs. 59.1176 ± 28.08487, p = .027), there was a difference between working non-flex shifts and acute fatigue (62.3602 ± 20.17162 vs. 70.9804 ± 18.17479, p = .017), there was a difference between these groups in intershift fatigue (52.0290 ± 18.94500 vs. 44.3137 ± 21.35998, p = .036), those nurses working four or more successive shifts had a higher level of intershift fatigue, (47.9012 ± 19.91463 vs. 54.1379 ± 18.62846, p = .026), nurses working a maximum of four or more successive shifts before having a day off had higher chronic fatigue (45.1282 ± 23.75642 vs. 57.7949 ± 24.93935, p = .001) and total workload of responding to cardiac alarms, (63.5000 ± 20.45992 vs. 71.1077 ± 19.12878, p= .013).

Conclusion: Critical care nurses experience high rates of fatigue, find the task of responding to cardiac monitoring alarms most temporal demanding and most frustrating, and have many concerns rated as very important to alarm issues.  The findings from this study provide valuable information on quantifying fatigue levels, assessing subjective workload and identifying issues of concern related to monitoring alarms. The findings reinforced the importance of understanding more fully the perceptions of how fatigue impacts nursing and the potential outcomes of nurse fatigue on patient safety and what concerns nurse have about alarms that could be important to industry when designing new monitoring devices.