Challenging Current Boundaries & Perceptions of Emergency Care - Essay Example

Challenging Current Boundaries & Perceptions of Emergency Care. The intention of this assignment is to critique an article that has been identified and to analyse its potential or actual impact on the emergency care system. The assignment will encompass recommendations for future and existing practice relating to emergency care setting. The emergency care setting hosts a variety of issues that could be explored and investigated. However, one of the most fundamental elements for an effective functioning department is a contented work force/team. Therefore the area that has been identified for critiquing and suggesting recommendations for change is the shift work/pattern of nursing staff. This subject is an ongoing predicament for any department or ward environment. The necessity for work schedules is frequently a source of frustration for nurses (Capuano, Fox & Green, 1992 cited in Marquis & Huston, 1998) A literature search was performed, to find a suitable article; using keywords such as shift pattern, internal rotation, 12 hour shifts and night/day work. The database used in the search included Science Direct, CINAHL, British Nursing Index and Wiley InterScience/Blackwell Synergy. The NHS National Library for Health and online journals for nursing were also investigated. Finally the article chosen for critiquing was “Strategies for Coping with Shift Work” by Ian Peate, published in Nursing Standard Volume 22 No: 4, May 25th 2007 (See appendix 1). While searching for similar articles related to the chosen topic it was found that there was very limited academic literature on shift work. However, sufficient information was available from other organization and professional sources such as the New Zealand government site, European Working Time Directive and Unison. Credibility & authenticity is attributed to the author Ian Peate EN (g), RGN, DipN (Lond), RNT, Bed (Hons), MA (Lond) & LLM. The author has many publications to his credit and his major teaching and publishing activities focuses on nursing care with special interest in HIV/AIDS, Sexual Health & Men’s Health. About 138 works of the author (both journals & books) have been published widely both nationally and internationally, and thus is available to a variety of audiences. Ian Peate is also a Fellow of the Royal Institute of Public Health, a member of the British Association of Sexual Health & HIV, the Gentio-urinary Nurse Association and a member of the Editorial board of the British Journal of Nursing, British Journal of Health Care Assistants & Continence UK. He is currently the Associate Head of the School of Nursing & Midwifery at the University of Hertfordshire. Thus this is a sufficient enough proof for the acceptable credibility of the author. This article lays emphasizes on the implications that shift work, particularly night work, has on nursing and the well being of individuals as well as patient care. It gives practical advice about how to cope with night shifts and also gives suggestions on the ways of improving health and well being. All of these could be examined and proven as to how it could be implemented in an emergency care setting. However, they do not detail the ways to cope with the turnaround from nights to days, the legal requirements in relation to the above, the health and safety issues associated with shift work (Basent, 2005; Drake et al, 2004 cited in Admi, 2008) and with nurse’s health. In addition patients safety has been poorly explored (Muecke, 2005 cited in Admi 2008). They have also failed to investigate the effectiveness of set shift patterns whether they are permanent night staff or set pattern of rotation. There are several other articles written on this subject with the majority of them following the same set out but however they have become outdated. This article has the nurse profession, regardless of their grade and experience, as its target audience. As stated previously the article highlights the implications that shift work, particularly night work, has on nursing and the well being of individuals. The article initially provides an understanding of sleep and the effects of sleep deprivation on performance, health implication & safety and then provides practical advice for night shift preparation. While the article title could mislead one to believe that it deals with both night and day shifts, the article, however, is centred on night shift work only. Shift work is defined as a period of work performed outside the normal spread of working hours, particularly in a factory or business that operates on a 24 hour basis (Red goldfish, 2009). According to reports almost 4 million people are shift workers (Unison, 2002). A night shift worker is someone who is working regularly for three or more hours between 23.00 hrs and 6.00 hrs. The nursing profession which the article deals with is a 24 hour job like which it has remained since the Crimea War. However nursing is more of a committed and natural occupation taken on based on a family environment context. Working at night is an essential part of providing a comprehensive 24 hour services to patients in the NHS. Nurses, in general, are expected to work a period of night duty and be able to demonstrate an understanding of patient experiences of health care 24hours a day and seven days a week as quoted by Nursing and Midwifery Council (2004a). Nevertheless there is contradiction with this as the above can be adhered to only if night duty does not inhibit a person’s fitness to practice, as if the person experiences problems which prevent them from working within the code (NMC, 2004) they are then generally unable to work a full 12 hour shift duty. However, a staff member could perform a shorter shift covering the start or the end of a night duty. Subsequently the nurse would then be unable to provide continuous levels of quality care as quoted in the article. People or patients are least alert in the early hours of the morning, (around 3am) (Unison, 2002) and thus maintaining alertness during the night can be a challenge, especially when important decisions about the well being of patients need to be made. Admi et al (2008), testifies a growing concern about the ability of individuals to maintain adequate levels of performance over long work shifts, particularly when those shifts span night hours. On an eight-hour night shift there is a 28% higher risk of experiencing an accident or injury(Sharpe, 2007).In contrast, the greater the number of hours worked increases the percentage rate of accidents; so if a staff member worked a 16 hour shift there is a probability that there would be a 56% chance of an accident. The ratio calculation for every 1 hour worked is that there is a 3.5% chance for an accident. From a safety point of view both sleep deprivation and fatigue could result in a compromise of patient’s safety and with a rotation of shift work there is a risk of increase in accidents. Previous research has shown that there can be undesirable consequences for those working on a shift system, particularly night shifts which can subsequently have an affect on performance and increase the likelihood of errors and accidents at work (HSE, 2009). Consdering the issue of driving home after night shift work would also put other road users at risk and thus the chances of being involved in an accident is heightened by fatigue after a night shift. It has been found that such drivers play a significant part in a quarter of all accidents on motorways and fast roads, resulting in death or serious injuries (Unison, 2002; HSE, 2009). This is mainly attributed to slower reactions, reduced ability to process information, memory lapses and absent minded slips (HSE, 2009; Learthart, 2000). Six hours or a lesser sleeping pattern triples the risk of fatigue. Refer to the issues that arise from excessive working time or poorly designed shift patterns (HAE, 2009). Peate then makes a reference to the lack of sleep which may potentially jeopardise clinical decision making, thus resulting in errors as insufficient sleep could result in impaired judgement and lack of concentration (Goff, 2006). Hence the nursing staff should be adequately trained and prepared for night shift work. However, on the contrary this a hard task to achieve with the ever growing family commitments and social activities. A lack of contact with family and friends can cause feeling of loneliness and isolation (Sleep Disorders Blog, 2008). Increasing noise levels and other social obligations can make it difficult for a person to sleep during the day (Philly, 2004; HSE, 2009).The Improving Working Lives Standard policy (2000), of the Department of Health, includes that staff work need to a addressed so that they can strike a healthy balance between work and other aspects of their life. The article then explores the natural patterns of sleep and the hours required to maintain a sound mind. Investigation of other articles that also deal with understanding sleep patterns has revealed that they all draw the same conclusion. Sleep deprivation can lead to long term health implications and thus considering this reason the local Trust accident and Emergency Department should propose a health surveillance scheme under the Working Time Directive for night shift workers at regular intervals (Working Time Directive, 1993). An employer must introduce policies for the night shift employees which includes a pre-employment and regular health assessment package (Everwell and Dolan & Holt, 2003). This should encompass a paper based assessment and a physical review that would help to determine whether a health care professional has any medical problems. If the professional is found to have one or more conditions typically associated with night shift work it can be assumed automatically that they are unsuitable for night shifts. Thus this is a means to identify the presence of any risk factors so that they can be managed effectively without compromising and affecting the employee’s health as well as patient’s safety. In addition staff should be transferred to day work if they are found to be unfit for night work so as to avoid putting unnecessary additional pressure on other staff members to support and make good the pending night duty work. Night shift workers are prime candidates for developing health problems associated with lack of sleep and are at a greater risk of being injured due to sleep deprivation (Philly, 2004). It is therefore necessary to discuss the effects of sleep deprivation and its effect on the inability to achieve or provide quality care for patients and performance as quoted by Muecke, 2005. In his article, Philly (2004) has stated that shift workers tend to experience reduced concentration, attention span and reaction time, diminished performance at work, job dissatisfaction (Morshead, 2002; Muecke, 2005 and Westfall-Lake, 1997 cited in Admi 2008) and make staff less attentive (Sleep Disorder Blog, 2008).This has been attributed to the fact that shift workers have on an average one to four hours less sleep than other workers (Sleep Disorders Blog, 2008). Staff who have shift work sleep disorder(SWSD) are twice as likely to have a work – related accident(Philly, 2004).Gold et al 1992 cited in Admi et al 2008, reported that the main reason associated with medical errors was shift work. Staff may themselves not be aware of the fact that their performance is not effective and would assume that they are just having an “off day” as this could be perfectly normal. It is only after repeated occurrence of an incident or when pointed out by other work professionals that they tend to realize the problem. Under the MNC code of professional conduct 2004, it becomes a moral responsibility to report such a problem without delay whether it is the person itself or a colleague or anyone else as such a conduct would mean putting someone else at risk. This is where the night workers health surveillance would be beneficial and come in handy to report any noticeable flagging up in case of a problem and bring them to the light. Panton and Eitzen, 1997 and Reid et al, 1997 have cited in the 2007 article of Peate that they had identified the illness and sickness rates to have increased in individuals who were working in rotational shift. Sick leaves have been reported by 63% of shift workers compared with 34% of those in the permanent day work (Philly, 2004). In order to resolve the effects of sleep deprivation, the author elaborates on how one could prepare oneself for a night shift and adds that if followed this preparatory step could be vital for improving performance and preventing fatigue which in turn would help to improve the health and safety of workers, reduce sickness, injury and accidents, and increase work efficiency and product quality (HSE, 2009). While emphasizing the recommendations that would aid in sleeping, in order to be physically and mentally prepared for work, Peate examines the importance of having a nap before work. The Royal College of Physicians 2006, have recommended a two hour nap in the afternoon to incorporate a beneficial period of deep sleep, while the Health Central, 2009 Harvard researchers have found that taking a 60 – 90 minute nap provides a benefit similar to that of night time sleep and Scott, 2008 has proposed taking a nap of 15 to 30 minutes, as sleeping longer would cause a person to go into deeper stages of sleep, which would make it difficult to awaken. Hypothetically, if no nap was taken during the day before a night shift it reduces the psychomotor performance similar to the levels of someone with a blood alcohol concentration of 0.10%; the current maximum level of legal driving in the UK is 0.08%(Dawson & Reid, 1997; Lamond & Dawson, 1999; Williamson & Feyer, 2000 & Arnedt et al, 2005 cited in Royal College of Physicians, 2006) This would also apply to napping during a night shift if there is no breach of contract. The local NHS authority Accident & Emergency department have no qualms or quibbles over staff napping in their designated rest area/staff rooms. Naps are a great way to increase alertness and reaction times, improve moods, reduce accidents, reduce stress and improve cognitive functioning, increased learning, more efficiency, better health and more patience (Health Central 2009 & Scott 2008). This would coincide with discussions stated previously. In addition to napping, the other issues contemplated by Peate are: environmental and nutritional considerations, effective ventilation, availability of refreshments and a diet high in protein and low in carbohydrates with the use of caffeine to help aid shift work. Caffeine is a known natural stimulant and the effects of a small cup of coffee can be felt within 20 minutes. By taking a small dose of caffeine just before a nap the effects should begin to be felt about the time one returns to duty (Royal College of Physicians 2006). The article also briefly explains the recovering effect from a night shift stating that it may take several weeks for people to re-adjust after night duty. According to the Department of Labour (2007) research on average shift workers lose 1- 1.5 hours of sleep for every 24 hour period. This builds up a sleep debt of 6 hours after 4 nights. Hence more sleep loss greater the sleep debt. Supposing a nurse worked a 7day night shift pattern, at the end of the rotation that person would have lost 10.5 hours of sleep, which is equivalent to 1 whole night worth of sleep thus exacerbating the issue of health and safety. The Royal College of Physicians (2006) proposes that doctors should not work any more than four nights in succession. The Department of Labour, 2007 also advocates policies to ensure that workers do not spend more than 2 – 4 days on night shift. In order for this article to have a potential or actual impact as to whether the recommendations for future/existing practice will work effectively in a local accident and emergency department there has to be an understanding of change management and the ways to accomplish it. For a change to be introduced and be successful, it would need to adopt a change theory which comprises of a 3 theory phase taken from the work of well known theorists Lewin, 1951cited in Yukl 2006. He was one of the best known classical change theorists who identified several rules that need to be followed for implementing change. The change should be implemented for a good reason, always be gradual, should be planned and not be sporadic or sudden and all the individuals who may be affected should be involved in the change planning process. The three phases of the change theory are freezing, changing and refreezing. In the freezing phase, people are made to realize that the old ways of doing things are no longer adequate; this could have been a result of an obvious crisis and people may have become discontented and confrontational. The change agent will have to motivate the staff by getting them ready for change. During the changing phase, people look at new ways or perspectives of doing things and select a promising approach. In the refreezing phase, the new approach chosen is implemented and it becomes established. For this stage to be effective the change agent must be supportive and must reinforce the individual adaptive efforts to those affected by the change. A strong resistance will be shown if the unfreezing phase has been missed and the person has moved directly to the change phase. As mentioned earlier an existing practice that needs to be revised and its impact analyzed in an emergency care setting is the shift work pattern. These changes will have a large influence on the staff. The article proposes shorter shift patterns considering the health and safety concerns regarding the 12 hour shift pattern during the night and for those nursing staff who are unable to complete night shifts due to family commitments and health reasons. This arrangement would, however, have a negative impact as there would be a requirement for an additional handover thus decreasing the time spent on patient care. This problem can be overcome by increasing the staff strength by recruiting more nurses to cover one shift. For example the local accident and emergency department operates with 6 staff during the night shift and if the shift was shortened, as mentioned above, a total of 12 staff would be required. Another consequence which would have to be considered is the cost implication due to additional recruitment and also the predicament of covering the shift in case the staffs become sick thus putting added pressure on the others. Crofts, 1999 also notes that on a 12 hour shift direct patient care decreases to 39 %. The Department of Health of the European working time directive (1998) and Unison, 2002 have also suggested a maximum of eight hours work per day for night workers in stressful jobs. Another solution that would help resolve this dilemma is that the nursing staff could continue with the 12 hour night shift and those who are unable to do a full night could be given the option to start the shift late and finish early in the morning to enable them to balance their home life. For example they could start their shift at 22.00 hours and finish at 06.00 hours. Such an arrangement would then cover the entire night period when it might be busy and thus the NMC guidelines would also be adhered to. In addition, there would also be extra staff with different competencies which will facilitate attending to the changing needs of the patients not only on a day to day basis but also during shifts. (Nursing Times, 2007). A negative attitude and disinterest from the staff will not help if such an arrangement needs to be trialled. Additionally evidence has also indicated recruitment and retention difficulties as in case the nurses do not show an interest to work in the night shifts they will simply opt to quit the job (Crofts 1999). The department at present has a twilight shift from 19.30 to 02.00 hrs which is extremely effective. The proposed suggestion would help cover the second half of the shift with an overlap of 4 hours. This again would be beneficial to patient care. The most prominent issue that needs to be addressed is the set rotation of the shift pattern where the staff work two days followed by two days off, then work for three days and then take two days off. They work for two days again, and then take three days off and the cycle then begins again. In this manner all the staff would get two weekends off a month. The sleep disorders guide, 2008 has advised that giving weekends off would be beneficial to the staff. Thus this cycle would enable the staff to plan and prepare for the forth coming shifts and would also help their family life to remain unproblematic and smooth. It would also help to eliminate the discrimination between the day and night shift staff as in many cases night shift staff are being considered equivalent to the maintenance personal (Crofts 1999). However, the turnaround from nights to days can fluctuate. It could mean returning to work immediately the next day after finishing a night shift and in a few cases a few days off are given, while the latter is usually given to those who are part time employees, in whose case timings can be more flexible. All the staff should be given a minimum of two days off both for adjusting the work schedule and also to prevent fatigue. A quick shift change should be avoided (Sleep disorders guide 2008) and Department of Labour 2007) and it should be part of the normal shift roster (Department of Labour 2007). This might bring up a question as to whether night shift should be given in blocks either at the beginning, middle or end of the shift so that the staff could be given an option to choice and to spread it over one week, to avoid excessive rotation of shifts. This is not a problem for those engaged in permanent night shift; however, it would affect those who rotate between nights and days. By doing this the staff would be able to prepare for their night shift by having days off on either side of the night duty. In practice this could be more effective but theoretically, on paper, there may be other working constraints that could prevent this from happening, like for example unfilled posts, sick leave(more so long term) and the number of staff that are able to complete night shifts. About 47% of NHS nurses have described internal rotation as an undesired shift pattern (Learthart, 2000). For the benefit of the entire department an introduction and practice of the compulsory night workers health surveillance check, as discussed previously, needs to be carried out by the occupational health services team. According to the Improving Working Lives document (2000) all the trusts need to modernize the employment services in order to meet nationally agreed standards. And along with frequent checks it would help to clarify whether a staff member is fit enough to work night shifts and about those who need short hours for medical reasons and those who are exempt from undertaking night shift. The checks ought to be trustworthy, thus putting the health of the work force at the forefront to promote better working lives for the staff. During the check the staffs should be given written and verbal advice about working during the night, preparation, survival and recovering. The Royal College of Physicians have published a guide that outlines the preparatory steps for junior doctor’s who take up night shift. The NMC or the Trust could emphasize all of the above along with their own guidelines for nurses. Good education and awareness about fatigue could lead to general understanding and appropriate workplace-specific solutions (Department of Labour 2007). At times the staff may feel pressurized and intimidated about having these checks and thus they might leave early or make excuses about not being able to attend the checks. In that case the checks should then be made done at suitable hours throughout the day to accommodate those working at night (as night workers are often overlooked) and those having other commitments apart from work. From the point of view of the wellbeing of the staff there is a necessity to have rest room and canteen facilities. The trust in question does adhere to rest room facility, however, there is no 24 hour canteen facility providing nutritional healthy hot meals throughout the night. The cooking appliances are exceptionally limited, with the canteen being provided with merely a microwave. Full canteen facilities should be made available to those on shift work. If not, workplaces should have an area where workers can store and prepare their own foods and with appropriate facilities (Unison, 2002). The trust, from a health and safety aspect, does not allow the use of toasters and cookers and so this again limits the means for cooking. Nevertheless the trust perhaps could provide vending machines that contain a cold healthy and nutritionally balanced diet preferably in the rest room (so the public are unable to diminish the stock). However such rooms are also limited due to building plans. The introduction of roster pro is being contemplated in the local Accident and Emergency department in the near future. There are various software programmes available. However this software may not take into account the effects of workload, environment, breaks within shifts, out of work activities, or other possible consequences of errors (Department of Labour, 2007). Much of the above could stem from the written rosters, nonetheless hand written rosters take into account out of work activities and thus all other factors depends on fate. All the above changes require financial support to achieve a positive and constructive outcome for a successful and contented work force. However, a planned and systematic approach to assessing and managing the risks of shift work can improve the health and safety of workers. Shift work for most nurses is a way of life, indeed some nurses see positive benefits while working in shifts and so an important factor is that staffs have control over their working lives with a flexible rostering, thus improving staff satisfaction and lowering the conflict often experienced between home life and non standard working hours. The Improving Working Lives Document (2000) encourages the trust to involve the staff in the design and development of a better, flexible working practice. While there is no perfect shift schedule they can, however, be improved by recruiting an extra staff member, set pattern of work enabling two weekends off and thus making it possible of staff to do extra shifts if required for two days off after a set of nights to recover and adapt to normal daily work pattern and to enable all the staff to participate in the night workers health surveillance check. Read More