With the imminent shortage of nurses and the accompanying problem of aging nursing professionals moving out of service, the issue of fatigue is a major topic of discussion in nursing circles, hence the selection of this topic. The nursing profession has the duty to provide a supportive environment to promote the health and safety of patients and staff; the problem of fatigue has however become a hurdle in the health promotion. Inadequate staffing, frequent overtime work, no coverage for breaks, keeping narrow safety precautions and problems in standardized processes have been considered as the reasons for fatigue.
Fatigue has been defined as the “physical or mental weariness resulting from exertion” and a ‘tiring effort or activity causing weariness” in the American Heritage Dictionary of the English Language (2000). Other meanings have also been given: “decreased capacity or inability of an organism” and “weakening or failure of a material from prolonged stress”. These do not suit our context. The Collins Dictionary defines fatigue as “extreme physical and mental tiredness” and another out of our context, “weakening of a material caused by repeated stress or movement” (2006). Words with similar meaning are tiredness, lethargy, weariness, languor and listlessness. “Freshness” is a word with opposite meaning.
The medical discipline defines fatigue as the “physical and/or mental exhaustion that can be triggered by stress, medication, overwork, or mental and physical illness or disease” (Davis, 1995). Fatigue is the way in which the body exhibits the need for rest and sleep. If these methods do not relieve the fatigue, the medical staff understands that something is absolutely wrong. Lack of energy, muscle weakness, lethargic movements or central nervous system symptoms or serious nervous breakdowns imply that much is to be done. Even memory loss may be noted.
Effort would be taken to diagnose the underlying condition and treat as early as possible to overcome the fatigue. Alternate medicine recommends that life-style changes are sufficient to beat the fatigue: change of occupation, lesser hours of work, avoiding night duty, irregular sleep patterns, cultivation of a harmonious family life. The discipline of surgery has a component called post operative malaise and fatigue. A new theory states that postoperative fatigue is the result of physiological, psychological and cultural changes that occur in the body during the convalescence period (Salmon & Hall, 1997). Research is attempting to find means of preventing the problem by reducing the pre-operative anxiety with medicines and psychological advice and shortening the convalescence.
Modern health care environments for nurses are facing a shortage of qualified nurses and a tough work environment due to “changing work patterns, long shifts and overtime” (Ellis, 2008). Heaviness of work schedules, fatigue and poor patient safety are the issues of nursing. Fatigue has been attributed to the prolonged hours of sleep loss and wakefulness and at the circadian time of day. It makes the nurse prone to decreased alertness and concentration. She may make wrong judgments and unknowingly reduce her vigilance and performance. Nurses have also been found driving dangerously, very much drowsy after night shifts.
Patient demands are increased due to their sharper knowledge and there are not enough nurses to cater to them. 24 hour shifts are also prevalent. Fewer days and longer hours on some days are the preferences of some who wish to spend more time with their families. The chances of more errors at work arise. Scott and his colleagues studied critical care nurses and their errors; the recommendations were that 12 hour shifts were to be reduced and nurses were to be posted for a maximum of 12 hours only in a period of 24 hours (2004). Nurses on night shift reported the severe levels of stress and physical and mental exhaustion in another study (Dorrian et al, 2006). Roger’s study found a relationship between stress and the increased use of sick leave and reduced satisfaction in the job (2004).
In my acute care ward, I as a nurse need to be fully awake and aware of my surroundings and patients. The acute conditions require frequent assessments and interventions. Patient safety and health promotion are my foremost priorities. Sharp attention, correct judgment and rapid reaction time should be my response behaviors in case of an emergency. Adverse events would occur if my memory or coordination or attention suffers in any manner.
I always remember not to be deprived of my sleep to less than 5 hours as this could harm my reflexes and memory. I may be able to do work but I would not be at my peak capacity. The acute care patients should have me at the peak level (Krueger, 1994 cited in Jha, 2001). It is said that one night’s loss of sleep reduces the cognitive level by 25 % on the next day and 40% on the following day (Cox, 1989 cited in Jha, 2001).
There is something called a sleep debt: it occurs when a person has sleep deprivation for many ongoing days (Krueger, 1994 cited in Jha, 2001). I take great care to avoid this. Night shifts and rotation have caused national disasters like Exon Valdez, Chernobyl, Bhopal and Three Mile Island by a report of the Association of Professional Sleep Societies (Mitler, 1988 cited in Jha, 2001). Changes in melatonin and cortisol levels occur in people who take shift duty (Akerstedt, 1978 cited in Jha, 2001). The sleep after night duty tends to be shorter than after day duty; sleep deprivation becomes worse then. Shift workers also have a poor quality sleep due to the lesser REM component.
I ensure that my sleep is not disturbed due to all the possible problems this can create. My alertness should never suffer or compromise the patients’ health. Hours of service also may be of importance; in this hospital, we are given 8-hour shifts. Studies have proved that the quality and quantity of nursing care was better with the 8-hour shifts. 6 studies have measured outcomes. 2 of them indicated that self-reported alertness, performance and satisfaction were more with the 8 hour shifts (Smith et al, 1998 cited in Jha, 2001). On the other hand, ICU nurses claimed to have higher job satisfaction and subjectively better performance with the 12-hour shifts. Errors too were less.
Direction and speed of shift rotation may cause fatigue. When the three shifts are from day to evening to night, the fatigue is less than when it is in the opposite manner (Knauth, 1995 cited in Jha, 2001). The circadian rhythm also adjusts better. Slow shift rotation is better than a faster one in 2-3 days; less sleepiness and better performances are reported (Knauth, 1005 cited in Jha, 2001). Maintaining good sleep hygiene without alcohol or caffeine before bedtime improves the quality of sleep. Educational programs have been conducted by our organization to improve our performances.
Lighting arrangements appear to affect alertness and performance. Exposure to bright lights during the night served the purpose of improving alertness and performance. (Foret et al, 1998 cited in Jha, 2001) Workers who were exposed to bright light at night while on duty and then to an environment of darkness in the daytime had a better cognitive performance and alertness (Czeisler et al, 1990 cited in Jha, 2001).
Napping is a common technique used for fighting fatigue among shift workers (Akerstedt, 1985 cited in Jha, 2001). Prophylactic naps are taken before duty. Therapeutic naps are taken during the hours of deprivation. Maintenance naps are taken while at work (Akerstedt, 1985 cited in Jha, 2001). They make up for the daytime sleep which was lost and fight the fatigue.
The operational definition that I would opt for would be as follows: Fatigue is the physical and/or mental exhaustion that can be triggered by stress, medication, overwork, sleep deprivation, heavy schedules and mental and physical illness or disease.
The Pender’s model provides a mechanism for understanding the effectiveness of nursing. Predicting the effectiveness also is involved. Four factors are mainly affected: “nursing knowledge, past achievement, decision-making skill and empathy of the nurse” (Polit and Beck, 2004). The Health Promotion Model provides the perspective to gauge the multi-dimensional nature of the people who are seeking health (Larsen and Lubkin, 2008).
Behavior change is possible if a positive personal value is upheld and a desired outcome is sought. The negative approach is absent in this model while self efficacy is a main component. Pender’s model requires an active approach by the person who needs to modify his behavior and the environment for attaining the health behavior. Nursing is the most appropriate discipline using Pender’s model. The patients with chronic illness may not be helped by this model.
The main points of the Pender’s Health Promotion model include the health promoting behavior which involves beliefs, affect and the enactment which are all influenced by previous behavior along with inherited features. Indulging in characteristic behaviors is for benefits which the individual values. Barriers are found to cause hindrances to the actions possible. These modify the action according to the type of barrier.
The person’s own perception of his competence or self efficacy is the decisive factor for an action. If this perception or self efficacy is great, barriers reduce in number. A positive or optimistic nature causes greater self efficacy and a positive outcome. Real life models of the expected behavior provide the encouragement for a doubtful individual to follow. Families, peers and health care providers who make up the important sources of interpersonal behavior can influence an individual to become more or less committed. Situational influences also change the patterns of behavior. Higher the commitment, the greater is the chance of health promotion taking place. Well defined plans ensure that health promoting behaviors are maintained for a long time.
Promoting physical activity for the elderly is one intervention that nurses do using the Health promotion model (Miller, 2008). The aged may not perceive that physical exercise may be beneficial to them; they may actually believe that it is to be avoided. The nurses have to assess the person’s beliefs, try to change them and lead the person to believe in the physical exercise. The nurse also has to look for factors which could harm the aged. Researchers have found a relationship between self efficacy and motivation (Alison and Keller, 2000 in Miller, 2008). Barriers may include pain, fatigue, sensory impairment or mobility impairment (Cooper, 2001 in Miller, 2008).
Mental health services may be provided in schools through the health promotion model (Adelman and Taylor, 1991 in Puskar et al, 2006). Barriers like transportation, financial problems and stigma-related issues are reduced in this manner. Treatment outcomes may also show a bigger response in the school environment. The issues of lack of coordination are absent.
Generally it is known that services are fairly effective when delivered in schools. The nurses’ role is significant in the delivery of these services (Puskar et al, 2006).
References
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