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Nursing fatigue: Dangerous for nurses and patients ​​​ 

Nurse fatigue caused by working long hours can be dangerous for both nurses and patients. For instance, a tired nurse may mistakenly record a healthcare provider’s phone orders to continue home medications on the wrong medical record, causing a patient with diabetes to fail to receive insulin. Nursing fatigue also costs the United States billions of dollars each year.

Nurses have a responsibility to themselves and their patients to ensure they’re adequately rested to provide the highest quality care possible. Working long shifts, night shifts, and rotating shifts, as well as mandatory or voluntary overtime, contributes to nurse fatigue, accidents, mistakes, and errors. Patient and nurse safety also decrease as a result of increased errors and injuries due to fatigue.

Besides the safety and ethical implications, fatigue can lead to legal consequences, such as loss of license. Although nurses are accountable for their individual practice, employers also have a responsibility to keep nurses, patients, the facility, and the public safe.

ANA weighs in

In 2006, the American Nurses Association (ANA) issued two position papers to ensure patient safety. The first statement addresses RNs’ responsibility to evaluate their level of fatigue when deciding to accept or reject any assignment extending beyond their regularly scheduled work day or week. This includes mandatory or voluntary overtime assignments.4

The second statement addresses the employer’s role in promoting healthy nurse work hours in all roles and settings. The ANA encourages employers to establish policies and procedures to promote healthy work hours and patterns that don’t go beyond the limits of nurse and patient safety.3 Evidence indicates that prolonged work hours, rotating shifts, and insufficient breaks slow reaction time, decrease attention to detail, promote errors, compromise problem solving ability, and reduce motivation.1

Changing a culture of blame

Worker fatigue and a “blame culture” are major factors that impede quality and safety.2 Nurses have an obligation to avoid working when fatigued and to advocate for workplace conditions that prevent fatigue.2 As professionals, nurses are ethically bound to strive to prevent errors. Many nurses are hindered by the fear of being disciplined for an error because they don’t feel comfortable reporting the error. The “blame culture” seeks to impose punishment, which is counterproductive to preventing mistakes.2 Most nurses have experienced this reaction in their work environment and find that it discourages a sense of accountability for practice improvement.2

The ANA advocates for a culture that recognizes that mistakes result from human error and faulty systems.1 This approach encourages an investigation of events leading to the error and discourages blaming individuals involved.1 If the mistake is associated with an environment that’s not supportive of safety, flaws in the system are identified and corrected.

Steps to safety 

Key strategies in preventing the costly consequences of fatigue include designing schedules and organizing work to reduce nurse fatigue.5 The Joint Commission recommends healthcare facilities assess their policies to identify fatigue-related risks, such as off-shift hours and consecutive shift work, and review their staffing to address areas that may be contributing to nurse fatigue.6 

Nurses working three consecutive 12-hour shifts suffer from sleep deprivation; they report an average of 5.2 hours of sleep on work days.7 This affects patient care and the health and well-being of the nurse. Examples of problems related to chronic lack of sleep include needle-stick injuries, musculoskeletal disorders, and drowsy driving.7 Nurse burnout is on the rise due to fatigue, causing health issues such as diet disorders, headaches, ulcers, depression, and increased alcohol and nicotine consumption. Nurses report disturbance in their personal relationships, reduction in work productivity, and negative attitudes toward work.

Suggestions to improve safety involve: 

  • developing a fatigue management plan

  • educating staff on sleep hygiene and the effects of fatigue on patient safety

  • providing opportunities for staff to express concerns about fatigue

  • supporting staff by taking action to address concerns

  • making sure those working extended shifts have adequate staff support and rest periods.6

Nurses can decrease their level of fatigue by working as a team in support of each other if they must work extended shifts and by practicing good personal sleep habits. But RNs should consider the impact that working multiple or extended shifts will have on their level of fatigue before accepting extended shift assignments. Ultimately, it’s the nurse’s responsibility to refuse an assignment if he or she is impaired by fatigue.

Organizations’ role 

By keeping the lines of communication open between management and staff, healthcare organizations can encourage and empower nursing staff to solve fatigue-related issues without fear of reprisal by management. To prevent fatigue and patient injury, managers should closely monitor nurses’ work hours. RNs must be accountable to themselves and their team to ensure they’re capable of accepting their shift assignment. Working with their organization, RNs must become a proactive force in establishing safe schedules and developing a fatigue management plan. 

REFERENCES 

  1. American Nurses Association. Nurse fatigue. http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/Work-Environment/NurseFatigue

  2. Brewer K.How a “just culture” can improve safety in health care. Am Nurse Today. 2011;6(6).

  3. American Nurses Association. Position statements: assuring patient safety: the employers' role in promoting healthy nursing work hours for registered nurses in all roles and settings. 

  4. American Nurses Association. Position statements: assuring patient safety: Registered Nurses' responsibility in all roles and setting to guard against working when fatigued. http://www.nursingworld.org/MainMenuCategories/Policy-Advocacy/Positions-and-Resolutions/ANAPositionStatements/Archives/Copy-of-AssuringPatientSafety-1.pdf​

  5. Caruso CC. Running on empty: fatigue and healthcare professionals. http://www.medscape.com/viewarticle/768414 

  6. Melville NA. Joint Commission recommendations address extended-shift fatigue. http://www.medscape.com/viewarticle/755427

  7. University of Maryland. Study reveals widespread fatigue, risk for errors with 12-hour nursing shifts. http://www.newswise.com/articles/study-reveals-widespread-fatigue-risk-for-errors-with-12-hour-nursing-shifts

  8. Cimiotti JP, Aiken LH, Sloane DM, Wu ES.Nurse staffing, burnout, and health care-associated infection. Am J Infect Control. 2012;40(6):486–490.

Adapted from “Nursing fatigue and staffing costs: What’s the connection?,” by Kimra Reed, BSN, RN, originally published in the April 2013 issue of Nursing Management © 2013 by Lippincott Williams & Wilkins, Inc.​

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