Nurses work long hours and play a critical role in keeping patients healthy. Many nurses feel that fatigue “comes with the territory” of such a high-stress, high-impact job. But what’s really at risk when a nurse is fatigued?
Nursing fatigue costs the United States billions of dollars each year.1
Mental exhaustion can lead to mistakes, and when those mistakes affect the health and wellbeing of patients, the consequences can be devastating. Imagine a tired nurse misinterpreting a healthcare provider’s orders to continue home medications, causing a diabetic patient to miss their insulin. Consider a patient who’s allergic to penicillin being mistakenly prescribed the drug to combat an infection, only to result in an allergic reaction, anaphylactic shock, or worse.
Patient and nurse safety decrease as a result of increased errors and injuries due to fatigue.2
Nurses have a responsibility to themselves and their patients to be well-rested in order 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, which results in accidents, mistakes, and errors.
But beyond the safety and ethical implications, fatigue can also lead to legal consequences, including 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.3
ANA weighs in
In 2014, the American Nurses Association (ANA) revised its two 2006 position papers focused on ensuring patient safety—one addressing RNs’ responsibility to consider their level of fatigue when deciding to take on assignments beyond their regularly scheduled work day or week (including mandatory or voluntary overtime4), and the other addressing the employer’s role in promoting healthy nurse work hours in all roles and settings.
As advocates for health and safety, registered nurses are accountable for their practice and have an ethical responsibility to address fatigue and sleepiness in the workplace that may result in harm and prevent optimal patient care.5
There must be a collaborative effort between employers and nurses to help prevent the risks presented by fatigue. 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
Registered nurses and employers must recognize the challenges faced from disruptions to normal human physiology that are caused by night and irregular work hours; both must adopt evidence-based strategies to reduce the associated health and safety risks.
-The Joint Commission (2011, 2012)
Shifting the “Blame Culture”
As professionals, nurses are ethically bound to strive to prevent errors. But many nurses are deterred from reporting an error for the fear of punishment or being viewed negatively by peers. This “blame culture” is counterproductive to preventing mistakes, because a lack of identifying the problem means a lack of fixing it.
Most nurses report having experienced the “blame culture” in response to reporting errors, which discourages accountability for practice improvements.2
The ANA advocates for a culture that recognizes that mistakes result from human error and faulty systems. This approach encourages an investigation of the 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 should be identified and corrected.2
Steps to Ensure Nurse and Patient 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.7
Developing a fatigue management plan.
Nurses working three consecutive 12-hour shifts suffer from sleep deprivation; they report an average of 5.2 hours of sleep on work days.8
Nurses report disturbance in their personal relationships, reduction in work productivity, and negative attitudes toward work.9
Educating staff on sleep hygiene and the effects of fatigue on nurse health and patient safety.
Chronic lack of sleep causes problems that include needle-stick injuries, musculoskeletal disorders, and drowsy driving.
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.
Providing opportunities for staff to express concerns about fatigue and taking action to address those concerns.
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.
Making sure extended shifts have adequate staff support and rest periods.7
To prevent fatigue and patient injury, managers should closely monitor nurses’ work hours.
Patient safety hinges on nurses’ well-being, and it’s important for nurse health to be front-and-center in the minds of both healthcare organizations and nurses themselves.
Nurses can decrease their level of fatigue by working as a team in support of each other during extended shifts, and by encouraging good personal sleep habits. But ultimately, it’s each nurse’s responsibility to refuse an assignment if he or she is impaired by fatigue.1
RNs should consider the impact that working multiple or extended shifts will have on their level of fatigue before accepting extended shift assignments, and should work proactively with their organization to establish safe schedules and fatigue management plans.
1American Nurses Association. Nurse fatigue.
2Brewer K.How a “just culture” can improve safety in health care. Am Nurse Today. 2011;6(6).
3American Nurses Association. Position statements: assuring patient safety: the employers' role in promoting healthy nursing work hours for registered nurses in all roles and settings.
4American Nurses Association. Position statements: assuring patient safety: Registered Nurses' responsibility in all roles and setting to guard against working when fatigued.
5American Nurses Association, Revised position statement: Addressing Nurse Fatigue to Promote Safety and Health: Joint Responsibilities of Registered Nurses and Employers to Reduce Risks, 2014.
6Caruso CC. Running on empty: fatigue and healthcare professionals.
7Melville NA. Joint Commission recommendations address extended-shift fatigue.
8University of Maryland. Study reveals widespread fatigue, risk for errors with 12-hour nursing shifts.
9Cimiotti 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.