1. DiGiulio, Sarah

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The American Nurses Association's revised position statement on nurse fatigue (published in September) combines two previous statements-one that had addressed the employer's role and one that had addressed the nurse's responsibility in reducing fatigue. The purpose of the new statement, according to the ANA, is to address the joint responsibilities of both nurses and their employers to reduce the risks from nurse fatigue, support a culture of safety, and create and sustain a healthy work environment.

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"We believe strongly that addressing nurse fatigue is a patient safety issue as well as a nurse safety issue-and it is important to pay attention to this," ANA President Pamela Cipriano, PhD, RN, NEA-BC, FAAN, said in a phone interview. "A key aspect of this paper is bringing the two previous papers together. The discussion about fatigue is a conversation that has to be had together-between staff and their managers."


The revised position statement is published online on the ANA's website (

ANA President PAMELA... - Click to enlarge in new windowANA President PAMELA CIPRIANO, PHD, RN, NEA-BC, FAAN. ANA President PAMELA CIPRIANO, PHD, RN, NEA-BC, FAAN: "One of the most important parts of addressing this issue is making sure there is active discussion in the workplace. Nurses need to feel confident and assertive in speaking up."

Key Recommendations

A key recommendation, updated from the previous position statements, is the recommendation that nurses not exceed 40 hours of professional nursing (paid or unpaid) in a seven-day period. That recommendation is more conservative than that of the Institute of Medicine's 2004 recommendation that nurses not work more than 60 hours in a seven-day period, which according to the statement, is based on subsequent research that working more than 40 hours a week adversely affects patient safety and the health of the nurse.


"A key issue for nurses for many years has been the length of shifts and number of hours worked in a week. We think it's important to suggest the nurse really shouldn't work more than 40 hours in a week," Cipriano noted. "We want to point out to nurses that they are sort of at the limit of what we consider to be the ideal or most appropriate duration of work-make sure nurses are aware of the research that says as you pass that 12-hour mark [in a shift] your ability to be sharp begins to diminish. And over a period of years, not getting good sleep can also take a toll.


"It's not more of a problem now-we just know more about it. And we need to act responsibly when we have new data, research, and evidence that points us to better practice," she added.


Additionally, the statement includes a section on responsibilities of nurses, including that: 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; nurses are responsible for practicing healthy behaviors to reduce the risk of working while fatigued; nurses are responsible for taking meal and rest breaks throughout shiftwork to maintain alertness; and nurses are responsible for negotiating or rejecting a work assignment if necessary to make sufficient time for sleep and recovery from work.


The statement also makes specific recommendations for nurses for implementing evidence-based fatigue countermeasures and personal strategies to reduce fatigue (see box).


The statement also includes a subsection with the responsibilities of employers, including that: employers are responsible for establishing a culture of safety, a healthy work environment, and evidence-based policies, procedures, and strategies that promote healthy nursing work schedules that improve alertness; employers should adopt the position, as official policy, that nurses have the right to accept or reject a work assignment on the basis of preventing risks from fatigue; nurses should be able to decline working extra shifts or overtime without being penalized; and employers should conduct regular audits to make sure policies are being maintained.


Specific strategies to implement to meet these recommendations are also included in the position statement (see box).


Specific to Oncology Nursing

Commenting for this article, Anne Ireland, MSN, RN, AOCN, CENP, Nursing Director of the Solid Tumor Program at City of Hope, an Oncology Nursing Society Director-at-Large, and an OT Nursing Editorial Advisory Board Member, noted via email that following the ANA guidelines could have a significant effect on several types of performance deficits, including the risk of errors.


"Given the complexity of oncology nursing care, the often fluctuating acuity of oncology patients, and the cognitive demands of oncology nurses' work, the surveillance and vigilance of the oncology registered nurse is an essential component of safe patient care.


"The inclusion of evidence-based fatigue countermeasures and personal strategies to reduce the risk of fatigue provides nurses and employers with a variety of practical considerations shown to minimize fatigue that both nurses and employers need to incorporate into the work culture to realize the benefits."


But, Will It Make a Difference?

Despite the evidence and recommendations, several barriers still exist threatening the adoption of these recommendations, said Jeanne Geiger Brown, PhD, RN, FAAN, Associate Professor at the University of Maryland School of Nursing, commenting for this article in an email. "Economic forces are a key driver in health care and may make it difficult for employers to fully implement these measures. Likewise, stagnant wages for nurses and an abundant labor pool may make it difficult for individual RNs to enact some of these recommendations."


Geiger Brown served on the ANA Professional Issues Advisory Panel that gave input during the development of the statement, though she was not involved in writing the statement.


The statement correctly asserts that nurses and employers both share the responsibility to reduce the risks of fatigue and sleepiness on the quality and safety of care that is delivered-and proposes a good list of personal strategies for nurses, and recommendations for employers, Geiger Brown added-and could form a basis for a good fatigue risk management system if followed.

JEANNE GEIGER BROWN,... - Click to enlarge in new windowJEANNE GEIGER BROWN, PHD, RN, FAAN. JEANNE GEIGER BROWN, PHD, RN, FAAN: "The policy statement is a voluntary guideline. Only nurses and their employers can take steps to make this [change] actually happen."

"The policy statement is a voluntary guideline. Only nurses and their employers can take steps to make this [change] actually happen."


Also commenting for this article, Joni Watson, MBA, MSN, RN, OCN, Director of the Baylor Scott & White McClinton Cancer Center and an OT Nursing Editorial Advisory Board Member, said that the ANA's position statement is an important step in caring for the profession of nursing, and, ultimately, caring for patients. But, she added: "A quick skim through the social media comments on this position statement shows that frontline nurses and leaders alike are highly skeptical and cynical of this change ever occurring (see box).


"I understand; I am a nurse leader and have to balance staffing and patient care while stewarding a budget, and I certainly remember my frontline days of long-shift after long-shift," she continued. "It's difficult. It takes a culture shift both inside the profession and among health care organizations, and it has great financial implications during financially strenuous times."


But, the revised position statement "is a much-needed step in the right direction," she added. "Can it be done? Absolutely. The benefits far outweigh the risks. The reward is worth the difficult work."


Specific Strategies Recommended

Specific recommendations for implementing evidence-based fatigue countermeasures and personal strategies for nurses follow to reduce fatigue included in the ANA position statement include, among others:


* Sleep seven to nine hours within a 24-hour period and take steps to improve quality of sleep, such as adjusting temperature and removing distractions (such as bright lights and electronics) from the sleep environment;


* Rest before a shift in order to avoid coming to work fatigued;


* Improve overall personal health and wellness through stress management, nutrition, and frequent exercise;


* Use naps (in accordance with workplace policies);


* Take scheduled meals and breaks during shift work; and


* Follow steps to ensure safety while driving.



The statement also recommends implementation of the following strategies for employers, among others:


* Eliminate the use of mandatory overtime as a staffing solution;


* Institute an anonymous reporting system for employees so they can give information about their accidents, errors, and near-misses;


* Reduce risks of drowsy driving by providing transportation home when a nurse is too tired to drive safely or providing sleeping rooms; and


* Promote fatigue management training and education for employees and managers.



Nurses Share Doubts about the Statement on Social Media

Despite much support for the ANA's recommendations for reducing fatigue, many nurses are still skeptical the position statement will be the catalyst for change. Others are skeptical that the statement will push change in the right direction. Here are a few of the comments noted on the ANA Facebook page reacting to ANA posts about the revised position statement:

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* "Good luck enacting all of this. The hospital I'm at has all these rules on the books already, but they don't play by them. I hardly ever get a lunch break and my 12 hour shift is usually 13; and it is mostly because the hospital refuses to abide by safe patient to nurse staffing ratios. If you really want to make a difference, change laws on staffing."


* "After over 30 yrs I am not anxious to hear more 'strategies' which my hospital system will never implement. It's all about the dollar, not the patient care."


* "Reducing long hours would mean that nurses would work more-40 hrs instead of 36. We would have less time for the patients and families, spend more time commuting, and deal with the stress of nursing more days per a week."


* "There should be laws on nurse-to-patient ratio, especially in inpatient settings! My hospital is trying to save money by increasing patient loads and understaffing. Patient satisfaction is down, falls/injuries increasing, and nurses' fatigue is at its highest! No good comes out of this! Even if hours were limited, having heavy pt loads will still create fatigue. Most nurses on my unit are part time with various shifts and we're ALL fatigued."



More on Shift Length, Wearing Schedules, and Oncology Nurse Fatigue...

From the OT archives: Research on the harms of the 12-hour shift, other risks associated with oncology nurse fatigue, and ongoing efforts to help nurses cope (3/25/13 issue).