1. Section Editor(s): Witt, Catherine L. MS, RN, NNP-BC

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Much has been written in the last few years on fatigue in health care workers and the impact on patient safety. Medical resident hours have been adjusted in response to concerns for patient safety. Attention has also been paid to the number of hours worked by nursing staff. Many nursing organizations, including the National Association of Neonatal Nurses (NANN), have issued position statements regarding length of shift and hours worked per week for nurses and nurse practitioners.1,2 These position statements have been posted on the NANN Web site and have been published in Advances in Neonatal Care.

Catherine L. Witt, M... - Click to enlarge in new windowCatherine L. Witt, MS, RN, NNP-BC

The evidence is clear that fatigue can play a role in the rate of errors. Error rates have been shown to increase after 12 hours of work in a day and after 60 hours in a week.3 In addition to error rates, long hours take a toll on nurses' health. Nurses working longer shifts are at increased risk for injuries, cardiovascular disease, psychiatric disorders, and diabetes.2,4


It is often noted that there are limited data available by which to determine optimal shift length. There are also limited data that limiting hours, particularly hours worked by medical residents, has actually improved patient safety. This does not mean that the evidence regarding the effects of sleep deprivation should be ignored. Fatigue has a significant impact on task performance, learning, and memory.3,4 A recent article noted that there are a number of reasons why improvements in patient safety have not been clearly documented with reduction in resident hours.5 It is unclear whether the recommendations have been implemented on a consistent basis. It is also unclear that responsibilities have been adjusted for work hours, meaning that residents might be trying to complete the same amount of work in a shorter period of time. It is also not clear that residents use increased time off for rest.


Employers and managers have a part to play in this. As the NANN statement on nurse shift length and fatigue points out, reasonable scheduling and shift assignments are important to mitigate fatigue in workers.1 Guidelines for hours worked in a day or a week should be implemented, and that should include hours on call. Nurses need to be allowed adequate time for rest in between shifts. Regular vacation time should be available for all staff. This sometimes becomes difficult in hospitals that routinely and frequently cancel nurses' shifts for low census, forcing nurses to use vacation time to get paid.


Nurses and other health care workers have a personal responsibility to come to work well rested. Professional responsibility means being educated about sleep physiology and being aware of personal fatigue issues. Sleep hygiene and personal lifestyle choices should reflect the personal responsibility we all have to be alert and able to provide safe patient care. Using vacation time for rest and relaxation is important and too often neglected. Nurses and nurse practitioners who work more than 1 job need to consider how many hours they can safely work in a week. Our professional organizations, including NANN, have rightly addressed this issue in their position statements. It is up to all of us to pay attention.




1. National Association of Neonatal Nurses. Position Statement 3054: the effect of staff nurses' shift length and fatigue on patient safety. Adv Neonatal Care. 2012;12:127-132. [Context Link]


2. National Association of Neonatal Nurses. Position Statement 3057: the impact of advanced practice nurses' shift length and fatigue on patient safety. Adv Neonatal Care. 2012;12:189-200. [Context Link]


3. Scott LD, Rogers AE, Hwang W, Zhang Y. Effects of critical care nurses' work hours on vigilance and patients' safety. Am J Crit Care. 2006;15(1):30-37. [Context Link]


4. Scott AJ. Shift work and health. Prim Care. 2000;27:1057-1079. [Context Link]


5. Horwitz LI. Why have working hour restrictions apparently not improved patient safety? BMJ. 2011;342:d1200 Accessed April 5, 2012. [Context Link]