1. Kelton, Diane BSN, RN
  2. Kingsley, Evelyn MBA, BSN, RN
  3. Davis, Charlotte BSN, RN, CCRN
  4. Miller, Diane BSN, RN

Article Content

Everyone experiences mild fatigue occasionally; it's the body's way of saying it needs rest and sleep. When fatigue becomes a persistent feeling of tiredness or exhaustion; however, it's a red flag that something's amiss.


In a survey of nurses in Texas, 38% of the respondents reported that they had committed a fatigue-related error that could've impacted patient safety. As nurses, we shouldn't work while fatigued because it can damage our health and impair our ability to provide safe, competent, empathetic, and conscientious care to our patients.


In this article, we'll discuss signs and symptoms, complications, contributing factors, and resolutions to nursing fatigue.


Risky business

Nursing fatigue is characterized by a profound lack of energy, feelings of muscle weakness, emotional exhaustion, slowed movements, diminished reflexes, and impaired critical thinking skills. You may feel like your mind is "fuzzy" or that you're in a mental "fog" as you struggle to concentrate on the routine tasks at hand. Fatigue can cause you to make costly mistakes that can injure patients.


Common complications of nursing fatigue include:


* slowed reaction time


* failure to rescue


* medication errors


* poor quality patient care


* inability to convey empathy


* poor teamwork


* errors of omission


* lapses in attention to detail


* compromised problem solving.



A nurse experiencing fatigue may exhibit nonverbal signs, such as sighing, folded arms, fixed facial expressions, rushed movements when providing patient care, exasperated eye rolling, and not making eye contact with patients or other team members. These negative cues signal that the nurse isn't engaged in meeting the patient's physical, spiritual, and emotional needs. Before nursing fatigue has progressed to this point, managers and administrators should intervene.


Besides causing problems at work, fatigue can also undermine your personal and home life. You may not realize how the heavy workload and excessive hours spent at work impair your ability to enjoy life and meet home and family obligations. We have many roles in addition to nursing: spouse, partner, parent, family caregiver, sibling, friend, and student to name a few. If you're experiencing fatigue, these relationships may be strained to the breaking point, undermining your social support system.


We must ensure that we don't overcommit to working extra shifts, additional hours, or on excessive projects or committees so that we have enough energy for family and friends. Balancing family relationships and a career should have equal importance in our lives. It's okay to say no to requests from employers to work overtime. Sometimes saying no to overtime simply means you've decided to properly care for yourself by resting that day.


Run up the red flag

Understanding the forces driving nursing fatigue is the key to combatting it. Common underlying causes include:


* inadequate staffing. All nurses have experienced times of inadequate staffing and understand the stress it can cause. Some healthcare facilities create a workplace culture in which nurses feel obligated to work extended hours, through their lunch and meal breaks, and overtime. If you fail to meet this unrealistic and unhealthy "obligation," you may feel guilty about letting down the team. You may also be concerned that other team members won't reciprocate in the future when you need help.


* mandatory overtime. According to the American Nurses Association, mandatory overtime is a major contributing factor to nurses leaving the workforce. Research clearly shows that errors significantly increase when nurses work shifts that are longer than 12 hours or work more than 40 hours in any 7-day period. Airline and trucking industries regulate the amount of hours a pilot or trucker can work in a 24-hour period. As a safety measure, these industries also mandate a specific number of hours of rest between flights or runs. Yet, although research has proven that nurses become so tired during long shifts that their performance deteriorates, only 16 states prohibited mandatory overtime for nurses in 2013.


* 12-hour shifts. A recent research study by the University of Maryland and Johns Hopkins School of Medicine found that nurses who work consecutive 12-hour shifts get an average of only 51/2 hours of sleep between shifts. Working several extended-hour shifts consecutively can lead to sleep deprivation, which has been linked to errors and the increased likelihood of motor vehicle accidents (MVA) for nurses who drive to work (see A drowsy driver is a lousy driver).



Many healthcare facilities have begun to limit how many consecutive 12-hour shifts nurses can work in an effort to decrease nursing fatigue, reduce sentinel events, and increase workplace and patient safety. Some state boards of nursing and professional organizations have issued position statements requesting that if nurses must work 12-hour shifts, the last 4 hours should be away from direct bedside care.


* unexpected patient emergencies. Many nurses work in areas of high stress that are always in transition. In challenging circumstances, you can't easily plan your entire shift's work in advance. When an unexpected patient emergency adds to the pressure, you experience excessive rushes of adrenaline. The body can handle occasional rushes of adrenaline, but when it's repeated and frequent, your energy stores are depleted, predisposing you to sleep deprivation, stress-related illness, and persistent fatigue.


* increased expectations from administration. Nurses often say that in the current budget-conscious environment, they're asked to "do more with less" by their management teams. To make sure you have the tools you need to perform your job, management teams should be encouraged to make daily rounds and interact with the healthcare staff. When members of the management team make routine onsite rounds and are readily available to nurses, they get a more realistic vision of what nurses need. This may motivate them to find innovative solutions acceptable to all parties.


* increased expectations from patients and families. Healthcare has shifted to a focus on holistic, patient-centered care that's tailored to meet each patient and family's healthcare needs. This customized nursing care delivery system takes additional time to plan and execute. When time is already tight, you may feel rushed and unable to meet all the patient's physical, emotional, and spiritual needs.


* frequent changes in management, policies, and procedures. Changes in management teams can add to stress as you learn to work with new personalities and management styles. All nurses need a dedicated unit manager to provide a vital link to the facility's core mission. When policies or procedures are changed, the management team should meet with the nursing staff to explain why the change is being made and how it will benefit nurses, patients, and the organization. This gives you a chance to offer insight and input based on your experience. When all parties are on board with the changes and rationales, stress and frustration are reduced for all. Well-informed nurses can make substantial contributions to the success of the organization.


* disruptive or hostile work environment. When disruptive or hostile workplace behavior isn't addressed, the workplace climate may become dysfunctional and unsafe. For example, when cliques form within a unit, nurses often become accustomed to working only with their small, accepted group. This can be dangerous if nurses withhold or limit their assistance to other nurses outside their group. Management teams should take a proactive role in addressing all workplace behavior that doesn't foster teamwork and professional respect between team members.


* neglecting personal health. Nurses committed to providing excellent care to others may at times neglect their own healthcare needs. Although we may be experts at recognizing how neglecting personal health increases the mortality risks in our patients, we often fail to recognize it in ourselves. Common ways we neglect our health are failing to get adequate rest before or after a shift, eating an unhealthy diet, and getting too little physical activity or exercise.


* failing to address chronic physical or mental disease. Although we'd like to believe we're invincible, many nurses can suffer from common chronic illnesses that require ongoing medical interventions. Even relatively minor acute illnesses, such as the common cold, can cause feelings of exhaustion. Taking medications that cause drowsiness may create more issues if you're already suffering from fatigue and diminished mental clarity.



Take steps to stamp out fatigue

Take the following steps to resolve nursing fatigue.


* Get at least 6 hours of uninterrupted sleep before each shift. If you have a sleep debt, it should be repaid in full in addition to the 6 hours of sleep (see Don't go into (sleep) debt). The Agency for Healthcare Research and Quality (AHRQ) has reported that after one night of missed sleep, cognitive performance may decrease 25% from baseline. After the second night of missed sleep, cognitive performance can fall to nearly 40% of baseline.


* Avoid shift rotations. The AHRQ reports that nurses who alternate between day and night shifts frequently have difficulty maintaining a normal sleep cycle and are more prone to medication errors. If you must rotate between day and night shifts, it should be done in 2- to 3-week increments. Slow shift rotation results in greater sleep length at home, less sleepiness on the job, better self-reported performance, and fewer errors.


* Take your 15-minute rest breaks and your lunch break in a quiet area off your unit if possible. This will allow you to briefly destress and refresh so that you can give your best care for the remainder of your shift.


* Eat a well-balanced diet and minimize consumption of caffeinated products. If you do drink caffeinated products, do so early in your shift so your sleep patterns won't be affected.


* Educate your management team and coworkers about the signs and risks of nursing fatigue. All members of the healthcare team should be able to identify team members who are working while fatigued and intervene to protect both the nurse's and patient's safety.


* Develop a work culture that accepts a nurse's choice to refuse to work overtime-without guilt. When the work peer group supports each other's commitment to maintaining a healthy work-life balance, workplace satisfaction improves.


* Develop open, honest, and respectful lines of communication between your management team and nursing staff regarding staffing needs. Nurses should feel free to discuss staffing needs with management, such as the skill mix of nursing staff, staffing ratios based on patient acuity, and the need for experienced nurses with specialty experience. When approached in the spirit of respect and cooperation, management teams will be more receptive to looking for an acceptable resolution that will allow nurses to avoid fatigue and meet patient needs safely.


* Commit to a healthy work-life balance. This includes preventive health maintenance, medical care, routine engagement in personal hobbies, and socializing with family and friends.



Despite the potentially serious consequences of working while fatigued, nurses are often reluctant to intervene with a fatigue-impaired colleague. If you believe a colleague is working while fatigued, convey your concerns in a respectful, caring manner. If the nurse isn't receptive and continues to work while fatigued, discuss your concerns with your supervisor or management team. Ignoring your colleague's fatigue will only enable him or her to continue endangering patients. Remember, we're all responsible for patient safety!


When both the management team and nurses are educated about nursing fatigue, they can work together to quickly identify when a team member is too fatigued to provide optimal patient care and intervene appropriately. Armed with this new knowledge, we can all work together to eradicate nursing fatigue!


Article Content

cheat sheet

Are you experiencing nursing fatigue?

Article Content

If you answer "yes" to any of the following questions, you may be too fatigued to safely provide direct patient care.


* Have you or your family, friends, or coworkers complained that you've been irritable?


* Have you slept less than 6 hours in the last 24 hours?


* Have you worked more than three consecutive 12-hour shifts in the last 5 days?


* Do you feel fatigued, sleepy, or as if you're in a "mental fog"?


* Have you missed routine exercise or physician visits within the last 5 days?


* Have you canceled social visits with friends and family within the last 5 days due to tiredness or fatigue?


* Have you made an error or "near miss" at work in the last 7 days?


* Do you feel a sense of irritation or impatience interacting with patients, families, or team members?


* Would you want you to take care of yourself if you were the patient?


* Would you feel guilt or shame if you made a patient care mistake if you went to work this fatigued?



A drowsy driver is a lousy driver

Article Content

Many nurses commute to their jobs by automobile. In a recent survey of Canadian nurses, 55.5% of the respondents indicated that they always or almost always feel fatigued during work, and 80% feel this way after work as they're traveling home.


Fatigue can impair a nurse's judgment as severely as alcohol. As of 2013, the legal blood alcohol content (BAC) is 0.08% in all states. According to recent research, 19 hours without sleep is similar to a BAC of 0.05% and 24 hours without sleep is similar to a BAC of 0.10%.


We shouldn't work or drive with less than 6 hours of uninterrupted sleep in the last 19 hours because our judgment, depth perception, and reflexes are impaired. In recent research, the risk of an MVA increased dramatically after each 12-hour shift worked consecutively. For day shift workers, the risk of an MVA increased by 2% after the second shift, 7% after the third shift, and 17% after the fourth shift. For night shift workers, the risk increased 6% for the second consecutive 12-hour night shift worked, 17% for the third shift, and 36% for the fourth.


We must consider our ability to safely commute to and from our workplace when agreeing to work extended-hour shifts or overtime. When in doubt, err on the side of caution and don't drive. If you've already completed your shift and are too fatigued to drive home, call a friend or family member to pick you up, call a cab, or find a safe place to rest.


Sources: Arizona Department of Public Safety. Driver fatigue.


Canadian Nurses Association. Nurse fatigue and patient safety: research report.


Rogers A. The effect of fatigue and sleeplessness on nursing performance and patient safety.


cheat sheet

Identifying a fatigued coworker

Article Content

If you answered "yes" to any of the above questions, your coworker may be experiencing nursing fatigue. You should discuss your concerns with your coworker and also convey your concerns to your management team if your coworker isn't receptive. Addressing your concerns in a respectful, caring way can help your coworker recognize the urgency and dangers of working while fatigued.


Don't go into (sleep) debt

Article Content

Nurses need a minimum of 6 hours of uninterrupted sleep every 24 hours to maintain our coping skills, problem-solving ability, and our health. Sleep deprivation can impair memory, depth perception, comprehension skills, and memory.


The length and quality of a person's sleep pattern directly relates to his or her ability to physically and mentally function while awake. If you don't get an adequate quality or quantity of uninterrupted sleep, you may acquire a "sleep debt." This deficit often requires more quality sleep hours than are "owed" to resolve. The brain requires extra hours of quality sleep patterns to repay the sleep debt caused by even small periods of sleep deprivation.


According to new research on night shift workers, "sleep loss is cumulative and by the end of the work week, the sleep debt (sleep loss) may be significant enough to impair decision making, initiative, integration of information, planning and plan execution, and vigilance." Sleep deprivation is also linked to increased cortisol levels and an increased risk of diabetes, hypertension, depression, decreased mental acuity, and memory impairment.


Source: Rogers A. The effect of fatigue and sleeplessness on nursing performance and patient safety.


Learn more about it


Canadian Nurses Association. Nurse fatigue and patient safety: research report.


Chinn P. Nurse fatigue and patient harm.


Rogers A. Staff nurse fatigue and patient safety.


Stimpfel AW, Sloane DM, Aiken LH. The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction. Health Aff(Millwood). 2012;31(11):2501-2509.


Texas Board of Nursing. Health and nurses inTexas: 2004 survey of Texas registered nurses.


Townsend T, Anderson P. Are extended work hours worth the risk?


Trinkoff AM, Johantgen M, Storr CL, Gurses AP, Liang Y, Han K.Nurses' work schedule characteristics, nurse staffing, and patient mortality. Nurs Res. 2011;60(1):1-8.