Patient Safety Tip of the Week

December 2, 2014

ANA Position Statement on Nurse Fatigue



Fatigue in health care workers as a contributing factor to many patient safety issues has been a central theme of many of our columns (see the list at the end of today’s column). Fatigue impacts everyone involved in the health care team and that even includes patients and their families. However, most of the literature on fatigue has focused on nurses and housestaff. And it shows adverse effects of fatigue not only on patient care but also on personal health.


Now the American Nurses Association has issued a position statement on nurse fatigue (ANA 2014) that calls upon nurses and employers to work together and take steps to minimize the impact of fatigue on patients and staff. It relies heavily on evidence-based strategies and outlines responsibilities for nurses individually and collectively and responsibilities for employers.


The position statement stresses that nurses must practice healthy behaviors to reduce the risk of working while fatigued and to recognize when they or a colleague are fatigued and potentially putting patient care at risk. It notes nurses should come to work well-rested and alert, take appropriate rest and meal breaks, and implement fatigue countermeasures as needed. The latter may include naps, caffeine, or both as appropriate. Note that we’ve stressed the value of naps and “power naps” as important but underutilized strategies to minimize the effects of healthcare worker fatigue in those working long shifts or night shifts (see our columns for November 9, 2010 “12-Hour Nursing Shifts and Patient Safety”, April 26, 2011 “Sleeping Air Traffic Controllers: What About Healthcare?”, January 2012 “Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety” and November 2012 “The Mid-Day Nap”). Employers must provide appropriate environments for such naps. It also often takes a change in culture to make naps acceptable (many nurses still fear the potential stigma a sleeping nurse might have in the perspective of a patient or family). One VA medical center implemented many good features to mitigate fatigue but did not attempt to introduce the at-work nap because of space and culture concerns (Fuller 2014).


The ANA position statement does focus on work hours, with recommendations for both nurses and employers. It recommends limiting work weeks to 40 or fewer hours per week and limiting shifts to 12 hours or less. It recommends one or two full days off to rest after 5 consecutive 8-hour shifts or 2 days off for rest after 3 consecutive 12-hour shifts. Note also that it stresses those hour limits should include not only paid hours but any time spent on unpaid activities (conferences, meetings, mandatory training, etc.) and on-call hours should be factored in as well.


The statement calls on employers to eliminate the use of mandatory overtime. It stresses that any nurse can and should refuse overtime or additional hours when fatigued and such refusal should be free of the risk of retaliation or other penalty.


Columns we’ve done that have attracted the most attention have been those looking at the 12-hour nursing shift (see the full list below). The new ANA position statement does not specifically comment on the 12-hour nursing shift. However, it does recommend for employers “Examine work demands with respect to shift length. Shifts longer than 8 hours may be unsafe when work is physically and cognitively demanding.” We’ve pointed out that because the 12-hour shift has become so popular in the US, both with nurses and hospitals, it will likely take compelling evidence to cause reversion to shorter shifts. While several pieces of information have pointed to the downsides of 12-hour shifts, conclusive evidence that adverse patient outcomes result from such shifts has been elusive, largely due to confounding variables in all studies.


The statement urges employers to involve nurses in development of staffing plans and design work schedules that limit overtime and take into account unanticipated events, like weather- or disaster-related situations. In addition, the organization should have in place policies and procedures for what to do if a worker is too fatigued to work.


Importantly, the ANA position statement urges nurses to consider the length of any commute before applying for positions. This is important because the literature demonstrates the impact of health care worker fatigue on motor vehicle accidents following work shifts. The ANA position statement also recommends that employers provide transportation home when a nurse is too tired to drive safely or provide sleep facilities at or near the facility as an alternative.


General health issues are important in avoiding fatigue. These include adequate diet and nutrition, adequate fluid intake, exercise, and stress management. In addition it is important to understand the potential effects of prescription and over-the-counter drugs and the signs and symptoms of sleep disorders. The statement also has recommendations about appropriate sleep hygiene.


Fatigue management training and education should also be provided not only for nurses and other employees but also managers. This should include education about sleep disorders as well.


Auditing adherence to work hour guidelines is an important responsibility of employers. But your typical hospital just looks at time card data. That does not include the additional hours noted above. And most hospitals don’t audit to see if nurses actually take their recommended rest and meal breaks.


Lastly, it is important that organizations have an anonymous reporting system so that information about fatigue can be conveyed in reports about accidents, errors and near-misses.


In our July 29, 2014 Patient Safety Tip of the Week “The 12-Hour Nursing Shift: Debate Continues” we predicted that someday we will have the equivalent of the brief “sobriety” or “breathalyzer” test that can rapidly identify healthcare workers who are impaired by fatigue. We envision that at regular intervals beyond 8 hours (maybe even sooner) the healthcare worker will get buzzed on his/her smartphone and have to complete some simple test of reaction times or attention span. If the worker scores outside the established threshold the hospital will need to have resources in place to take over duties of that worker (completely or at least temporarily until fatigue is alleviated by, for example, a nap). We are actually not that far away from such a test. Studies have demonstrated alteration of saccadic eye movement metrics correlate with fatigue in several settings and recently studies in surgical residents confirmed such a correlation (Di Stasi 2014). Such a test could probably be easily adapted to most of today’s smartphones.


We’d be remiss if we failed to point out that in the Di Stasi study surgical residents who were fatigued (by both the saccadic eye movement metrics and subjective measures of fatigue) did not have their performance on simulated laparoscopic procedures affected. That, of course, demonstrates that fatigue and prolonged work hours do not always result in errors. The interaction among multiple factors is much more complicated. The literature on management of fatigue in healthcare has overwhelmingly focused on hours of work. We know that the work hour reductions for housestaff have not produced convincing evidence that patient outcomes are improved (see our many columns on work hours and housestaff listed below).


A very interesting contribution from the psychology/sociology literature looked at strategies healthcare workers use to combat fatigue (Ferguson 2013). Though the research was based upon focus groups and semi-structured interviews and not correlated with actual patient or staff outcomes (hence not considered “evidence-based”), it offers a unique look at the additional layers of defense to prevent fatigue-related errors. And, not surprisingly, it turns out that most of these strategies involve informal processes rather than formalized processes and are strongly related to non-technical skills. Yes, use of caffeine and taking breaks were strategies used by individuals. But they also found keeping busy to be a useful strategy. They also used informal error-proofing practices such as focusing on one task at a time, switching temporarily to another task, double checking oneself or asking a colleague to double check, and deferring decisions to later or to another colleague. Teams also had work practice strategies such as prioritizing finishing times for colleagues who had the shortest break between shifts, facilitating napping by “batching” tasks on the night shift, and rotating night-shift naps.


Barriers to fatigue management in the Ferguson study were individual (eg. personal responsibility for work and non-work time), organizational (eg. staffing, workload, financial, cultural), and community-based (eg. expectations for service delivery and availability).


One theme that echoes a point included in the ANA position statement is the importance of incident reporting (for fatigue-related incidents and near-misses). Though the Ferguson study was qualitative rather than quantitative, the general feeling was that such incidents are currently underreported.


We also found some interesting comments in both the ANA and Ferguson papers about individual safety in driving home after long shifts. In the Ferguson study taxi vouchers offered by some hospitals were seldom used. The ANA paper notes that things we all do when struggling with drowsy driving (such as putting windows down, turning up the radio, pinching ourselves) don’t work! Maybe that smartphone app we talked about above will also mount on our rear view mirror!



We again recommend you read our November 9, 2010 Patient Safety Tip of the Week “12-Hour Nursing Shifts and Patient Safety” to see some of the excellent prior work that has been done by Geiger-Brown and colleagues (Geiger-Brown 2010) and Fallis and colleagues (Fallis 2011) regarding some of the strategies to mitigate nurse fatigue and also our columns listed below on the impact of fatigue in healthcare and other industries and use of strategies such as power naps.




Some of our other columns on the role of fatigue in Patient Safety:


November 9, 2010      12-Hour Nursing Shifts and Patient Safety

April 26, 2011             Sleeping Air Traffic Controllers: What About Healthcare?

February 2011             Update on 12-hour Nursing Shifts

September 2011          Shiftwork and Patient Safety

November 2011          Restricted Housestaff Work Hours and Patient Handoffs

January 2010               Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety

January 3, 2012           Unintended Consequences of Restricted Housestaff Hours

June 2012                    June 2012 Surgeon Fatigue

November 2012          The Mid-Day Nap

November 13, 2012    The 12-Hour Nursing Shift: More Downsides

July 29, 2014               The 12-Hour Nursing Shift: Debate Continues

October 2014              Another Rap on the 12-Hour Nursing Shift



Our previous columns on the 12-hour nursing shift:


November 9, 2010      12-Hour Nursing Shifts and Patient Safety

February 2011             Update on 12-hour Nursing Shifts

November 13, 2012    The 12-Hour Nursing Shift: More Downsides

July 29, 2014               The 12-Hour Nursing Shift: Debate Continues

October 2014              Another Rap on the 12-Hour Nursing Shift



Some of our other columns on housestaff workhour restrictions:


December 2008           IOM Report on Resident Work Hours

February 26, 2008       Nightmares: The Hospital at Night

January 2010               Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety

January 2011               No Improvement in Patient Safety: Why Not?

November 2011          Restricted Housestaff Work Hours and Patient Handoffs

January 3, 2012           Unintended Consequences of Restricted Housestaff Hours

June 2012                    Surgeon Fatigue

November 2012          The Mid-Day Nap

December 10, 2013     Better Handoffs, Better Results

April 22, 2014             Impact of Resident Workhour Restrictions










American Nurses Association. Position Statement. Addressing Nurse Fatigue to Promote Safety and Health: Joint Responsibilities of Registered Nurses and Employers to Reduce Risks. September 10, 2014



Fuller HJA, Haubert M-K. Managing Fatigue. VA National Center for Patient Safety. Topics in Patient Safety TIPS 2014; 14(5): 2



Di Stasi LL, McCamy MB, Macknik, SL, et al. Saccadic Eye Movement Metrics Reflect Surgical Residents' Fatigue. Annals of Surgery 2014; 259(4): 824-829



Ferguson SA, Neall A, Dorrian J. Strategies used by healthcare practitioners to manage fatigue-related risk: beyond work hours. Medical Sociology Online 2013; 7(2): 24-33



Geiger-Brown J. Trinkoff AM. Is It Time to Pull the Plug on 12-Hour Shifts? Part 3. harm reduction strategies if keeping 12-Hour Shifts. Journal of Nursing Administration 2010;  40(9): 357-9, 2010 Sep



Fallis, WM, McMillan DE, Edwards MP. Napping During Night Shift: Practices, Preferences, and Perceptions of Critical Care and Emergency Department Nurses

Crit Care Nurse March 31, 2011 vol. 31 no. 2 e1-e11






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