TONE Monthly
March 2018

Fatigue in Nursing: Should we be Concerned?

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We all are aware of the challenging and intense nature of nurses’ work – the long hours, the mental stress and the opportunities (or demand) to work far beyond the typical 40-hour workweek. The data is overwhelming. Fatigue in nursing is a problem that affects both patient safety and the nurse’s individual health (Smith-Miller, Shaw-Kokot, Curro & Jones, 2014). Fatigue and long working hours have a negative impact on health in areas such as sleep disturbances, injuries, musculoskeletal disorders, mood disorders, and increased risk for needle sticks (Bae & Fabry, 2014; Rogers, 2008).  Nurses who are tired may put their patients’ safety in jeopardy. Working fatigued has been shown to increase the risk of patient care errors, reduce reaction time, and impair attention to detail and problem-solving ability (Geiger-Brown et al., 2012; Ruggiero, 2003; Scott, Arslanian-Engoren & Engoren, 2014; Trinkoff et al., 2011).

Fatigue among nurses is such an important issue that it has been addressed by the American Nurses Association (ANA, 2014), the Institute of Medicine (Colten & Altevogt, 2006) and The Joint Commission (2011). Despite the extensive research and reports about fatigue in nursing, adoption of evidence-based practices and policies to address fatigue is limited (Steege, Pinekenstein, Rainbow & Knudsen, 2017). The good news is that many opportunities exist to manage fatigue by both the individual nurse and the healthcare organization leadership. 

Each individual nurse carries the professional responsibility to come to work rested, alert and able to give full energy and attention to his or her nursing practice and to help create a healthy work environment in which to provide safe and effective patient care. Following are some specific strategies for the individual nurse to avoid fatigue (ANA, 2014):

  • Sleep 7-9 hours per 24 hours.
  •  Improve overall personal health and wellness through stress management, nutrition, and exercise.
  • Take scheduled meals and breaks during the work shift.
  • Be willing to negotiate or reject a work assignment if you are too fatigued.
  • Be willing to initiate discussion with a colleague if they seem impaired from fatigue.
  • Be aware of your personal and ethical responsibility to go to work rested, alert and able to take on the immense responsibility of safe nursing practice.  

The Code of Ethics for Nurses (ANA, 2015) clearly establishes the nurse’s responsibility for promoting, advocating and protecting the health and safety of the patient as well as promoting and protecting the nurse’s own individual health and safety. Raising nurses’ awareness of this important responsibility is an essential first step in avoiding fatigue.

While it is clear that nurses have an individual responsibility to manage fatigue, employers have an equally important responsibility to embrace strategies and policies to reduce risks from nurse fatigue. In its position statement addressing nurse fatigue, ANA (2014) recommends the following strategies for employers to reduce the risks of working fatigued: 

  • Eliminate the use of mandatory overtime as a staffing solution.
  • Adopt as official policy that RNs can reject a work assignment in good faith on the basis of fatigue with no adverse consequences.
  • Establish at least 10 consecutive hours per day of protected time off for nurses to obtain 7–9 hours of sleep.
  •  Institute anonymous reporting systems for errors and near misses and include risk for fatigue-related errors in incident investigations.
  • Promote fatigue management education for employees and managers, including education about sleep disorders.
  • Reduce risks of drowsy driving by providing transportation home when a nurse is too tired to drive safely.

The responsibility of the employer is also addressed in a recent study, which concluded that “nursing leaders, in partnership with other organizational leaders, should develop a plan to monitor fatigue and implement multiple levels of interventions to prevent fatigue and mitigate its consequences” (Steege et al, 2017, p. 426).  Nurses must be supported at the organizational level, as well as accept their own professional responsibility  to be rested and able to provide high quality, safe nursing care while also taking care of their own personal health and well-being. 



American Nurses Association. (2014). Addressing nurse fatigue to promote safety and health: Joint responsibilities of registered nurses and employers to reduce risks. Available online at

American Nurses Association. (2015). Code of ethics for nurses.  Available online at

Bae, S., & Fabry, D. (2014). Assessing the relationships between nurse work hours/overtime and nurse and patient outcomes: Systematic literature review. Nursing Outlook, 62(1), 138–156.

Colten, H. & Altevogt, B.  (2006). Sleep disorders and sleep deprivation: An unmet public health problem. Washington, DC: National Academic Press.

Geiger-Brown, J., Rogers, V. E., Trinkoff, A. M., Kane, R. L., Bausell, R. B., & Scharf, S. M. (2012). Sleep, sleepiness, fatigue, and performance of 12-hour-shift nurses. Chronobiology International, 29(2), 211–219.

Rogers, A.E. (2008). The effects of fatigue and sleepiness on nurse performance and patient safety. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Washington, DC: Agency for Healthcare Research and Quality, p. 509-546.

Ruggiero J.S. (2003). Correlates of fatigue in critical care nurses. Research in Nursing and Health, 26(6), 434-444.

Scott, L. D., Arslanian-Engoren, C. M., & Engoren, M. (2014). The association of sleep and fatigue with decision regret among critical care nurses. American Journal of Critical Care, 23(1), 13–23.

Smith-Miller, C.A., Shaw-Kokot, J., Curro, B., & Jones, C.B. (2014). An integrative review: Fatigue among nurses in acute care settings. JONA, 44(9), 487-494.

Steege, L.M., Pinekenstein, B.J., Rainbow, J.G., & Knudsen, E.A. (2017). Addressing occupational fatigue in nurses: Current state of fatigue risk management in hospitals, Part 1. JONA, 47(9), 426-433.

The Joint Commission. (2011). Health care worker fatigue and patient safety. Oakbrook Terrace, IL: The Joint Commission.

Trinkoff, A. M., Johantgen, M., Storr, C. L., Gurses, A. P., Liang, Y., & Han, K. (2011). Nurses’ work schedule characteristics, nurse staffing, and patient mortality. Nursing Research, 60(1), 1–8.


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