Managing fatigue reduces nurse errors

Sleepiness affects day, night shifts

Night shift nurses aren't the only ones fighting sleepiness during work. Even day shift nurses suffer from sleep deprivation from getting too little sleep at night. A recent study in Michigan found that a comprehensive fatigue management program can improve alertness and prevent fatigue-related errors in nurses regardless of their shift.1

"Most people know we have a strong drive to sleep at night, but most people don't realize we have a strong drive to sleep in the afternoon [because of the circadian rhythm]," says Linda Scott, PhD, RN, NEA-BC, FAAN, a professor and associate dean at the Kirkhof College of Nursing of Grand Valley State University in Grand Rapids, MI. "If you could take a strategic nap during that time period, it would refresh you for the commute home or the rest of the afternoon."

Educate employees on fatigue

According to the guidance on Fatigue Risk Management in the Workplace, employees and managers should be educated on:

The hazards of working while fatigued and the benefits of being well rested.

• The impact of chronic fatigue on personal relationships, mental/physical well-being, as well as general life satisfaction.

• Recognizing that although fatigue cannot be eliminated, it can be managed and minimized.

• Adequate quantity and quality of sleep as the key to managing fatigue.

• Basics of sleep physiology, circadian rhythms, and what is getting adequate sleep.

• Sleep hygiene — how to obtain adequate quantity and quality of sleep.

• Sleep disorders — why they matter, how to tell if one may have one, and what to do about it.

• The importance of diet, exercise, stress management, and management of other health conditions that affect fatigue, as well as information about how to address these issues.

• How to recognize fatigue in oneself or one's coworkers.

• Alertness strategies to be used while at work, such as appropriate use of caffeine, rest or exercise breaks, and social interactions.

• Advice on managing personal relationships for shift workers.

Source: American College of Occupational and Environmental Medicine

In the study, 47 nurses received education about fatigue, sleep and strategies to improve alertness. Schedules were adjusted so nurses could take breaks in which they were completely relieved by other nurses, and they had the opportunity to take strategic naps during their break or mealtime.

After the interventions, the nurses reported that their nighttime sleep duration had increased by 50 minutes. Their reported errors and near-errors decreased.

While fatigue management strategies have often been used in transportation and other 24-7 industries, this study "showed it was feasible to do this in health care," says Scott.

Nurses respond to sleep education

To combat fatigue, both nurses and managers had to change some assumptions about sleep and work. For example, some nurses believed they could handle a lack of sleep during the work week and make it up by sleeping more on their days off, says Scott.

"We found people who did not sleep in the 24 hours before work and then went to work and worked another 12 hours. Then they drove home, putting the public at risk on the road," she says.

Sleep duration improved immediately after the education sessions, Scott says.

Meanwhile, the managers agreed to avoid assigning overtime, which might make it more difficult for nurses to have enough time off between shifts to allow for adequate sleep. They made sure that staffing allowed for nurses to take breaks in which they were completely off duty, and they suspended policies that didn't allow people to sleep on the job.

Instead, the three study hospitals found space for nurses to take a nap. Even taking a complete break improved function, Scott says. "There is evidence that respite from the job will help you increase awareness. It allows you to refresh and refocus," she says.

Nurses used logbooks to track their sleep, drowsiness, errors, near-errors and other fatigue-related issues. In the 16-week study period, they reported 117 errors or near-errors. Those reports decreased with the fatigue management strategies, while errors that were discovered and prevented increased.

Sleep quality still a problem

Still, there were challenges. Nurses felt guilty about taking naps and some stopped during the study. Managers were supportive of the naps and other strategies, but sometimes had trouble finding adequate space, says Scott. For example, one hospital converted old physician call rooms for nap space, but nurses felt it was too far from their unit.

"It wasn't inconvenient to get to, but it was far enough from the unit that they felt uncomfortable," Scott says.

Almost all the nurses (92%) continued to report problems with their daily sleep quality. In fact, 18 of the 47 nurses reported severe daytime sleepiness even after the fatigue management intervention.

Know these signs of excessive fatigue

• Physical signs

• Yawning

• Drooping eyelids

• Rubbing of eyes

• Head dropping

• Microsleeps

• Digestive problems

• Mental signs

• Difficulty concentrating on tasks

• Lapses in attention

• Difficulty remembering tasks being performed

• Failing to communicate important information

• Failing to anticipate events or actions

• Accidentally doing the wrong thing

• Accidentally not doing the right thing

• Emotional signs

• More quiet or withdrawn than usual

• Lack of energy

• Lacking the motivation to perform the task well

Source: American College of Occupational and Environmental Medicine

Health care employers should promote good sleep hygiene and implement fatigue management, Scott says. And employees need to understand that they should come to work well-rested, she says.

"As health care providers, we all have an accountability to go to work being fit for duty," she says. "As employers, we have an obligation to ensure that the work environment is safe for our customers."

Addressing fatigue in health care is one important part of a safe workplace, Scott says.


1. Scott LD, Hofmeister N, Rogness N, et al. An interventional approach for patient and nurse safety. Nursing Research 2010; 59:250-258.