Manage fatigue to boost safety

ACOEM: Staffing, education path to culture change

It will take a culture shift for doctors, nurses and other health care workers to consider fatigue as a major factor in patient and employee safety. But that moment may be a step closer with new guidance on fatigue management in the workplace.

The American College of Occupational and Environmental Medicine (ACOEM) issued detailed guidance on establishing a fatigue management system and urged occupational medicine physicians to be involved in developing such programs.1 "Well-rested, alert employees are critical to safe and productive operations," ACOEM declared.

ACOEM touts a "science-based, data-driven" system to reduce the risk of fatigue that puts responsibility on both employees and employers. That means adequate scheduling and staffing levels and treatment of sleep disorders.

"As part of a comprehensive fatigue risk management system, management provides for the opportunity for employees to get adequate sleep. Management also provides training that is designed to inform employees of the risks associated with inadequate sleep and what they can do to get an adequate quality and quantity of sleep," says Steve Lerman, MD, MPH, FACOEM, lead author of the guidance and occupational health manager at Exxon Mobil Corp.

The guidance document was drafted by sleep experts and occupational medicine physicians on ACOEM's Task Force on Fatigue Risk Management.

Fatigue management rules and interventions are commonplace in some sensitive industries, such as trucking, airlines, and nuclear power. The paradigm shift has been much slower in health care, says Ann E. Rogers, PhD, RN, FAAN, Edith F. Honeycutt Chair in Nursing and director of Graduate Studies at the Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta.

"Our culture doesn't value it," says Rogers, who has studied the impact of shift length on nursing errors. "You don't want to short-staff the unit and make your colleagues overburdened. Our culture values the workaholic, [and the idea] that you can get by without sleep, which is not true."

The ACOEM guidance provides powerful evidence, she says. "They supported this with data," she says.

HCWs need time off

Work hour limits and alertness strategies alone won't solve the problem of fatigue, although they are components of the solution. The ACOEM outlines elements of a fatigue risk management system. They include analyzing fatigue as a risk to patients and employees and considering the role of fatigue in incident investigations.

ACOEM urges employers not just to react to adverse events that are related to fatigue, but to be proactive and try to avoid them. "Excess fatigue is a known risk factor for errors leading to incidents," Lerman says.

A major issue: staffing levels that enable employees to have adequate time off and breaks during their work shifts. "One of the most important (but frequently overlooked) root causes of employee fatigue is an imbalance between workload and staffing levels," ACOEM says.

Managers tend to correct a staffing imbalance with overtime, which leads to fatigued workers and ultimately to absenteeism, the guidance says. A small portion of workers may volunteer for overtime, and they may become financially dependent on the extra money.

Short-staffing may prevent nurses from taking breaks during their shifts, says Rogers. Many nurses in our data show they'll work through [their breaks], they may or may not get lunch, they'll eat on the unit," she says. "They're going to have trouble staying alert.

Meanwhile, employees may not even realize that they are fatigued or that their performance is suffering, says Rogers.

"We're really not good at assessing our level of fatigue and we're often in denial," she says. "We're all human beings. We're all going to be affected by sleep deprivation, and we're all going to be affected by working nights."

Lerman suggests conducting a workload-staffing analysis to make sure you have enough employees to cover the needed positions. "Management should take into account such factors as vacations, anticipated turn-over, illness absence and variations in workload to determine the right level of staffing for their organization," he says.

Sleep disorders lead to fatigue

What can you do about employees who are fatigued because they don't get enough sleep at night, either because of poor habits or sleep disorders?

Education about sleep hygiene, fatigue and alertness can change behavior, ACOEM says. Ideally, the education could occur in "natural work teams," where an instructor would customize the program for the unit, the guidance says.

Meanwhile, more than 40 million Americans suffer from a sleep disorder, a leading cause of fatigue. Fatigue is also a symptom of depression and other conditions.

ACOEM recommends using a questionnaire to screen for sleep disorders. "There are a variety of validated questionnaires that can be used to detect excess daytime sleepiness, which may be the result of a sleep disorder," Lerman says.

A physical exam, a sleep diary and a mental health evaluation are other ways to assess sleep disorders.

It's hard to change longstanding behaviors, but there are signs that fatigue management is gaining recognition in health care. The Joint Commission accrediting body issued a Sentinel Event Alert on fatigue and the Accreditation Council for Graduate Medical Education issued stricter duty limits for first-year residents

"There is increasing awareness," says Rogers. "But we also need nurses and physicians and [others in health care] to alter the culture."

[Editor's note: A copy of the ACOEM Guidance Statement, "Fatigue Risk Management in the Workplace," is available at]


1. Lerman SE, Eskin E, Flower DJ, et al. ACOEM Guidance Statement: Fatigue risk management in the workplace. Jrl Occ Environ Med 2012; 54:231-258.