PATI ENT SAF ET Y

Overextended: Fighting the fatigue of long shifts

By Jessica A. Douglass, MSN, AGPCNP-BC

EXTENDED WORK SHIFTS of 12

or more hours are the norm for
clinical nurses. Although many
nurses report increased satisfaction
with extended shifts, nurses must
ask themselves if their fatigue may
be putting themselves and their
patients in harms way. Because
patient safety is nurses number
one goal, this issue impacts every
nurses practice.
In December 2011, The Joint
Commission issued a sentinel event
alert to healthcare organizations
identifying the patient safety risks
of healthcare worker fatigue.1 This
alert inspired the author to perform
a literature review of countermeasures used to help clinical nurses
identify and manage fatigue in their
own practice. This article provides
updates about current trends for
combating fatigue and provides
useful tips to prevent fatigue.
Impact on patient safety
Nurses find themselves fatigued at
different times during their practice
due to sleep disturbances, extended
shifts, family issues, school commitments, and other personal and professional reasons. Nurses who are
tired can have trouble paying attention and staying focused. Other consequences of fatigue include reduced
motivation, irritability, memory
lapses, impaired communication,
diminished reaction time, slowed
information processing and judgment, and loss of empathy.1,2 One
study showed that the incidence of
needlestick injuries, musculoskeletal
injuries, medication errors, and
blood administration errors in shifts
of 12 hours or more was significantly
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increased compared with shifts of

8.5 hours.2
The toll on nurses health
According to Keller, extended shifts
are more likely to undermine nurses
health and well-being: Nurses working extended shifts are more prone
to chronic illnesses, musculoskeletal
injuries, car crashes after their shift,
and disturbed sleep cycles.3,4 Theyre
also more prone to unhealthy lifestyle choices such as smoking,
drinking, and exercising less than
recommended, and more susceptible
to immune system impairment and
depression.3 The extent of negative
effects depends on the nurses work
schedule and work tasks.5
After 17 to 19 hours at work, a
nurse driving home would be as
impaired as someone whos driving
with a blood alcohol level thats
over the legal limit.3 Driving while
fatigued is a risk that no one should
take lightly. This is a risk not only
to the individual nurse but also to
others on the road.
The aging of the nursing workforce is another factor. As people
age, theyre less tolerant of sleep loss
and take longer to recuperate after
extended shifts.3,5 Older nurses are
more prone to chronic illnesses.
Those in the sandwich generation
may be caring for their older children, young grandchildren, and
older parents. If given the option,
older nurses prefer shorter shifts to
extra days off work.3
How nurses can protect
themselves
These practical tips can help nurses
stay fresh and avoid fatigue.

Minimize sleep loss. Sleep deficits

build up, contributing to chronic
fatigue. To prevent a sleep deficit,
nurses should get 7 to 8 hours of
uninterrupted sleep before working
days or nights.6
Using rest periods and strategic
napping can help to eliminate sleep
deficits, especially if a nurse cant
get 7 to 8 hours of sleep.6 Effective
naps can be long or short. Long
naps lasting 3 hours or more allow
the nurse to complete one full sleep
cycle, including deep sleep. Long
naps are beneficial before a night
shift or to make up for a large sleep
deficit.7
Napping for a short time (15 to
45 minutes) minimizes the chances
of entering a deep sleep.7 Interrupted deep sleep can lead to
increased fatigue. Short naps are
best used just before duty or as
planned napping during a shift. If
nurses wake up somewhat sluggish
from short naps, they should make
the nap slightly shorter the next
time and give themselves more time
to wake up before resuming patient
care. Many employers dont have
policies in favor of napping of any
kind. Reform of nap policies and
work hours of medical residents
put into place in 2003 may provide
a springboard for nurses to promote a change in napping or
extended shift policies for safer
patient care.5
Good sleep habits. The best way
to fight fatigue is to use good sleep
habits, such as following a daily routine and making the sleep area comfortable. This area should be dark,
quiet, and free of distractions (such
as TV, radio, and cell phones) that
March l Nursing2014 l 67

Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

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could interrupt sleep. When winding down for a good sleep, its best
to avoid large meals, caffeine, alcohol, and nicotine.8
Caffeine. Although many nurses
use caffeine to stay alert during
long shifts, most dont use it as
effectively as they could. Caffeine
shouldnt be used on a regular
basis because tolerance may
develop; instead, caffeine should
be used strategically throughout
shifts. Nurses who are already
alert benefit more from drinking
water than a caffeinated drink.
Caffeine should be used in anticipation of drowsiness to increase
alertness; caffeine is best consumed
about an hour before a decrease in
alertness is expected.6 To prevent
insomnia, nurses should avoid
caffeine for at least 3 hours before
bedtime.3
Work environment. Especially
during the night shift, paying special
attention to the work environment
can help nurses prevent excessive
fatigue. Strategic lighting can
increase alertness in work areas.3
For example, keeping hallways
dark and nurse work areas bright
increases attention and encourages
wakefulness.9
Another environmental component that can affect alertness is room
temperature. A workplace thats too
warm can decrease alertness and
cause drowsiness. Alertness is
increased with slightly cooler temperatures or air moved across the
face with a fan.3
Teamwork. Because most individuals cant accurately judge their
own impairment, they should enlist
coworkers to help gauge their fatigue.6
Realizing fatigue may be occurring,
coworkers can help tired nurses with
difficult tasks or double-check highrisk work. Knowing their own limitations and working as a team on the

unit protects nurses and their

patients.
Waking up to safety
Clinical nurses need to know the
risks involved when working
extended shifts. By understanding
these risks, nurses can protect
themselves from falling victim to
fatigue. Proper sleep hygiene and
using countermeasures during the
shift can improve alertness and
safety. Protect yourself and your
patients from the effects of fatigue
in healthcare.
REFERENCES
1. The Joint Commission. The Joint Commission
Sentinel Event Alert. 2011. http://www.jointcommission.org/assets/1/18/SEA_48.pdf.
2. Geiger-Brown J, Trinkoff AM. Is it time to pull
the plug on 12-hour shifts? Part 1. The evidence.
J Nurs Adm. 2010;40(3):100-102.
3. Keller SM. Effects of extended work shifts and
shift work on patient safety, productivity, and
employee health. AAOHN J. 2009;57(12):497-502.
4. Lorenz SG. 12-hour shifts: an ethical dilemma
for the nurse executive. J Nurs Adm. 2008;38(6):
297-301.
5. Miller JA. When time isnt on your side: 12-hour
shifts. Nurs Manage. 2011;42(6):39-43.
6. Rogers A. The effects of fatigue and sleepiness on
nurse performance and patient safety. In: Patient
Safety and Quality: An Evidence-Based Handbook for
Nurses. Rockville, MD: Agency for Healthcare
Research and Quality; 2008:509-533.
7. Roth T. Appropriate therapeutic selection for
patients with shift work disorder. Sleep Med.
2012;13(4):335-341.
8. Akerstedt T, Wright KP Jr. Sleep loss and fatigue
in shift work and shift work disorder. Sleep Med
Clin. 2009;4(2):257-271.
9. 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. J Nurs Adm.
2010;40(9):357-359.

Jessica A. Douglass is an NP at Bronson Methodist

Hospital in Kalamazoo, Mich. Ms. Douglass wrote this
article as an Adult-Gerontology Primary Care Nurse
Practitioner capstone project at the University of
Cincinnati in Cincinnati, Ohio.

The author has disclosed that she has no financial

relationships related to this article.

DOI-10.1097/01.NURSE.0000441895.42899.0c

www.Nursing2014.com

Copyright 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.