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Department: PATIENT SAFETY

Overextended

Fighting the fatigue of long shifts

Douglass, Jessica A. MSN, AGPCNP-BC

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doi: 10.1097/01.NURSE.0000441895.42899.0c
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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 harm's way. Because patient safety is nurses' number one goal, this issue impacts every nurse's 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 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 They're 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 nurse's work schedule and work tasks.5

After 17 to 19 hours at work, a nurse driving home would be as impaired as someone who's driving with a blood alcohol level that's 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, they're 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 can't 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 don't 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 could interrupt sleep. When “winding down” for a good sleep, it's best to avoid large meals, caffeine, alcohol, and nicotine.8
  • Caffeine. Although many nurses use caffeine to stay alert during long shifts, most don't use it as effectively as they could. Caffeine shouldn't 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 that's 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 can't 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 high-risk 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 isn't 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.
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