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Fatigue is a reality in nursing. Every day, during every shift, nurses can experience fatigue of their minds, bodies and spirits. Workload, work hours, work structures and many other factors can indirectly or directly cause fatigue in this professional group.
Professional, caring, competent, compassionate, and courageous nurses are what the public expects and the patients and families who entrust us with their care deserve. As nurses and nurse leaders, we have an obligation to be "fit for duty" when reporting to work, and a duty to construct and support healthy work environments for optimizing professional practice.
Fatigue & Med Errors
What we know from the literature is that nurse fatigue is linked to errors in healthcare. It is clear from the Agency for Healthcare Research and Quality (AHRQ) that the risk of errors is increased by 3.4 percent when nurses do not get 6 or more hours of sleep in the 24 hours preceding their shift. In a hospital with 1,000 nursing shifts per day, that translates to 34 more errors per day.1 In many hospitals, more than 80 percent of nurses work 12-hour shifts.
In a study by the Texas Board of Nursing (BON) in 2008 with 11,785 respondents, 81 percent being direct care nurses, 95 percent of direct care nurses did not want the BON to regulate nurse work hours or shift lengths.2 In a survey of chief nursing officers in Texas, 92 percent of CNOs reported they have no way to monitor outside work hours of direct care nurses, and 47 percent believe the maximum number of hours worked in 7 days should not exceed 60.3
So, if we understand that nurse fatigue is a source of risk to patient safety and a health issue for this profession; that direct care nurses do not want work-hour regulation from the BON; that the BON delegates this professional responsibility/accountability to the individual nurse to be "fit for duty," and that CNOs have no current or practical way to monitor total hours worked by nurses outside their facility, what can we do to protect both the nurses and patients?
 Protecting Patients & Nurses
We turn to the research in fatigue and best practices in the community. The literature specific to nurse fatigue is limited, but what does exist is similar to other industries where shift work in a 24-hour-per-day operation exists. The literature suggests the following, including best practices:
- Getting plenty of rest prior to the shift. It is recommended that nurses have a minimum of 6 hours of uninterrupted sleep in the 24 hours prior to the start of the shift.
- Eating right and exercising. Not too much new to add here, but we do know that these two elements help us to regulate hormonal levels and circadian rhythms.
- Nurse executives teaching employees that it's okay to say no when the nurse is not "fit for duty."
- Teaching nurses self-care, stress management, signs and symptoms of fatigue, and providing peer support to them to reinforce the "fit for duty" concept.
- Judicious use of caffeine.4 Limiting caffeine when off-shift and using it early in the shift or before anticipated sleepiness.
- Rest periods and even naps at work can improve focus and stamina. Many organizations have implemented quiet spaces and nap rooms as best practices. Recommended nap length is between 20 and 45 minutes.
- Organizations have codified expectations around shift lengths, number of shifts that may be worked consecutively, minimum required time away from work between shifts, and limited shift rotations.
- Position statements from boards of nursing and professional organizations have proposed that if nurses work 12-hour shifts, the last 4 hours be out of direct patient care.
- States such as Texas have mandated through hospital licensing rules the elimination of mandatory overtime for nurses as an option, except in specifically defined situations.
Matt Miller in his book, The Tyranny of Dead Ideas, challenges us to think about the ideas of our society, our professions and our lives that are no longer true or relevant.5 I would encourage the nursing profession to think about our dead ideas. It is in that spirit that I would suggest we vet the 12-hour shift for the design of nursing work and patient care environments in light of research findings, and our lack of evidence in managing fatigue in one of the most honorable, noble and trusted professions in our nation.
I do not advocate the abolishment of the 12-hour shift. Instead, I would advocate for more research on how to best manage fatigue in nurses, the creation of evidence-based institutional policies that protect nurses and patients, and the design of nursing work environments and processes to modify and eliminate those elements that are directly linked to fatigue in nurses.
References
1. Agency for Healthcare Research and Quality. (2010). Staff nurse fatigue and patient safety. Retrieved from the World Wide Web: http://www.ahrg.gov/.
2. Texas Board of Nursing. (2008). A survey of Texas nurses. Retrieved from the World Wide Web: http://www.bon.state.tx.us/.
3. McDermott, S., Marshall, J. & Edmonson, C. (2009). Nurse fatigue: Research, administrative, and practice perspectives. Retrieved from the World Wide Web: http://www.myntone.com/.
4. Rogers, A. (2010) The effect of fatigue and sleeplessness on nursing performance and patient safety. Retrieved from the World Wide Web: http://www.ncbi.nlm.nih.gov/.
5. Miller, M. (2009). The Tyranny of Dead Ideas. New York: Holt Paperback.
 Cole Edmonson is vice president and chief nursing officer at Texas Health Presbyterian Dallas Hospital.
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