Running head: IMPACT OF NURSES FATIGUE ON PATIENT SAFETY

Nursing Fatigue Impacts Performance and Patient Safety

Greg Angelo, Katie Cardon, William Skinner, Grace Thayer

Youngstown State University

NURS 3749

June 24th, 2015

IMPACT OF NURSES FATIGUE ON PATIENT SAFETY 1

Abstract

The unpredictable hours of a nurses shift are a well-known occurrence throughout the
nursing community. A nurses schedule can vary from: a scheduled eight hour shift to an
unforeseeable amount of hours. What comes along with these unforeseeable amounts of hours is
an increase in nurses fatigue, an increase in medication errors and patient safety can be at risk.
According to Ohio Senate house bill 346 which was passed in 2008, hospitals must implement a
written nursing services staffing plan. The Joint Commission has also sent out a sentinel event
referring to the numbers of hours and nurse has worked and the amount of errors that have
occurred. Our literature review, suggests there should be additional guidelines in place to
regulate nurse staffing more thoroughly. These guidelines should include increased emphasis on
patient safety and caregiver satisfaction.
IMPACT OF NURSES FATIGUE ON PATIENT SAFETY 2

Introduction

Nurses fatigue affects the ability of a nurse to perform his/her duties as a healthcare

professional. A nurse has many duties and keeping a patient safe is a critical one. Nurses can

work an unforeseeable amount of hours. Several research articles, such as, Fatigue,

performance and the work environment: a survey of registered nurses, suggest there is a direct

correlation between the fatigue that comes along with these unpredictable amount of hours and

patients safety. The Joint Commission is making an attempt to implement plans in order to

decrease the number of mistakes made by nurses due to fatigue.

Review of Literature

In the first research article, the role nursing fatigue plays in poor care is investigated. It is

hypothesized that there is a positive correlation between the number of hours a nurse works and

the number of performance decrements. In an article by Barker & Nussbaum (2010), there are

two issues being addressed. First, the perceived levels of mental, physical and total fatigue

among registered nurses. Secondly, the relationship between dimensions of fatigue and the

effects on nursing performance was investigated. The focus of the study is the effects of

perceived fatigue on rates of medical errors and worker injuries associated with stress and safety

performance decrements in a number of health care settings. The sample consisted of registered

nurses that were currently employed in a hospital, community or public health settings,

ambulatory care or a nursing home/extended care facility. An online survey was used to measure

physical, mental and complete fatigue dimensions. Participants were recruited using convenience

sampling in cooperation with professional nursing organizations. In total: 745 registered nurses

completed the survey between February 2008 and April 2009. The results of this study support
IMPACT OF NURSES FATIGUE ON PATIENT SAFETY 3

the hypothesis that fatigue levels are negatively correlated with performance; which further

supports the role of fatigue in nursing performance. Longer shift lengths and hours worked per

week were associated with increases in physical and total fatigue levels (Barker & Nussbaum,

2010).

Another article describes an innovative research protocol to test the total of missed

nursing care as a mediator of the association between nurse workload and patient outcomes in a

neonatal intensive care unit. This study hypothesizes that there is a causal relationship between

the increase in a nurses work load, missed care and infant outcome. Missed nursing care is

frequently hypothesized explanation for the association between workload and outcomes. This

study uses a longitudinal, observational study design. The sample consists of approximately 125

nurses (80% of target population) providing direct patient care in one neonatal intensive care

unit. Four, 6-week data collection cycles occur over 1 year. At the end of every shift, nurses

report their workloads and frequency with which specific patient care activities were missed for

each infant care for during the shift Tubbs-Cooley et al. (2014). Missed care may explain the

effects of nurse workload on patient outcomes.

In a third research article titled, Nurse Fatigue and Shift length: A Pilot Study Deborah

Maust Martin evaluates levels of fatigue associated with 12 and 8 hour shifts over a four week

period. Martin looks at acute fatigue, chronic fatigue, and inter-shift recovery to examine the

effects of working 12-hour shifts versus working 8-hour shifts.

Martin notes, The occupational Safety and health Administration (2013) cautions people

against working more than 8-hour shifts as longer shifts may result in reduced alertness. Shift
IMPACT OF NURSES FATIGUE ON PATIENT SAFETY 4

lengthy was a focus of the Joint Commission (2011) recommendations to mitigate fatigue in

health care workers (Martin 2015, p.1).

Factors used to determine quality patient-care between 12 and 8-hour shifts include job-

satisfaction, injury to self or patient, as well as physical and mental fatigue. Fatigue is correlated

to nurse performance and chronic fatigue is related to the number of hours worked (Martin p.2).

Longer work hours are shown to increase risk for errors. Longer shifts are associated with

nurse fatigue. This is a growing concern in the United States with 12-hour shifts becoming the

norm in patient care.

The last research article - by Stimpfel, Sloane, and Aiken (2012), a study was conducted

to investigate how extended work hours affect nurses fatigue and patient dissatisfaction. Nurses

are now working twelve hour shifts, rather than the traditional eight hour shifts. However, these

twelve hour shifts are sometimes unpredictable, due to fluctuations in patient needs and

unanticipated nursing changes (Stimpfel, Sloan, Aiken, 2012, p. 1). What comes along with

these fluctuations in hours is an increase in nurses fatigue, which in turn puts patients safety at

an increased risk.

The researchers conducted the study using surveys to determine shift length, working

conditions, fatigue, job satisfaction, and intentions to leave their jobs. Stimpfel, Sloan, and

Aiken, created four categories for the following shift lengths, 8-9 hours, 10-11 hours, 12-13

hours, and more than 13 hours.

In the portion of the study which concentrated on nurses scheduling practices and

outcomes, according to Stimpfel, Sloan, and Aiken (2012) the percentages of nurses reporting

fatigues and an intention to leave the job increased incrementally as shift length increased (p.5).
IMPACT OF NURSES FATIGUE ON PATIENT SAFETY 5

The increase of nurses fatigues and intention to leave their jobs, will most likely

influence patient satisfaction. Nurses who are tired and not well rested, may not have as much

patience with patients as nurses who only worked an eight hour shift the day before and got a full

nights rest. Stimpfel, Sloan, and Aiken stated, Hospitals in which a higher proportion of nurses

reported working more than thirteen hours on their last shift, higher percentages of patients

reported that they would not recommend the hospital to friends and family and gave the hospital

lower overall ratings (p.6).

This study concluded that there is a direct correlation between the longer the shifts for

hospital nurses, the higher the levels of fatigue and patient dissatisfaction (Stimpfel, Sloan,

Aiken, 2012, p.1).

Which of the issues is the best one to tackle, the number of errors that are committed, or

the fatigue of the nurse providing the care? While each of these has significant importance and

implications, nurses fatigue is recognized as one of the most important factors of errors in

patient care. Fatigue overarches and is causative of patient care errors. The prevention of the

fatigue factor is key in preventing mistakes in patient care and increasing affirmative outcomes

in patient health and satisfaction. In 2011, the Joint Commission decided it could no longer

remain silent on this issue and took a stance. The Commission let health care facilities know that

mistakes, caused by nurses fatigue, would not be tolerated.

In 2011, the Joint Commission sent out a sentinel event alert on nurse fatigue. The alert

states that there is a direct correlation with the amount of hours worked and the number of errors

that were committed (Joint Commission, 2011). In this sentinel event, there were several things

that the joint commission suggested to help improve the fatigue related mistakes.
IMPACT OF NURSES FATIGUE ON PATIENT SAFETY 6

The first and most important step that the Joint Commission suggested assessing the

organization for fatigued related risk (Joint Commission, 2011). Just like in the nursing process

one must know if there is a potential problem before there is anything that can be done about it.

Next, the joint commission suggested implementing a fatigue management plan (Joint

Commission, 2011). When finished assessing it is very important for the organization to now

find possible solutions and put them in place to help their employees. One of the major ways of

helping employees is educating them on sleep hygiene (Joint Commission.2011). If the health

care organizations focus on these topics then they will be able to reduce errors or adverse

situations caused by fatigue.

Conclusion

In conclusion, nurses shifts should be more regulated in order to decrease the number of

errors, and improve patient safety and satisfaction. Every single research article blatantly stated

that there is indeed a positive correlation between nurses fatigue and patient safety. With the

Joint commission implementing fatigue management plans, nurses will now be able to work

under more satisfactory working conditions, and patients will be safer.

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References

Alan, V (n.d). Bill Analysis: Sub. H.B. 346. Retrieved June 5, 2015, from

http://www.lsc.ohio.gov/analyses127/h0346-rs-127.pdf

Barker, L.M. & Nussbaum M.A. (2010). Fatigue, performance and the work
environment: a survey of registered nurses. Journal Of Advanced Nursing, 67(6),
1370-1382.doi: 10.111/j01365-2648.2010.05597.x

The Joint Commission Sentinel Event Alert. (2011, December 14). Retrieved June
3,2015, from http://www.jointcommission.org/assets/1/18/SEA_48.pdf

Martin, D. M. (2015, April). Nurse Fatigue and Shift Length: A Pilot Study. Nursing Economics,

33, 81-87.

Stimpfel, Sloane, & Aiken (2012). The Longer The Shifts for Hospital nurses. The
higher the Levels of Fatigue and Patient Dissatisfaction. Health Affairs, 31, no.
11

Tubbs-Cooley, H.L., Pickler, R.H., Mark, B.A. & Carle, A.C. (2014). A research protocol
for testing relationships between nurse workload missed nursing care and
neonatal outcomes: the neonatal nursing care quality study. Journal Of Advanced
Nursing, 71(3), 632-641. Doi: 10.1111/jan.12507