The Impact of Fatigue on Nurses: Research Findings

United American Nurses, AFL-CIO

Health and Safety Factsheet
Fatigue in Night Shift and Rotating Shift Workers
Night shift work conflicts with nurses’ and other workers’ circadian rhythms, which tend
to peak in the late afternoon and decrease to their lowest point in the early morning hours.
Workers must fight against the natural tendency to be drowsy late at night and must try to
sleep during the day when it feels more natural to be awake. Day sleepers tend to sleep
lightly and may also get fewer hours of sleep due to other responsibilities. Fatigue builds
up after several days of night shift work, as the worker is deprived of deep sleep and
enough hours of sleep, making night work harder.1
Fatigue combines with the circadian low-point to effect productivity and alertness on the
job. Fatigue built up over several days can accumulate to unsafe levels, especially if a
worker works six or seven days in a row without a day off. Some researchers suggest that
only two to four nights should be worked in a row before a few days off. Working ten to
fourteen days in a row and then having five to seven days off should be avoided. It is
harder for older workers to recover from such long work periods. Employers could also
consider eight-hour night shifts instead of twelve-hour shifts.
Most night shift workers return to a day schedule on their days off, making it difficult for
their bodies to completely adjust to a night schedule. Night shift work also interferes with
family and social life, causing stress. Digestive problems and heart disease has been found
more often in night shift workers. They often do not have access to nutritious meals while
at work. Night shift workers are also more sensitive to toxic substances, because the
circadian rhythm makes the body more sensitive to toxic exposure at certain times.
People working rotating schedules also face fatigue. Research suggests that forward
rotation (clockwise) is better because it is easier to remain awake later and go to bed later,
rather than the opposite. Backward rotation—getting up earlier to go to work earlier—
works against the body’s rhythm, requiring the worker to go to bed earlier and earlier. If
shifts are closely scheduled, a worker does not have enough time to sleep between shifts.
Speed of rotation also affects the circadian rhythms and ability to adjust. Longer rotations
(weeks or months) are supposed to allow the worker to get used to the shift. However,
some researchers have found that fast rotations (days) allow the worker to get through a
few (two or three) difficult night shifts, and then allows the worker a few days off. This
spreads the burden of night shift work to everyone. Fast forward rotations are used more
frequently in Europe. Backward rotation schedules are more common in the United
States.
Unpredictable schedules also interfere with workers’ sleep schedules, requiring them to
return to work without adequate rest, or preventing deep sleep because a worker knows
she or he can be called back at any time. Breaks of only seven to ten hours and quick shift
changes prevent the worker from getting adequate rest. Twenty-four hours are needed
after a night shift before rotating to another shift.
• Nurses reported that they did not have job performance problems when they had
consistent shifts and sleep patterns, but that they did have job performance issues
when their shifts changed from night to day. (Novak and Auvil-Novak, 1996)2
Injuries to Nurses Due to Long Shifts, Shift Work, or Overtime
Long hours of work, night shifts, or rotating shifts increase nurses’ risk of musculoskeletal
injuries (MSDs) and reduce recovery time between shifts that nurses need due to the
cumulative effect of lifting patients. Fatigue can also cause errors resulting in needlestick
injuries or car accidents.
• RNs working twelve or more hours per shift were at increased risk for
musculoskeletal disorders compared to those working eight-hour shifts. RNs
working twelve or more hours per day and 40 or more hours per week increased
their odds of getting a back, neck, or shoulder injury twofold.3
• RNs working nights or weekends also significantly increased their risk of MSD
injuries, due in part to lower staffing levels on those shifts. RNs working rotating
shifts had twice the number of reported accidents as those working day or night
shifts only.4
• In another study, nurses working rotating shifts had twice the number of reported
accidents or errors related to sleepiness than nurses who worked only a day or an
evening shift. (Gold et al, 1992)5
• Danish nurses working rotating shifts were found to have significantly more clinic
visits for strains and sprains than nurses working other shifts.6
• The number of needlestick injuries and incidents of biological fluid exposure
increased in the last two hours of twelve-hour shifts in a study by Macias et al. No
 increase in these incidents was found in the last two hours of eight-hour shifts.7
• As health care workers’, work hours’ increase, car crashes and occupational
accidents increase. (Kircaldy et al, 1997)8
• Ninety-six percent of ICU nurses reported car crashes or near misses while
driving home after a night shift. (Novak and Auvil-Novak, 1996)9
• Bureau of Labor Statistics injury data indicate that the risk of injury during the
night shift is substantially higher than during the day or evening shifts for all workers.
Risk of injury is nearly three times greater very early in the morning than at mid-
afternoon, the low and high points of the circadian cycle.10
Cardiovascular Impacts of Overtime
There has been much research on the impact of overtime on cardiovascular health,
although the research has not focused on nurses and much of it has been done on men.11
• Overtime work has been demonstrated to increase 24-hour average blood
pressure in workers who worked 60 or more hours of overtime per month
compared to those working 30 or fewer hours of monthly overtime. (Hayashi et
al., 1996)
• There is an increased risk of acute myocardial infarction associated with working
greater than eleven hours per day. (Sokejima and Kagamimori, 1998)
• Another study reported a twofold increased risk of experiencing an acute
myocardial infarction when working 61 hours or more on a weekly basis. (Liu and
Tanaka, 2002)
• Jobs with high pressure to work overtime and low rewards for overtime were
associated with health complaints, burnout, and negative work-home interference.12
Other Health Impacts
• Working night shifts longer than eight hours increased the incidence of smoking
among nurses. (Trinkoff and Storr, 1998)13
• Overtime, shifts longer than eight hours, night shifts longer than eight hours, and
rotating shifts longer than eight hours were associated with higher alcohol
consumption among nurses. (Trinkoff and Storr, 1998)14
• Overtime has been associated with unhealthy weight gain in two studies.15
Impact on Patient Safety
In recognition of the key role nurses play in patient safety and the estimated 98,000
hospital deaths each year in the United States attributed to errors, the Institute of
Medicine (IOM) conducted a comprehensive study to identify aspects of nurses’ work
environment that have an impact on patient safety. Most US nurses work eight- or twelve-
hour shifts, but in one study, 33.5 percent of scheduled shifts exceeded twelve hours,
including shifts of 22.5 hours. Another study found that 27 percent of full-time hospital
and nursing home nurses reported working more than thirteen hours at a time one or more
times per week. 16
The IOM recommends that nurses work no more than twelve hours in any given 24-hour
period and that they do not work in excess of 60 hours per seven-day period.
• Prolonged periods of wakefulness (17 hours without sleep) can produce
performance decrements equivalent to a blood alcohol concentration of 0.05
percent, the legal intoxication level in many European nations.
• The effects of fatigue include slowed reaction time, lapses of attention to detail,
errors of omission, compromised problem solving, reduced motivation, and
decreased energy for successful completion of required tasks.
• Reaction time, visual search, perceptual motor-tracking and short-term memory is
worse at night than during the daytime.
• One study found that 35.3 percent of nurses with rotating shifts reported falling
asleep during the night shift at least once a week.
• Nurses working nights or rotating shifts made more procedural errors and
medication errors because of sleepiness compared to nurses working other shifts.
• Working more than four consecutive twelve-hour shifts is associated with
excessive fatigue and longer recovery times.
• Two consecutive nights of recovery sleep can return performance and alertness to
normal levels following two or three twelve-hour shifts and longer rest intervals
are even more beneficial.
• Anecdotal evidence indicates that 24-hour shifts are becoming more common,
particularly in emergency rooms and on units where the nurses self-schedule.
Upcoming NIOSH Study on the Impacts of Shift Work and Overtime on RNs
The National Institute for Occupational Safety and Health (NIOSH), CDC is gathering
data for a study on the combined influence of shift work and overtime on the safety and
health of the current RN population. This research will provide much needed information
on the effect of fatigue on nurses. Both shift work and overtime have independently been
associated with increased health and safety risks, but little is known about their combined
impact. The study will provide data for recommendations on work schedule design to
reduce RNs’ safety and health risks and to improve patient outcomes.
One thousand RNs from ten large hospitals were randomly surveyed. Data collection is
continuing according to the director of the study. Most previous shift studies of nurses
have used young participants, but this study examines a more representative sample of the
RN population.
The study will examine shift length, night shifts, rotating shift schedules, and how they
interact to influence safety and health risks. The impact of the disturbance of sleep, family
life, and social life will also be included. Incidence of car crashes and near misses will be
calculated as well.
NIOSH Studies on Long Hours and Fatigue in Interns
NIOSH funded three recent studies on medical interns (first-year doctors in training).
• The majority of interns studied routinely worked more than 30 consecutive hours
and were awake on average 96 percent of those 30-plus hours. Over twelve
months, interns reported working an average of 80 hours or more during 46
percent of work weeks and 100 hours or more during eleven percent of work
weeks.17
• Interns made 35.9 percent more serious medical errors during shifts of over 24
hours compared to interns who worked shorter shifts and fewer total hours per
week.18
• Interns working fewer than 80 hours per week had less than half the rate of
attentional failures while working on-call nights compared to interns working 80 or
more hours.19
• Interns who worked shifts longer than 24 hours were more than twice as likely to
have a car crash leaving the hospital and five times as likely to have a near miss
incident as interns who worked shorter shifts.20
1 Roger Rosa and Michael J. Colligan, Plain Language about Shift Work, NIOSH, CDC,
HHS, 1997.
2 Claire Caruso et al, Overtime and Extended Work Shifts: Recent Findings on Illnesses,
Injuries, and Health Behaviors, NIOSH, CDC, HHS, 2004.
3 Jane Lipscomb, Alison M. Trinkoff, et al, “Work-schedule characteristics and reported
musculoskeletal disorders of registered nurses,” Scandinavian Journal of Work and
Environmental Health, 2002; 28(6): 394-401.
4 Ibid.
5 Ibid.
6 Ibid.
7 Claire Caruso et al, Overtime and Extended Work Shifts: Recent Findings on Illnesses,
Injuries, and Health Behaviors, NIOSH, CDC, HHS, 2004.
8 Ibid.
9 Ibid.
10 Kenneth Fortson, “The diurnal pattern of on the job injuries,” Monthly Labor Review,
September 2004.
11 Ibid.
12 Ibid.
13 Ibid.
14 Ibid.
15 Ibid.
16 Keeping Patients Safe: Transforming the Work Environment of Nurses, Institute of
Medicine, 2003.
17 Charles Czeisler, Laura Berger, et al, “Extended work shifts and the risk of motor
vehicle crashes among interns,” New England Journal of Medicine, January 13, 2005.
18 Charles Czeisler, Christopher Landrigan, et al, “Effect of reducing interns’ work hours
on serious medical errors in intensive care units,” New England Journal of Medicine,
October 24, 2004.
19 Charles Czeisler, Steven Lockley, “Effect of reducing interns’ weekly work hours on
sleep and attentional failures,” New England Journal of Medicine, October 28, 2004.
20 Charles Czeisler, Laura Berger, et al, “Extended work shifts and the risk of motor
vehicle crashes among interns,” New England Journal of Medicine, January 13, 2005.
1
SME: 2005