red flags
Running on empty? The facts
about nursing fatigue
By Diane Kelton, BSN, RN; Evelyn Kingsley, MBA, BSN, RN; Charlotte Davis, BSN, RN, CCRN; and Diane Miller, BSN, RN
Everyone experiences mild fatigue occasion-
ally; it’s the body’s way of saying it needs
rest and sleep. When fatigue becomes a
persistent feeling of tiredness or exhaustion;
however, it’s a red flag that something’s
amiss.
In a survey of nurses in Texas, 38% of the
respondents reported that they had commit-
ted a fatigue-related error that could’ve
impacted patient safety. As nurses, we
shouldn’t work while fatigued because it can
damage our health and impair our ability to
provide safe, competent, empathetic, and
conscientious care to our patients.
In this article, we’ll discuss signs and
symptoms, complications, contributing factors,
and resolutions to nursing fatigue.
Risky business
Nursing fatigue is characterized by a
profound lack of energy, feelings of muscle
Are you experiencing cheat
nursing fatigue?
sheet
If you answer “yes” to any of the following questions, you may be
too fatigued to safely provide direct patient care.
• Have you or your family, friends, or coworkers complained that
you’ve been irritable?
• Have you slept less than 6 hours in the last 24 hours?
• Have you worked more than three consecutive 12-hour shifts in the last
5 days?
• Do you feel fatigued, sleepy, or as if you’re in a “mental fog”?
• Have you missed routine exercise or physician visits within the last
5 days?
• Have you canceled social visits with friends and family within the last
5 days due to tiredness or fatigue?
• Have you made an error or “near miss” at work in the last 7 days?
• Do you feel a sense of irritation or impatience interacting with patients,
families, or team members?
• Would you want you to take care of yourself if you were the patient?
• Would you feel guilt or shame if you made a patient care mistake if you
went to work this fatigued?
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weakness, emotional exhaustion, slowed
movements, diminished reflexes, and im-
paired critical thinking skills. You may feel
like your mind is “fuzzy” or that you’re in
a mental “fog” as you struggle to concen-
trate on the routine tasks at hand. Fatigue
can cause you to make costly mistakes that
can injure patients.
Common complications of nursing fatigue
include:
• slowed reaction time
• failure to rescue
• medication errors
• poor quality patient care
• inability to convey empathy
• poor teamwork
• errors of omission
• lapses in attention to detail
• compromised problem solving.
A nurse experiencing fatigue may exhibit
nonverbal signs, such as sighing, folded
arms, fixed facial expressions, rushed
movements when providing patient care,
exasperated eye rolling, and not making
eye contact with patients or other team
members. These negative cues signal that the
nurse isn’t engaged in meeting the patient’s
physical, spiritual, and emotional needs.
Before nursing fatigue has progressed to this
point, managers and administrators should
intervene.
Besides causing problems at work, fatigue
can also undermine your personal and
home life. You may not realize how the
heavy workload and excessive hours spent
at work impair your ability to enjoy life and
meet home and family obligations. We have
many roles in addition to nursing: spouse,
partner, parent, family caregiver, sibling,
friend, and student to name a few. If you’re
experiencing fatigue, these relationships
may be strained to the breaking point,
undermining your social support system.
March/April 2014 Nursing made Incredibly Easy! 45
 red flags

We must ensure that we don’t overcom- to meet this unrealistic and unhealthy “obli-
mit to working extra shifts, additional hours, gation,” you may feel guilty about letting
or on excessive projects or committees so down the team. You may also be concerned
that we have enough energy for family and that other team members won’t reciprocate
friends. Balancing family relationships and a in the future when you need help.
career should have equal importance in our • mandatory overtime. According to the
lives. It’s okay to say no to requests from American Nurses Association, mandatory
employers to work overtime. Sometimes overtime is a major contributing factor to
saying no to overtime simply means you’ve nurses leaving the workforce. Research clearly
decided to properly care for yourself by shows that errors significantly increase when
resting that day. nurses work shifts that are longer than 12
hours or work more than 40 hours in any
Run up the red flag 7-day period. Airline and trucking industries
Understanding the forces driving nursing regulate the amount of hours a pilot or
fatigue is the key to combatting it. Common trucker can work in a 24-hour period. As a
underlying causes include: safety measure, these industries also mandate
• inadequate staffing. All nurses have expe- a specific number of hours of rest between
rienced times of inadequate staffing and flights or runs. Yet, although research has
understand the stress it can proven that nurses become so tired during
cause. Some healthcare facili- long shifts that their performance deteriorates,
ties create a workplace culture only 16 states prohibited mandatory overtime
in which nurses feel obligated for nurses in 2013.
to work extended hours, • 12-hour shifts. A recent research study
through their lunch and meal by the University of Maryland and Johns
breaks, and overtime. If you fail Hopkins School of Medicine found that
nurses who work consecutive 12-hour
shifts get an average of only 5½ hours
A drowsy driver is a lousy driver of sleep between shifts. Working several
Many nurses commute to their jobs by automobile. In a recent survey of extended-hour shifts consecutively can lead
Canadian nurses, 55.5% of the respondents indicated that they always or to sleep deprivation, which has been linked
almost always feel fatigued during work, and 80% feel this way after work to errors and the increased likelihood of
as they’re traveling home. motor vehicle accidents (MVA) for nurses
Fatigue can impair a nurse’s judgment as severely as alcohol. As of
who drive to work (see A drowsy driver is a
2013, the legal blood alcohol content (BAC) is 0.08% in all states.
lousy driver).
According to recent research, 19 hours without sleep is similar to a BAC of
0.05% and 24 hours without sleep is similar to a BAC of 0.10%.
Many healthcare facilities have begun to
We shouldn’t work or drive with less than 6 hours of uninterrupted sleep limit how many consecutive 12-hour shifts
in the last 19 hours because our judgment, depth perception, and reflexes nurses can work in an effort to decrease
are impaired. In recent research, the risk of an MVA increased dramatically nursing fatigue, reduce sentinel events, and
after each 12-hour shift worked consecutively. For day shift workers, the increase workplace and patient safety. Some
risk of an MVA increased by 2% after the second shift, 7% after the third state boards of nursing and professional
shift, and 17% after the fourth shift. For night shift workers, the risk organizations have issued position state-
increased 6% for the second consecutive 12-hour night shift worked, 17% ments requesting that if nurses must work
for the third shift, and 36% for the fourth. 12-hour shifts, the last 4 hours should be
We must consider our ability to safely commute to and from our work-
away from direct bedside care.
place when agreeing to work extended-hour shifts or overtime. When in
• unexpected patient emergencies. Many
doubt, err on the side of caution and don’t drive. If you’ve already com-
pleted your shift and are too fatigued to drive home, call a friend or family
nurses work in areas of high stress that are
member to pick you up, call a cab, or find a safe place to rest. always in transition. In challenging circum-
Sources: Arizona Department of Public Safety. Driver fatigue. http://www.azdps.gov/Information/Fatigue. stances, you can’t easily plan your entire
Canadian Nurses Association. Nurse fatigue and patient safety: research report. http://www.cna-aiic. shift’s work in advance. When an unex-
ca/~/media/cna/page%20content/pdf%20en/2013/07/26/10/39/fatigue_safety_2010_report_e.pdf.
Rogers A. The effect of fatigue and sleeplessness on nursing performance and patient safety.
pected patient emergency adds to the pres-
http://www.ahrq.gov/professionals/clinicians-providers/resources/nursing/resources/nurseshdbk/ sure, you experience excessive rushes of
RogersA_EFSNPPS.pdf.
adrenaline. The body can handle occa-

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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
sional rushes of adrenaline, but when it’s
repeated and frequent, your energy
stores are depleted, predisposing you to
sleep deprivation, stress-related illness,
and persistent fatigue.
• increased expectations from administra-
tion. Nurses often say that in the current
budget-conscious environment, they’re
asked to “do more with less” by their man-
agement teams. To make sure you have the
tools you need to perform your job, man-
agement teams should be encouraged to
make daily rounds and interact with the
healthcare staff. When members of the man-
agement team make routine onsite rounds
and are readily available to nurses, they get
a more realistic vision of what nurses need.
This may motivate them to find innovative
solutions acceptable to all parties.
• increased expectations from patients and
families. Healthcare has shifted to a focus
on holistic, patient-centered care that’s tai-
lored to meet each patient and family’s
healthcare needs. This customized nursing
care delivery system takes additional time
to plan and execute. When time is already
tight, you may feel rushed and unable to
meet all the patient’s physical, emotional,
and spiritual needs.
• frequent changes in management, policies,
and procedures. Changes in management
teams can add to stress as you learn to
work with new personalities and manage-
ment styles. All nurses need a dedicated
unit manager to provide a vital link to the
facility’s core mission. When policies or pro-
cedures are changed, the management team
should meet with the nursing staff to ex-
plain why the change is being made and
how it will benefit nurses, patients, and the
organization. This gives you a chance to of-
fer insight and input based on your experi-
ence. When all parties are on board with
the changes and rationales, stress and frus-
tration are reduced for all. Well-informed
nurses can make substantial contributions
to the success of the organization.
• disruptive or hostile work environment.
When disruptive or hostile workplace
behavior isn’t addressed, the workplace
climate may become dysfunctional and
unsafe. For example, when cliques form
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Identifying a fatigued coworker cheat
sheet
• Have you noticed your coworker acting unjustifiably irritable?
• Has your coworker worked more than three consecutive 12-hour
shifts?
• Do your coworker’s critical thinking skills seem impaired?
• Does your coworker work a second job that demands he or
she work over 12 hours a week?
• Does your coworker attend college fulltime or have coursework
that demands more than 8 hours of clinical time in addition to
classes?
• Have you noticed your coworker inadvertently sleeping while
on duty?
• Have you noticed your coworker arriving late or departing early
from work?
• Have you noticed your coworker having difficulty concentrating
on basic or complex nursing tasks?
• Has your coworker experienced a medication error, near miss, or
sentinel event?
• Do your coworker’s basic reflexes or nursing judgment seem
impaired?
• Does your coworker seem apathetic or unable to convey empathy?
• Has your coworker experienced new onset physical health problems?
• Has your coworker experienced lapses in attention to detail or has
he or she been noted providing poor patient care?
• Does your coworker refuse to or selectively offer assistance to team
members?
If you answered “yes” to any of the above questions, your coworker
may be experiencing nursing fatigue. You should discuss your concerns
with your coworker and also convey your concerns to your management
team if your coworker isn’t receptive. Addressing your concerns in a
respectful, caring way can help your coworker recognize the urgency and
dangers of working while fatigued.
within a unit, nurses often become accus-
tomed to working only with their small,
accepted group. This can be dangerous if
nurses withhold or limit their assistance to
other nurses outside their group. Manage-
ment teams should take a proactive role in
addressing all workplace behavior that
doesn’t foster teamwork and professional
respect between team members.
• neglecting personal health. Nurses com-
mitted to providing excellent care to others
may at times neglect their own healthcare
needs. Although we may be experts at rec-
ognizing how neglecting personal health
increases the mortality risks in our pa-
tients, we often fail to recognize it in our-
selves. Common ways we neglect our
health are failing to get adequate rest be-
fore or after a shift, eating an unhealthy
March/April 2014 Nursing made Incredibly Easy! 47
 red flags
diet, and getting too little physical activity
or exercise.
• failing to address chronic physical or mental
disease. Although we’d like to believe we’re
invincible, many nurses can suffer from
common chronic illnesses that require ongoing
medical interventions. Even relatively minor
acute illnesses, such as the common cold, can
cause feelings of exhaustion. Taking medica-
tions that cause drowsiness may create more
issues if you’re already suffering from fatigue
and diminished mental clarity.
Take steps to stamp out fatigue
Take the following steps to resolve nursing
fatigue.
• Get at least 6 hours of uninterrupted sleep
before each shift. If you have a sleep debt, it
should be repaid in full in addition to the 6
hours of sleep (see Don’t go into (sleep) debt).
The Agency for Healthcare Research and
Quality (AHRQ) has reported that after one
night of missed sleep, cognitive performance
may decrease 25% from baseline. After the
second night of missed sleep, cognitive per-
formance can fall to nearly 40% of baseline.
• Avoid shift rotations. The AHRQ reports
that nurses who alternate between day and
night shifts frequently have difficulty main-
taining a normal sleep cycle and are more
Don’t go into (sleep) debt
Nurses need a minimum of 6 hours of uninterrupted sleep every 24 hours
to maintain our coping skills, problem-solving ability, and our health. Sleep
deprivation can impair memory, depth perception, comprehension skills,
and memory.
The length and quality of a person’s sleep pattern directly relates to his
or her ability to physically and mentally function while awake. If you don’t
get an adequate quality or quantity of uninterrupted sleep, you may
acquire a “sleep debt.” This deficit often requires more quality sleep hours
than are “owed” to resolve. The brain requires extra hours of quality sleep
patterns to repay the sleep debt caused by even small periods of sleep
deprivation.
According to new research on night shift workers, “sleep loss is cumu-
lative and by the end of the work week, the sleep debt (sleep loss) may be
significant enough to impair decision making, initiative, integration of
information, planning and plan execution, and vigilance.” Sleep depriva-
tion is also linked to increased cortisol levels and an increased risk of
diabetes, hypertension, depression, decreased mental acuity, and memory
impairment.
Source: Rogers A. The effect of fatigue and sleeplessness on nursing performance and
patient safety. http://www.ahrq.gov/professionals/clinicians-providers/resources/nursing/
resources/nurseshdbk/RogersA_EFSNPPS.pdf.
48 Nursing made Incredibly Easy! March/April 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
prone to medication errors. If you must ro-
tate between day and night shifts, it should
be done in 2- to 3-week increments. Slow
shift rotation results in greater sleep length
at home, less sleepiness on the job, better
self-reported performance, and fewer errors.
• Take your 15-minute rest breaks and your
lunch break in a quiet area off your unit if
possible. This will allow you to briefly
destress and refresh so that you can give
your best care for the remainder of your
shift.
• Eat a well-balanced diet and minimize
consumption of caffeinated products. If you
do drink caffeinated products, do so early
in your shift so your sleep patterns won’t
be affected.
• Educate your management team and co-
workers about the signs and risks of nursing
fatigue. All members of the healthcare team
should be able to identify team members who
are working while fatigued and intervene to
protect both the nurse’s and patient’s safety.
• Develop a work culture that accepts a
nurse’s choice to refuse to work overtime—
without guilt. When the work peer group
supports each other’s commitment to main-
taining a healthy work-life balance, work-
place satisfaction improves.
• Develop open, honest, and respectful lines
of communication between your manage-
ment team and nursing staff regarding staff-
ing needs. Nurses should feel free to discuss
staffing needs with management, such as
the skill mix of nursing staff, staffing ratios
based on patient acuity, and the need for ex-
perienced nurses with specialty experience.
When approached in the spirit of respect
and cooperation, management teams will be
more receptive to looking for an acceptable
resolution that will allow nurses to avoid fa-
tigue and meet patient needs safely.
• Commit to a healthy work-life balance.
This includes preventive health maintenance,
medical care, routine engagement in personal
hobbies, and socializing with family and
friends.
Despite the potentially serious conse-
quences of working while fatigued, nurses
are often reluctant to intervene with a
fatigue-impaired colleague. If you believe a
colleague is working while fatigued, convey
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your concerns in a respectful, caring man-
ner. If the nurse isn’t receptive and contin-
ues to work while fatigued, discuss your
concerns with your supervisor or manage-
ment team. Ignoring your colleague’s
fatigue will only enable him or her to con-
tinue endangering patients. Remember,
we’re all responsible for patient safety!
When both the management team and
nurses are educated about nursing fatigue,
they can work together to quickly identify
when a team member is too fatigued to pro-
vide optimal patient care and intervene
appropriately. Armed with this new knowl-
edge, we can all work together to eradicate
nursing fatigue! ■
Learn more about it
Canadian Nurses Association. Nurse fatigue and patient
safety: research report. http://www.cna-aiic.ca/~/media/
cna/page%20content/pdf%20en/2013/07/26/10/39/
fatigue_safety_2010_report_e.pdf.
Chinn P. Nurse fatigue and patient harm. http://ansjour
nalblog.com/2012/11/21/nurse-fatigue-and-patient-harm/.
Rogers A. Staff nurse fatigue and patient safety. http://
archive.ahrq.gov/about/annualmtg07/0927slides/rogers/
Rogers-1.html.
Stimpfel AW, Sloane DM, Aiken LH. The longer the shifts
for hospital nurses, the higher the levels of burnout and
patient dissatisfaction. Health Aff (Millwood). 2012;31(11):
2501-2509.
Texas Board of Nursing. Health and nurses inTexas: 2004
survey of Texas registered nurses. http://www.uthscsa.
edu/rchws/Reports/2004RN%20Survey%20of%20Texas.pdf.
Townsend T, Anderson P. Are extended work hours worth
the risk? http://www.americannursetoday.com/article.
aspx?id=10272&fid=10226.
Trinkoff AM, Johantgen M, Storr CL, Gurses AP, Liang Y,
Han K. Nurses’ work schedule characteristics, nurse staffing,
and patient mortality. Nurs Res. 2011;60(1):1-8.
At Alvin C. York VA Medical Center in Murfreesboro, Tenn., Diane
Kelton is a Nurse Manager, Evelyn Kingsley is a Nurse Manager,
and Diane Miller is a Clinical Nurse. Charlotte Davis is a CCU/CVICU
Clinical Nurse at Heritage Medical Center in Shelbyville, Tenn., and a
Clinical Nurse/Charge Nurse/ CCRN Review Program Coordinator at
Alvin C. York VA Medical Center in Murfreesboro, Tenn. She is also
a Nursing made Incredibly Easy! Editorial Advisory Board Member.
The authors have disclosed that they have no financial relationships
related to this article.
DOI-10.1097/01.NME.0000438415.52535.3d

Page 15 answer key

1 2 3 4
Q U A N T I T A T I V E
5
U U O A M
6 7 8 9
A C L U S T E R L R E S E A R C H
10
R O L A L A A I A A E
11 12 13
S I S S L N D A T A N A
14 15 16
T T H E O R Y D I I L E A D
19 20
A A S C O N T R O L I N
21
T E S T M Y I T A
22 23 24
S I N Q U I R E S T U D Y L
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V U B A R T Y
26 27 28 29 30
L I T E R A T U R E I A B S T R A C T S

I S Y A G E I I
32 33 34 35 36
K C H I M E A S U R E M E N T S

E O O N E
38 39 40 41
L O G D O F I E L D M O D E
42 43 44 45
I S C I E N C E N A M E T E

H R Y R R D
46 47 48 49
O P A R A D I G M R E L I A B I L I T Y
50
O A O E A I M N A A
51 52 53
D E E P R D T C L N E T
53
E U Y D E S I G N W
56
C U R V E C O
57 58 59 60
T A T T R I B U T E
61 62
C O G N I T I O N N O E A
63 64
O V N M O D E L S B E T A
65 66 67 68
O N E L I K E R T V E T L
69 70
T R I H A S M E T A

E B G E
71 72
K N O W P R O B A B I L I T Y S

T R H

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