Too Tired to Nurse

By Shawn Kennedy, AJN editor-in-chief

by patchy patch, via flickr

by patchy patch, via flickr

Just about every nurse I know has been “asked” (or “guilted” or “mandated”) to work an additional shift on top of a grueling one. The worst such experience I ever had was having to work from midnight to 8 am after working a straight week of 4 pm to midnight shifts. I was exhausted, but someone had called in sick, leaving only two RNs and one aide for the 11-bed ED trauma unit.

I was so tired that at one point I found myself falling asleep while I was standing by a patient’s bed charting vital signs. I couldn’t remember the blood pressure reading I had obtained just moments before. It was good luck that I didn’t make an error—and had the good sense to have a colleague double-check medications I was readying (these were the old days, before unit dosing).

So I was very pleased to see the ANA issue its position statement on nurse fatigue. In a press release announcing the statement, ANA president Pam Cipriano has this to say:

“We’re concerned not only with greater likelihood for errors, diminished problem solving, slower reaction time and other performance deficits related to fatigue, but also with dangers posed to nurses’ own health.”

The statement summarizes research into working long hours and its association with errors, reduced alertness, and job performance as well as its effects on nurses’ health—manifested perhaps most dramatically in the dangers of drowsy driving, which has been implicated in deaths of nurses and others. (See our report about one case, “Can a Nurse Be Worked to Death?”).

Key recommendations from the ANA include:

  • “…that registered nurses not exceed 40 hours of professional nursing work (paid or unpaid) in a seven-day period.”
  • “…that employers should limit shifts (including mandatory training and meetings) to a maximum of 12 hours in 24 hours. (Those limitations include on-call hours worked in addition to actual work hours.)”
  • “…that employers adopt—as official policy—the position that registered nurses have the right to accept or reject a work assignment on the basis of preventing risks from fatigue.”

Of course, staffing is a key factor in nurse fatigue and one that seems too often to get swept under the rug. Even within the recommended work times noted above, we’ve seen too many errors occur at the end of a long shift after several consecutive days. Twelve-hour shifts are problematic in themselves—see this previous blog post about that issue.

But kudos to the ANA—its statement is a good rallying point to support change. The next step: These recommendations should be developed into accreditation criteria for hospitals seeking Magnet status. I wonder, though: do most RNs see long hours and risk for errors as a real issue that might be addressed or just a fact of life that nurses must continue to deal with?

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Senior editor/social media strategy, American Journal of Nursing, and editor of AJN Off the Charts.


  1. Sreelatha December 16, 2014 at 5:48 am

    Addressing this issue is great. Nurse administrators &managers are the key personnel to solve this to some extent. In many situations, nurses sacrifice for the patients & the administration take advantage of this.

  2. Lilah Sawyer December 9, 2014 at 6:42 pm

    I recently joined the field of nursing after leaving EMS in New York, where crews regularly worked 12 and 24-hour shifts. The safety issues surrounding 24-hour shifts were shockingly not addressed in our response area until a fatal accident, which was caused after the driver nodded off at the end of the twenty-third hour. Although no other vehicle was involved the second crew member was killed as a result of the crash. The death of a young man was finally enough for the policies to be re-evaluated.

    Although 12-hour shifts are less glaringly flawed than 24-hour shifts, they still pose the same danger- particularly at the bedside, or in any patient care position that doesn’t offer the same time breaks that EMS occasionally provides. I’m curious what the research says. How is reaction time affected? Decision making? Critical thinking?

    My hope is that these issues will be explored before their evaluation is demanded in the wake of a tragedy.

  3. Sue Younkin RN December 8, 2014 at 10:26 pm

    I still remember the change-over back in the 90s, when we had been working 8 hour shifts, and I would stay over, after working 3p – 11p, to work 11p – 7a because of nurse shortage for the night. It was a blessing to go to 12 hour shifts, and only work 7p – 7a, and get to go home!! After 16 hour shifts, 12 hours were a piece of cake!! And 3 nights a week were so much better than 5 evening a week!!

  4. Tricia December 8, 2014 at 9:05 pm

    I love my 12 hour shifts but anything beyond is too much. In a previous job, I was working 16+ hours 4-5 days a week. I had to refuse to work by saying I was “unsafe” to work longer. Once I started using that wording, I didn’t get bullied into staying anymore.

  5. Cynthia Taylor December 8, 2014 at 5:20 pm

    I made it clear to my new supervisor in ER that I did not want to work 12 hr. shifts.The previous ER I had been working in, had gone strictly to 12’s. I feel it isn’t healthy and I was having trouble working the overtime, etc. with 8 and 10 hr. shifts. My new place of employment was still working 8 hr. shifts. The new supervisor told me, “As long as I am the supervisor here, that will never happen”.
    Well, guess what? It did. I was told that I did not have a choice, and then I had cancer surgery, cataract surgery and when I got back from medical leave, and had been on an extended sit-down job in triage, which was eliminated, I was forced to work 4 hr. then 8 hr. then 12 hr. shifts. I lost my job because I did not want to work 12’s. I was not the only nurse who did not want to work 12 hr. shifts, but those younger nurses with families outvoted those of us who did not want them. The entire hospital is now on 12 hr. shifts exclusively, like all hospitals in the Midwest.
    It would be interesting to know the statistics on the numbers of nurses who cannot physically work 12 hr. shifts and have been eliminated or just not hired because of this! It isn’t fair, and chances are that quite a few very good nurses are being eliminated because of this stupidity! What a shame that good nurses cannot find jobs just because of 12 hr. shifts. It seems there is no hope for common sense anymore!

  6. Rachelle Richard December 8, 2014 at 4:40 pm

    I have been in the nursing field for nearly 19 years. I have sweat, laughed, and even teared up beside some of the best nurses in the field. I, first hand, have worked so hard and long that I could barely drag my worn out body to my car. Praying to God to just help me left my legs to get in the car. I have driven home so
    exhausted, I know my eyes have closed once or twice. The worse part was knowing that in 8 more hours I had to go back and do it all again. But I despise, after all I’ve been through, to read articles like this one that refer to registered nurse only, as if they are the only ones out there working hard. I guarantee you that they are not the only ones working hard. This is the problem! I find it to be a bit disrespectful. I have a clear understanding of the whole “nurses are not considered professionals unless they are at the Bachelor level”, I also have a family in every aspect of the medical field (from CNA, LPNs, BSN, to MD ). Well explain that when there is a code blue, and evey disapline is expected to participate. I am in the tail end of my studies of earning my BSN in nursing, so i can get paid for the hard work that I do, but my goal will be to make every member of my team feel and know that their contributions in the field is acknowledged and appreciated. There is no “I” in team, so lets make any one feel like the other is not important.

  7. Linda Batts December 8, 2014 at 2:35 pm

    Absolutely unsafe for patients and nurse. “Too tired to think” is an unfortunate reality. Very happy it’s being addressed

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