Managing Fatigue During Times of Crisis: Guidance for Nurses, Managers, and Other Healthcare Workers

At times of crisis, healthcare workers (e.g., nurses, advanced practice nurses, physicians, nursing assistants, etc.) continue to provide care, despite ever challenging work demands, including higher influx of critically ill patients, increased work stress, and a frequent need for overtime. These work demands can compound already challenging work schedules (i.e. 12-hour shifts, night shifts), making it more difficult to obtain regular shift breaks and enough time off between shifts for adequate recovery. All of these work factors (i.e. physical, emotional, and/or mental demands) combined with insufficient sleep, contribute to fatigue.^1-3

Healthcare workers experiencing fatigue can jeopardize their own health and safety, such as increasing their susceptibility to infectious diseases,⁴ needlesticks,⁵ work-related muscle injuries,⁶ and burnout,⁷ as well as committing patient care errors.^8,9 Nurses providing care during disasters or emerging disease epidemics^10,11 have reported sleeping less, experiencing intense levels of fatigue, decreased well-being, and depression.

It can be difficult to step away when the healthcare system is flooded with people needing care. During these periods, fatigue among healthcare workers may be impossible to avoid. So how can employers and healthcare workers balance the high demands for health care with the need to protect workers from fatigue? Workers and managers must actively share the responsibility to control the risks of injuries and incidents associated with fatigue through personal and workplace strategies, as well as a fatigue risk management system.^3,12 For example, one step is to recognize healthcare worker sleep is critical for the delivery of quality health care. Workers and managers should try to plan for 7 or more hours of sleep in addition to recovery time each day, as needed to maintain alertness and health. Fatigue management is a shared responsibility that requires planning and ensures organizations the sustainability of healthcare services during times of public health crises, as well as protects the health and safety of workers and their patients.

Practical Fatigue Management Tips:^13,14

For healthcare workers-

• • Prioritize sleep by decreasing off-work obligations as much as possible, until feeling fully rested.
  • Use relaxation apps or techniques to aid in sleep onset, if you have trouble falling asleep (longer than 15-25 minutes),
  • Create a pre-sleep, bedtime routine and keep your sleeping environment comfortable, dark, cool, and quiet.
  • Avoid alcohol, spicy foods, and nicotine for at least 2-3 hours prior to sleep time.
  • Avoid caffeine at least 5 hours before bedtime (longer if sensitive to caffeine).
  • Avoid sunlight/bright lights 1.5 hours prior to sleep, as it can stimulate your circadian system to promote wakefulness.
  • Use strategically timed naps to decrease fatigue. Short naps (15-30 minutes) can help to decrease fatigue during work hours. Longer naps (1.5 hours) can help prevent fatigue before working night shift.
  • Find a fellow worker to be a buddy for checking-in on how you each are coping.
  • Watch for signs and symptoms of fatigue in yourself and coworkers (e.g., yawning, difficulty concentrating, emotional instability, flawed logic, poor communication).
  • Report to a manager when you feel too fatigued to work.

For managers-

• • Communicate with staff about their flexibility to work when needed, avoiding repercussions for those who may have restricted availability. When workers are unable to establish strong off-duty support action plans, it can create undue stress and decrease the off-work time devoted to recovery.
  • Provide daily communication rounds with staff to share information on work hour needs, work processes.
  • Educate staff on sleep and self-care strategies.
  • Try to limit scheduling staff for extended shifts (>12 hours). Extended shifts increase the risk for fatigue-related incidents, as well as increases worker exposure time to infectious diseases and other workplace hazards
  • During times of crisis, provide a minimum of 10 hours off in-between shifts (each 24-hour period), and one full day of rest per seven days for adequate sleep and recovery.
  • Provide strategies for staff to take short breaks every 2 hours during their shifts, including short naps and longer for meals.
  • Consider providing supportive services onsite (e.g., laundry, sleeping rooms, healthy food and drinks).
  • Monitor staff for signs and symptoms of fatigue (i.e., yawning, difficulty concentrating, emotional instability, flawed logic, poor communication).
  • Ensure all staff have a buddy in place to monitor for signs and symptoms of fatigue and other poor health outcomes.
  • Consider creating a signal or some procedure for workers to report when they feel they or a colleague are too fatigued to work, potentially contributing to an unsafe situation

Additional Resources:

The NIOSH Training for Emergency Responders program provides additional education for preventing fatigue during emergency and critical needs situations. The training takes approximately 30 minutes to complete.

For individuals working evening or night shifts, additional education specific to working evening and night shift can be found in NIOSH Training for Nurses on Shift Work and Long Work Hours, Part 2, Module 9 (approximately 12 minutes to complete).

For a more comprehensive training program, the NIOSH Training for Nurses on Shift Work and Long Work Hours, is available for all nurses and nurse managers. The entire training takes approximately 3.5 hours to complete with continuing education credits available upon completion.

What strategies have you and/or your employer put in place to manage fatigue risks?

This blog is available in Spanish, Portuguese and Japanese.

This blog is part of a series hosted by NIOSH to commemorate nurses during the Year of the Nurse.

Other blogs in the series include:

Year of the Nurse

Nurses’ and Other Health Professionals’ Wellness and Safety Resource Update

Surgical Smoke Inhalation: Dangerous Consequences for the Surgical Team

Safety Culture and Health Care

Work Ability among Older Nurses

The Unique Occupational Environment of the Home Healthcare Worker

Can Exoskeletons Reduce Musculoskeletal Disorders in Healthcare Workers?

Preventing Needlesticks and Sharps Injuries: Reflecting on the 20th Anniversary of the Needlestick Safety and Prevention Act

Celebrating Nurses

Beverly Hittle, PhD, RN, is a post-doctoral fellow with the Division of Science Integration at the National Institute for Occupational Safety and Health. She also is on faculty at the College of Nursing, University of Cincinnati, with expertise in nurse health and safety.

Imelda Wong, PhD, is the Co-Chair for the Work Hours and Fatigue Workgroup and an Industrial Hygienist/Epidemiologist at the National Institute for Occupational Safety and Health, Division of Science Integration.

Claire Caruso, PhD, RN, FAAN, is research health scientist and Co-Chair for the Work Hours and Fatigue Workgroup in the National Institute for Occupational Safety and Health, Division of Science Integration.

References:

1. Wong IS, Popkin S, Folkard S. Working time society consensus statements: A multi-level approach to managing occupational sleep-related fatigue. Industrial Health. 2019;57(2):228-244.
2. Caruso CC, Baldwin CM, Berger A, et al. Position statement: Reducing fatigue associated with sleep deficiency and work hours in nurses. Nurs Outlook. 2017;65(6):766-768.
3. Lerman SE, Eskin E, Flower DJ, et al. Fatigue risk management in the workplace. J Occup Environ Med. 2012;54(2):231-258.
4. Bryant P, Trinder J, Curtis N. Sick and tired: does sleep have a vital role in the immune system? Nature Reviews Immunology. 2004;4:457-467.
5. Weaver MD, Landrigan CP, Sullivan JP, et al. The association between resident physician work hour regulations and physician safety and health. The American Journal of Medicine. 2020;In press.
6. Caruso CC, Waters TR. A review of work schedule issues and musculoskeletal disorders with an emphasis on the healthcare sector. Industrial Health. 2008;46(6):523-534.
7. Chin W, Guo YL, Hung YJ, Yang CY, Shiao JSC. Short sleep duration is dose-dependently related to job strain and burnout in nurses: A cross sectional survey. International Journal of Nursing Studies. 2015;52(1):297-306.
8. Rogers AE, Hwang W-T, Scott LD, Aiken LH, Dinges DF. The working hours of hospital staff nurses and patient safety. Health affairs. 2004;23(4):202-212.
9. Lockley SW, Barger, L. K., Ayas, N. T., Rothschild, J. M., Czeisler, C. A., Landrigan, C. P. Effects of Health Care Provider Work Hours and Sleep Deprivation on Safety and Performance. The Joint Commission Journal on Quality and Patient Safety. 2007;33(11):7-18.
10. Su T-P, Lien T-C, Yang C-Y, et al. Prevalence of psychiatric morbidity and psychological adaptation of the nurses in a structured SARS caring unit during outbreak: A prospective and periodic assessment study in Taiwan. Journal of Psychiatric Research. 2007;41(1):119 – 130.
11. Yokoyama Y, Hirano K, Sato M, et al. Activities and Health Status of Dispatched Public Health Nurses after the Great East Japan Earthquake. Public Health Nursing. 2014;31(6):537-544.
12. Dawson D, McCulloch K. Managing fatigue: it’s about sleep. Sleep medicine reviews. 2005;9(5):365-380.
13. Caruso CC, Funk R, Butler CR, et al. Interim NIOSH Training for Emergency Responders: Reducing Risks Associated with Long Work Hours. https://www.cdc.gov/niosh/emres/longhourstraining/. Published 2014. Accessed.
14. Livornese K, Vedder J. The emotional well-being of nurses and nurse leaders in crisis. Nursing administration quarterly. 2017;41(2):144-150.