“Nurse-to-patient ratios are very healthy in managing fatigue, but finding a standard ratio is difficult,” Hunter explains. “In California, we have a scheme of 75 different ratios for different types of facilities. You can define an emergency room 30 different ways if you want.” For example, a large hospital’s emergency room has much different staffing requirements than a small treatment center’s urgent care unit. Therefore, the NFPIP is not aiming to decide on an ideal nurse-patient ratio, just validate that realistically set ratios really do work, added Barry.

The NFPIP is combining nurse fatigue, nurse responsibility, and employer responsibility into one issue. The reason is simple: This time around the ANA wants the issues of nurse fatigue solved, not just identified. The way to achieve that is to shape policy that affects employer behavior, as well as nurse behavior. Applied purely to nurse behavior, recommendations from the NFPIP would fall to the feet of nurse altruism.

Continue Reading

“Nurses have this culture of altruism. We’ve been a bit brainwashed in school to think that as a nurse we take care of other people but we don’t need to take care of ourselves. It’s good for us to take care of ourselves so we can take care of our patients,” Repique explained.

The ANA’s new policy statement on nurse fatigue will attempt to walk the fine line between professional self-regulation and the rules employers are obliged to abide by. Repique, also a member of the NFPIP panel, predicts generational shifts from the panel’s findings. For example, older nurses push the limits of work fatigue further than younger ones. “The young nurses are better at taking care of themselves and resting,” he said, “whereas the older generation of nurses have the harder time shifting the work ethic paradigm that helps reduce fatigue.”


The panel also intends to awaken a better understanding of sleep deprivation and the physical and emotional effects of working night shifts and multiple shifts. Panel members will hear from experts on sleep deprivation, and several NFPIP participants are certified sleep deprivation experts as well. “We are definitely going to talk about day-versus-night shifts. We are going to be talking about sleep and wake cycles, when sleep hormones are released, when the best time to sleep is, and what are the best ways to get to sleep,” said Barry.

Off-hours time management is the responsibility of nurses not their employers. But the NFPIP aims to shift some of that responsibility to employers in an effort to ensure that new guidelines on nurse fatigue within a refreshed policy statement are followed when hospitals draft employee policy.

“Like any career today, nursing is not just about doing the job. It’s really related to juggling multiple demands, young children, picking up elderly parents , working short staffed, not taking breaks, working multiple jobs to pay the mortgage, not sleeping at night when you are off, not sleeping during the day when you are off, and being tired when you are working. Those kinds of things,” said Barry.

When the NFPIP concludes its work in February 2014, the ANA will take advantage of the current national focus on health care issues to deliver its refreshed policy statement on nurse fatigue to lawmakers, striking for change while the iron is hot. Barry adds, “We think there is a very strong ethical obligation to find what kind of tools we can give employers to work through this very complicated issue of nurse fatigue, and this time we want to get it right.”

Dan Neel is a medical writer based in San Francisco, California. 


1. Rogers AE. The effects of fatigue and sleepiness on nurse performance and patient safety. In Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: The Agency for Healthcare Research and Quality; 2008:Chapter 40. http://www.ncbi.nlm.nih.gov/books/NBK2645/. Accessed December 17, 2013.

2. Nurse fatigue professional issues panel. American Nurses Association Web site. http://www.nursingworld.org/Nurse-Fatigue-Panel. Accessed December 17, 2013.

3. Kronos survey reveals nurse fatigue is pervasive in the healthcare industry and directly linked to on-the-job errors [press release]. Kronos Web site. March 20, 2013. http://www.kronos.com/pr/kronos-survey-reveals-nurse-fatigue-is-pervasive-in-the-healthcare-industry-and-directly-linked-to-on-the-job-erros.aspx. Accessed December 17, 2013.

4. Debucquoy-Dodley D. Lawsuit: Ohio nurse was ‘worked to death.’ http://www.cnn.com/2013/11/12/health/ohio-nurse-worked-to-death-lawsuit-says/. Accessed December 18, 2013.