Chapter 40. The Effects of Fatigue and Sleepiness on 

Nurse Performance and Patient Safety 

Ann E. Rogers 

Background 

Although the words “fatigue” and “sleepiness” are often used interchangeably, they are 

distinct phenomena. Sleepiness refers to a tendency to fall asleep, whereas fatigue refers to an 

overwhelming sense of tiredness, lack of energy, and a feeling of exhaustion associated with 

impaired physical and/or cognitive functioning.1

 Sleepiness and fatigue often coexist as a 

consequence of sleep deprivation. 

Even though fatigue can be due to a variety of causes (e.g., illness, a vigorous workout, or a 

period of prolonged concentration), this chapter will focus on the effects of fatigue associated 

with insufficient sleep (see Key Terms and Definitions). The impact of extended work shifts and 

the relationship of these work schedules to nurse and patient safety will also be explored. Several 

practices that show demonstrable potential for reducing the adverse effects of fatigue on patient 

safety will be reviewed at the end of the chapter. 

Insufficient Sleep 

Studies suggest that average sleep durations have decreased from 9 hours in 1910 to as little 

as 6.9 hours on workdays in 2002.2–6 Objective measurements, however, suggest that mean sleep 

times may actually be somewhat lower than are typically reported in surveys. For example, 273 

randomly selected middle-aged residents of San Diego (40 to 64 years) reported sleeping 

approximately 7 hours, an amount that appeared to correspond to their time in bed. Mean sleep 

times obtained from wrist actigraphy, however, revealed that participants slept on average 6.22 

hours, approximately 43 minutes less than their subjective reports.7 

Sleeping longer on weekends and nonworkdays is also common,4, 6 suggesting that 

individuals are obtaining insufficient sleep on workdays, then attempting to “catch up” on 

weekends. Americans slept on average 36 minutes more on weekends in 2002,4 which is 

somewhat longer than the 23 minutes reported by British adults.6

 American nurses who 

participated in a recent survey, however, obtained on average 84 minutes more sleep on 

nonworkdays than work days (8.2 hours on nonworkdays compared to 6.8 hours on workdays),8

which is more than triple the amount reported by British adults and more than double that of 

other Americans. 

Individuals working nights and rotating shifts rarely obtain optimal amounts of sleep. In fact, 

an early objective study showed that night shift workers obtain 1 to 4 hours less sleep than 

normal when they were working nights.9 Sleep loss is cumulative and by the end of the 

workweek, the sleep debt (sleep loss) may be significant enough to impair decisionmaking, 

initiative, integration of information, planning and plan execution, and vigilance.10, 11 The effects 

of sleep loss are insidious and until severe, are not usually recognized by the sleep-deprived 

individual.12, 13

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

Finally, it is not uncommon for nurses and other shift workers to acknowledge falling asleep 

when working nights.8, 14, 15 Almost one-fifth of the nurses working permanent night shifts 

reported struggling to stay awake while taking care of a patient at least once during the previous 

month.15 Another survey found that the occurrence of falling asleep during the night shift 

occurred at least once a week among 35.3 percent of the nurses who rotated shifts, 32.4 percent 

of the nurses who worked nights, and 20.7 percent of the day/evening shift nurses who worked 

occasional nights.16 Objective recordings using ambulatory polysomnographic recorders and 

actigraphy have verified that nurses, air traffic controllers, and even commercial truck drivers 

regularly fall asleep for brief periods during the night shift.17–19

Effects of Insufficient Sleep 

Although the exact amount of sleep needed by healthy adults has not been determined, the 

effects of insufficient sleep have been well documented. A review of the relevant literature over 

the past 15 years reveals that insufficient sleep (or partial sleep deprivation) has a variety of 

adverse effects. Despite the wide range of research methodologies (e.g., qualitative studies, 

surveys and clinical trials, instruments) and settings (e.g., field studies, and time-isolation 

laboratories, and sample sizes), the results are quite similar: insufficient sleep has been 

associated with cognitive problems, mood alterations, reduced job performance, reduced 

motivation, increased safety risks, and physiological changes. Results from laboratory studies of 

total sleep deprivation (one or more nights without sleep) were not included in this review, since 

the focus of this section is on insufficient sleep (partial sleep deprivation) and not on total sleep 

deprivation. 

It is important to note that none of the several hundred studies reviewed for this paper 

showed any positive effects from sleep restriction in healthy adults. While it is true that one night 

of sleep deprivation can temporarily elevate mood in depressed patients,20, 21 it has adverse 

effects on mood in healthy individuals of all ages,22, 23 including nurses.24 Depression 

increases,25, 26 irritability increases,27, 28 and people report feeling more stressed when sleep is 

restricted.24 Extended sleep times, however, are not associated with improved mood or health 

and may be associated with poor health. Mortality rates were highest among subjects ages 30 to 

100 years who slept 8 or more hours, and lowest among those who slept 7 hours sleep,29 findings 

that were identical to those obtained a year later from a prospective study of 82,975 registered 

nurses (Nurses Health Study).30

Contrary to what one might expect, partially sleep-deprived older women (55 to 65 years) in 

one study suffered fewer ill effects when compared to younger women (20 to 30 years),31 and 

sleep-deprived older drivers (52 to 63 years) of both genders performed better than sleepdeprived younger drivers (20 to 25 years).32 An earlier study, however, reported that younger 

male drivers were more resistant to the adverse effects of sleep deprivation than older male 

drivers.33

Although some people are less impaired by insufficient sleep than others,34 several studies 

have shown that failure to obtain adequate sleep is an important contributor to medical error.25, 

35–37 Although most studies have focused on measuring the effects of sleep deprivation on the 

performance of interns and resident physicians, sleep deprivation also has adverse effects on the 

performance of hospital staff nurses.8

 Using data from the first sample of nurses (n = 393) who 

participated in the Staff Nurse Fatigue and Patient Safety Study, Dawson and his colleagues 

(Dawson, personal communication, 2005) found a significant relationship between sleep in the 

prior 24 hours and the risk of making an error. Nurses who reported an error or near miss 

2 
Effects of Fatigue and Sleepiness 

obtained significantly less sleep than nurses who did not report an error or near miss (6.3 ± 1.9 

hours versus 6.8 ± 1.7 hours). Using techniques described in one of their papers,38 researchers 

determined that there was a 3.4 percent chance of an error when nurses obtained 6 or fewer hours 

of sleep in the prior 24 hours and 12 or fewer hours of sleep in the prior 48 hours (Dawson, 

personal communication, 2005). Although a 3.4 percent risk of an error or near miss sounds 

insignificant, it would translate to a probability of 34 events per day in an average teaching 

hospital with 1,000 nursing shifts per day.

In addition to jeopardizing patient safety, nurses who fail to obtain adequate amounts of sleep 

are also risking their own health and safety. According to the National Center for Sleep 

Disorders Research and the National Highway Transportation Safety Administration Expert 

Panel on Driver Fatigue and Sleepiness,39 sleep loss is the leading cause of drowsy driving and 

sleep-related vehicle crashes. Drowsy drivers have slower reaction times,40 reduced 

vigilance,41, 42 and information processing deficits,40 which make it difficult to detect hazards and 

respond quickly and appropriately.39 Laboratory studies have shown that moderate levels of 

prolonged wakefulness can produce performance impairments equivalent to or greater than 

levels of intoxication deemed unacceptable for driving, working, and/or operating dangerous 

equipment.43, 44 Dawson and his colleagues43, 44 were the first to report that prolonged periods of 

wakefulness (i.e., 20 to 25 hours without sleep) can produce performance decrements equivalent 

to a blood alcohol concentration of 0.01 percent, and numerous other studies have confirmed that 

prolonged wakefulness significantly impairs speed and accuracy, hand-eye coordination, 

decisionmaking, and memory.45–49 Although numerous studies have shown that night shift 

workers report very high rates of drowsy driving and motor vehicle accidents when driving home 

after work,50–52 the majority of research on drowsy driving among health care providers has 

focused on the dangers of resident physicians driving home after a night of being on-call. 

There is also a growing body of evidence that sleep duration is (1) linked to metabolism and 

the regulation of appetite, and (2) decreased sleep times may be a contributing factor to the 

growing epidemic of obesity in this country. Several large-scale studies have shown dosedependent relationships between sleep duration and obesity, with greater sleep deprivation 

associated with a higher risk of obesity.53, 54 Glucose tolerance is altered by short-term sleep 

restriction,55 and habitually short sleep durations have been shown to significantly increase the 

risk of developing diabetes in women.56 Tightly controlled laboratory studies have also shown 

that short sleep durations, e.g., 4 hours per night, can result in alterations of hormones involved 

in the regulation of appetite (e.g., leptin, cortisol, and thyrotropin).57

Sleep is also believed to play a role in regulating immune function. Both human and animal 

studies have shown that immunological challenges such as vaccinations and both experimentally 

induced and spontaneous infections tend to increase sleep duration, often increasing the duration 

and intensity of slow-wave sleep (deep sleep) and decreasing REM sleep (rapid eye movement 

sleep or dream sleep).58, 59 Even though studies evaluating the effects of sleep deprivation on 

immunity have shown a variety of effects,60–65 no study has been able to link these changes in 

immune function with increased rates of infection or other adverse effects on health. 

Extended Work Hours

Although the hazards associated with the prolonged hours worked by resident physicians and 

interns have been documented in numerous studies,25, 65–68 limited attention has been paid to the 

hours worked by nurses or the effects of these hours on patient safety. Early studies tended to 

focus on nurse satisfaction with the new 12-hour shift schedule, only minimally addressing the 

3 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

increased risk of errors.35 More recent studies, however, have shown that the 12-hour shifts 

favored by many nurses and frequent overtime are associated with difficulties staying awake on 

duty, reduced sleep times, and nearly triple the risk of making an error.14, 69, 70 

Although the majority of hospital staff nurses (75 percent) now work 12-hour shifts, some 

nurses report being scheduled to work for periods as long as 20 consecutive hours.14, 69 Data 

collected on 11,387 shifts revealed that nurses left work at the end of their scheduled shift less 

than once every six shifts (15.7 percent), and worked on average 49 to 55 minutes extra each 

shift they worked.14, 69 Working overtime, whether at the end of a regularly scheduled shift (even 

an 8-hour shift) or working more than 40 hours in a week, was associated with a statistically 

significant increase in the risk of making an error.14, 69 The most significant elevations in the risk 

of making an error occurred when nurses worked 12.5 hours or longer; the risk was unaffected 

by whether the nurse was scheduled to work 12.5 hours or more, volunteered to work longer than 

scheduled, or was mandated to work overtime.14, 69

A little over two-thirds of the nurses participating in the Staff Nurse Fatigue and Patient 

Safety Study reported struggling to stay awake on duty, and 20 percent reported actually falling 

asleep on duty.14, 71 In fact, critical care nurses reported struggling to stay awake almost once 

every five shifts they worked. Not all of the difficulties remaining alert occurred at night (24:00–

06:00); 479 episodes of drowsiness (40 percent) occurred between 6 a.m. and midnight, and 40 

episodes (23 percent) of actually falling asleep on duty were reported between 6 a.m. and 

midnight.14 Nurses working 12.5 hours or longer were significantly more likely to report 

difficulties remaining alert than nurses working fewer hours per day,14 and they obtained on 

average 30 minutes less sleep. 

Although the participants (n = 35) in Urgrovics and Wright’s 1990 study72 reported fewer 

difficulties driving home after switching to 12 hour shifts, at least two recent studies contradict 

their findings. All but two of the nurses (n = 45) who worked 12-hour night shifts in an intensive 

care unit of a large tertiary care center reported having at least one motor vehicle accident or near 

accident during the previous 12 months driving to or from work.73 More recently, over half of the 

participants in the Staff Nurse Fatigue and Patient Safety Study (54 percent) reported struggling 

to stay awake driving home from work during the 28-day data-gathering period.74 While 

difficulties remaining alert driving home were common (drowsy driving was reported 

approximately once every five shifts), critical care nurses reported difficulties remaining awake 

driving home after working 12.5 consecutive hours or more approximately once out every three 

shifts they worked. In fact, critical care nurses who worked 12-hour shifts had a 1.87 percent 

greater risk of fighting sleep on their drive home from work than nurses working traditional 8-

hour shifts (95 percent confidence interval [CI] = 1.43–2.45, P < 0.0001).74

According to a recent report of the National Institute of Occupational Safety and Health 

(NIOSH),75 working more than 40 hours per week (overtime), working extended shifts (more 

than 8 hours), and working both extended shifts and overtime can have adverse effects on worker 

health. Extended shifts have been associated with increased musculoskeletal injuries,76 more 

cardiovascular symptoms,77–79 the development of hypertension,80 and higher risks for injury.81–

83 Working overtime has also been associated with poorer perceived health,84, 85 increased neck 

and musculoskeletal discomfort,76, 86, 87 increased risk for preterm birth,88 diabetes,89, 90 and 

cardiovascular disease,91–93 as well as increased morbidity and mortality94 and higher rates of 

accidents.95, 96 Not all studies, however, suggest that overtime is associated with poorer perceived 

health,97 increased risk of developing diabetes mellitus, or cardiovascular disease.98

4 
Effects of Fatigue and Sleepiness 

Studies have shown that accident rates increase during extended periods of work,96 with 

accident rates rising after 9 hours, doubling after 12 consecutive hours,81, 83 and tripling by 16 

consecutive hours of work.82 Data from the National Transportation Safety Board aircraft 

accident investigations also show higher rates of error after 12 hours.99 Other studies show no 

change in accident frequency or severity of accidents,100, 101 while one study showed that workers 

on a 12-hour shift schedule had lower rates of injuries at work, but higher rates of more 

significant injuries away from work.82 The combination of extended shifts and overtime, while 

rarely studied, has been associated with high rates of motor vehicle accidents or near misses in 

the prior year,73 more musculoskeletal pain, and cardiovascular symptoms.77 

Consecutive Shifts 

Fatigue can be exacerbated with increased numbers of shifts worked without a day off,102, 103

and working more than four consecutive 12-hour shifts is associated with excessive fatigue and 

longer recovery times.104 Folkard and Tucker83 also suggested that the accumulation of fatigue 

over successive work shifts might explain the rise in accident rates observed in their metaanalysis. On average, risk of an accident was approximately 2 percent higher on the second 

morning/day shift; 7 percent higher on the third morning/day shift, and 17 percent higher on the 

fourth morning/day shift than on the first shift. Accident risks also increased over successive 

night shifts (e.g., on average risk was 6 percent higher on the second night, 17 percent higher on 

the third night, and 36 percent higher on the fourth night) and were significantly higher than on 

day/morning shifts, a finding similar to that reported by Hanecke and colleagues several years 

earlier.81

Fatigue Countermeasures and Other 

Recommended Safety Practices 

Fatigue-related problems are believed to cost the United States an estimated $18 billion 

dollars per year in lost productivity and accidents.105 More than 1,500 fatalities, 100,000 crashes, 

and 76,000 injuries annually are attributed to fatigue-related drowsiness on the highway.105 Onthe-job performance also deteriorates: railroad signal and meter reading errors increase at night, 

minor errors occur more often in hospitals, and switchboard operators take longer to respond to 

phone calls.106 Two significant nuclear power plant accidents (Three Mile Island and Chernobyl) 

and the environmentally disastrous grounding of an oil tanker (Exxon Valdez) occurred at night, 

during early morning hours when vigilance is at its lowest. In the case of the Exxon Valdez 

grounding, sleep deprivation was identified as one of the major causal factors of the grounding 

(the third mate had been awake 18 hours and the ship’s master had not slept in the 36 hours prior 

to the accident).107 According to a supplemental report,108 sleep deprivation was a contributory, if 

not causal, factor in the poor decisions made the night before the launch of the Space Shuttle 

Challenger. 

A variety of industries and professions have developed programs to reduce sleepiness-based 

errors under the aegis of “fatigue management.”109–111 These programs usually include an 

educational component 112–116 and sometimes include schedule alterations.114, 117 Employees are 

usually given information about circadian rhythms, sleep hygiene measures, shift work and its 

adverse effects, and a variety of strategies that can be used to reduce fatigue (e.g., judicious use 

of caffeine and napping during night shifts).118, 119 Managers may be urged to consider altering 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

the starting times of shifts whenever possible to make schedules more compatible with circadian 

rhythms; to avoid scheduling employees to work more than two or three consecutive night shifts; 

and to provide adequate recovery time between shifts, especially when an employee is rotating 

off night shift. Hours of service regulations, where applicable, are also considered in the 

development of a fatigue management program.119 

Only limited information about the efficacy of these programs is available to the public. 

Although several specialized fatigue countermeasures programs have been developed and tested 

by the U.S Coast Guard, the Crew Endurance Management System,113 and the Commercial 

Mariner Endurance Management System,112 information about the efficacy of these programs 

has not been disseminated. Private companies implementing Fatigue Countermeasures Programs 

consider their use to be proprietary information. In fact, the only paper describing the efficacy of 

a fatigue countermeasures program reported only equivocal results.116

Other Recommended Safety Practices 

Rest breaks, napping, exercise, bright lights, and pharmacologic measures may be used to 

provide temporary relief from the symptoms of fatigue during the work shift. Although frequent 

short rests breaks are usually recommended for the prevention of fatigue, anecdotal information, 

collective bargaining agreements, and even research studies suggest that nurses are regularly 

sacrificing their breaks and meal periods to provide patient care.120–126 In fact, a recent study 

revealed that hospital staff nurses were completely free of patient care responsibilities during a 

break or meal period less than half the shifts they worked (2,429 out of 5,221 shifts). There were 

334 shifts (10 percent) in which nurses reported having no opportunity to sit down for a break or 

meal period. The rest of the time (2,249 out of 5,211 shifts) nurses reported having the time for a 

break or meal, but that they were not relieved of patient responsibilities during that time.126 On 

average nurses reported having only 25.7 minutes break during their entire shift. Nurses working 

the longest hours were least likely to receive appropriate breaks (e.g., 10 minutes every 2 hours 

and a 30-minute meal period free of patient care responsibilities). 

Studies have shown that short breaks not only improve performance and reduce subjective 

fatigue,127–130 they are effective in controlling the accumulation of risk associated with prolonged 

task performance (e.g., 2 hours sustained work)131, 132 and sleepiness.129 Other studies however, 

have shown that rest breaks and tea breaks can decrease fatigue but not necessarily accident risk 

or errors.126, 133

Napping. Even though napping during breaks or meal periods is often prohibited, both 

laboratory and field studies suggest that naps (15 minutes to 3 hours) are quite effective in 

increasing alertness during extended work periods or at night.134–139 Since few operational 

settings allow for long naps (e.g., 3 hours), most naps studied in operational settings are short. 

For example, 20-minute single naps during the first night shift improved the speed of responses 

on a vigilance task at the end of the shift,134 and 26-minute in-seat naps have been shown to 

increase physiological alertness and psychomotor performance of airline pilots.140 When pilots 

were allowed a nap during night flights, their performance improved by 34 percent, and 

physiologic alertness improved 54 percent compared to the no-nap condition.140 

The alerting effects of naps are varied, with most studies suggesting that improvements in 

subjective alertness and performance are sustained for up to an hour or more postnap.138, 139, 141

Longer naps tend to produce longer periods of alertness and improved performance.142 Although 

some studies report sleep inertia, or a period of decreased alertness and performance immediately 

following a nap,138, 139, 141 this effect was not seen in Driskell’s meta-analysis.142

6 
Effects of Fatigue and Sleepiness 

Stimulants. Caffeine is probably the most commonly used fatigue countermeasure.143 Its 

effects have been studied alone,144 as well as in combination with rest breaks, naps, and other 

stimulant medications.145–147 Generally, caffeine’s onset of action occurs approximately 15–30 

minutes after ingestion and its effects last 3–4 hours. Although tolerance can develop, significant 

increases in alertness and performance can be obtained with 200 mg of caffeine (approximately 

the amount of caffeine in one to two cups of coffee), with positive effects occurring with doses 

ranging from 100 mg to 600 mg.143, 145 Although caffeine alone improved alertness and 

performance during a laboratory study, the combination of napping and caffeine was more 

efficacious than just napping or just caffeine alone in a field study of evening and night shift 

workers.146 Six hundred milligrams of caffeine was also as effective as 20 mg d-amphetamine 

and 400 mg modafinil in producing short-term performance and alertness during prolonged sleep 

loss.148 Modafinil has also been shown to be effective in increasing alertness on laboratory 

measures of performance among workers diagnosed with shift work sleep disorder (see Table 1 

for a description of the disorder),149–151 but produced mixed results when evaluated during a 

randomized, double-blind cross-over study of sleep-deprived emergency room physicians. Even 

though modafinil improved some aspects of cognitive functioning and perceived alertness, 

participants had difficulties falling asleep when given an opportunity.152 Although other 

compounds have been recommended (e.g., melatonin), their efficacy has not been 

established.153, 154

Bright light. Although a number of studies have shown that bright lighting in control rooms, 

work areas, and laboratory environments can increase alertness at night and facilitate 

entrainment to night shift work,154–157 this strategy may not help nurses as much as other types of 

workers. Protocols typically involve exposure to bright lights (approximately 2,500 lux) or 

normal lighting (approximately 150 lux) while working at a desk for periods of 2 to 6 hours. No 

one has evaluated the efficacy of intermittent exposure to bright lights or the effects of 

alternating exposure to bright lights with the dim lighting typically found in patient rooms at 

night. 

Exercise. Exercise typically produces increased subjective alertness and improved cognitive 

performance in both sleep-deprived and nonsleep-deprived subjects.158, 159 Exercising for 10 

minutes, however, produces only transient (30–50 minutes) increases in subjective alertness. In 

one study there were no effects on performance after exercise, but within 50 minutes there were 

signs of increased drowsiness on electroencephalogram (EEG) recordings.160 As a result of this 

finding, the authors of the study caution that people who use exercise as an intervention for 

maintaining alertness during a period of sleep loss may end up sleepier than if they had not 

exercised. 

Research Evidence 

There is a very large, strong body of evidence showing that insufficient sleep has adverse 

effects on cognition, performance, and mood. These effects have been documented by at least 

two meta-analyses22, 150 and several clinical trials,32, 161, 162 as well as by studies using somewhat 

less robust designs including time series, cross-sectional, before-and-after designs, and 

noncomparative descriptive studies.11, 30, 37, 163–167 The adverse effects of insufficient sleep have 

also been documented in a variety of settings ranging from tightly controlled 

laboratories11, 32, 162, 163, 166 to field studies, 30, 37, 164–167 and in a variety of occupational groups. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

The studies demonstrating a relationship between adverse effects on health and obtaining less 

than 7 hours sleep per night tend to use less robust designs (e.g., cross-sectional designs, time 

series designs, comparative and noncomparative descriptive designs), but they often include 

large numbers of participants. Although survey and cross-sectional designs may not be as 

rigorous as controlled clinical trials, the number of recent studies suggesting similar relationships 

between insufficient sleep, altered glucose metabolism,56, 168 and increased risks of developing 

diabetes mellitus54, 169 and obesity53, 54 is powerful and convincing evidence that a relationship 

exists between these variables. Longer sleep durations (e.g., more than 8 to 9 hours per night) 

were also associated with greater risks of dying or developing a chronic illness such as DM or 

cardiovascular disease,29, 56, 168 leading researchers to speculate that individuals who routinely 

obtain higher than normal amounts of sleep may have preexisting health problems.29

The evidence regarding shift duration, however, is less clear-cut. Although some studies 

suggest that reductions in the work hours of resident physicians and interns is associated with 

fewer errors,35 other studies suggest that the implementation of work hour limitations has not 

decreased the number of adverse events.169,170 Although there are numerous literature 

reviews,171–173 descriptive and other comparative studies,14, 25, 26, 69, 174–176 there are no metaanalyses and only one systematic review177 focusing on the impact of work hours on medical 

errors or work performance. The strongest study, involving 20 critical care residents and interns 

and direct observation of errors, found that traditional schedules were associated with 35 percent 

more serious errors, and shortened workdays (16 hours) were associated with both fewer orderwriting errors and diagnostic errors.35 Unfortunately, this study has not been replicated outside of 

the critical care setting or at any other institution. 

The evidence demonstrating a relationship between working long hours and adverse effects 

on health is stronger. Not only are there several large-scale studies documenting higher injury 

rates when people worked overtime or extended shifts,82, 178, 179 there are several literature 

reviews83, 170 and three meta-analyses examining the effects on worker health.78, 79, 83 

Clinical trials that would provide more definitive answers to questions regarding shift 

duration and adverse health effects have not been done, nor are they likely to be done because of 

ethical issues. 

Although more than 170,000 employees from a variety of industries (including aviation, rail, 

trucking, maritime, health care, petrochemical, nuclear energy, and law enforcement) have been 

exposed to fatigue countermeasures programs,115 there is very limited information about their 

efficacy. Typical reports indicate that some aspects of a particular program were successful (e.g., 

employees slept longer at night,180 napping improved alertness on duty,129 and that participants 

used most of the suggested strategies),116 but the reports rarely assess the efficacy of the program 

as a whole for improving alertness on the job and reducing errors. The only published study 

describing the outcomes of a fatigue countermeasures program for resident physicians involved a 

very small sample (n = 6) and produced mixed results.116 Although participants reported 

increased subjective alertness after using the suggested strategies for a month, there were no 

improvements in their performance, mood, or the amount of sleep obtained when working the 

night shift. 

There is strong evidence that short naps can improve alertness during night shifts and 

prolonged periods of wakefulness. Data obtained from several small clinical trials,134, 138, 140, 146

and a meta-analysis142 all support the use of this strategy for improving alertness at night. In 

addition, there are several small clinical trials that suggest a short daytime nap can improve 

alertness during the afternoon.181–184

8 
Effects of Fatigue and Sleepiness 

The effects of rest breaks were more variable. Study designs evaluating the efficacy of rest 

breaks on performance and alertness also tended to be weaker, involving quasi-experimental 

designs128, 130, 131, 133, 185 rather than randomized clinical trials129 or meta-analyses. Given that 

almost all of the aforementioned studies were field studies conducted at actual worksites during 

regular workhours, the choice of somewhat less rigorous designs is understandable. 

There is strong evidence that use of caffeine, either alone or in combination with a nap, can 

increase alertness. Although there are no meta-analyses evaluating the efficacy of caffeine, the 

utility of caffeine for increasing alertness has been demonstrated through numerous clinical 

trials,144, 145, 147 and its widespread use by adults. (Mean caffeine consumption in the United 

States is estimated at 238 mg or slightly more than two cups of coffee per day per person.)186

Other measures to increase alertness, such as bright lighting and exercise, either lack sufficient 

evidence or may not be practical for nurses. 

Evidence-Based Practice Implications 

Although studies have not always been able to document that the cognitive deficits 

associated with insufficient sleep lead to medical mishaps, there is enough evidence to suggest 

that insufficient sleep can have adverse effects on patient safety and the health of nurses. The 

effects, summarized in Table 1, provide the basis for the two recommendations in Table 2. 

Table 1. Adverse Effects of Restricted Sleep on Patient Safety and the Health of Nurses 

Sleep 

Duration in 24 

Hour Period 

Adverse Effects on Patient Safety Adverse Effects on Health 

< 7 hours More likely to report struggling to stay 

awake during work shift14 Increased risk of developing cardiovascular 

disease and DM among nurses187

Increased risk of becoming obese over a 10-

year period53

≤ 6 hours Risk of making an error is 3.4% during a 

work shift among nurses who slept ≤ 6 

hours in 24 hours prior to shift (Dawson, 

personal communication) 

Increased prevalence of DM and altered 

glucose metabolism56, 168 

Risk of obesity is 23% greater than subjects 

sleeping 7–9 hours53

< 5 hours Increased subjective and objective 

sleepiness, and reduced performance on 

cognitive tasks22, 161

Increased risk of developing DM demonstrated 

in nurses187

Risk of obesity is 50% greater than among 

subjects sleeping 7–9 hours53

≤ 4 hours Altered levels of appetite-regulating hormones 

(leptin, cortisol, and thyrotropin)57

Risk of obesity is 73% greater than among 

subjects sleeping 7–9 hours53

9 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

Table 2. Evidenced-Based Recommendations for Practice Related to Sleep Duration32 

Recommendation Practice Implication 

Nurses need to obtain 7–8 hours sleep per night to 

protect both the health of their patients and their own 

health 

Get 7 to 8 hours of sleep each day (24-hour period) 

before you go to work. 

Younger nurses (e.g., those 20–30 years old) need to 

be particularly careful about obtaining sufficient sleep, 

since their mood and performance may be more 

adversely affected by insufficient sleep. 

If you are younger than 30 years of age, adequate 

sleep is especially important for providing safe and 

high-quality patient care. 

To implement these recommendations, many nurses will have to be willing to make 

substantial changes in their behavior. Despite their more sophisticated knowledge about health 

and illness, the sleep habits of nurses mirror those of other Americans. Only a little more than 

one-fourth of the participants in the Staff Nurse Fatigue and Patient Safety Study (27.2 percent) 

obtained at least 6 hours sleep prior to every shift they worked during the 28-day study period; 

more than one-quarter of the 11,387 shifts studied (29.1 percent) were worked by nurses who 

obtained less than 6 hours sleep, an amount that has been associated with higher risks of errors 

(Dawson, personal communication, 2005). Although few nurses would consider coming to work 

if they were legally drunk, the data suggest that many nurses are unaware of or disregard the 

equally serious risks associated with insufficient sleep. 

Although it might be argued that family responsibilities prevented hospitals staff nurses from 

obtaining sufficient sleep, regression analysis has shown that this is not the case. Neither 

childcare nor elder care responsibilities were associated with reduced sleep times on workdays. 

Instead, longer work shifts, longer commutes, higher caffeine intakes, complaints of poor sleep, 

and older age (of the nurse) were associated with shorter sleep durations.188 Childcare 

responsibilities, however, were associated with shorter sleep times on nonworkdays. 

Several authorities have recommended that work shifts be limited to 12 hours in a 24-hour 

period and employees limited to working no more than 48 to 60 hours per week.171, 173, 189, 190 

Although 12-hour shifts are quite popular among nurses, most authorities do not recommend the 

use of 12-hour shifts unless there are sufficient rest breaks, there are adequate arrangements for 

coverage of absentees, overtime will not be added, and shift systems are designed to minimize 

the accumulation of fatigue.173, 190, 191 Rosa173 also recommends that 12-hour shifts not be 

adopted if there are staffing shortages, citing the dangers associated with an already fatigued 

worker covering part or all of a vacant shift. 

In fact, legislation pending in the Massachusetts State legislature would (1) prohibit resident 

physicians from working more than 10 consecutive hours in all high-intensity settings, (e.g., 

emergency departments, intensive care units, etc.); (2) limit resident physician workhours to 18 

consecutive hours in all other areas; (3) mandate 16 consecutive hours off after an 18-hour shift 

and require 10 consecutive hours off between all other work shifts; and (4) require all physicians, 

not just trainees, to notify patients before providing care if the physician has been awake 22 

hours out of the prior 24 hours.192 Although the workhours of most nurses will not be altered by 

this legislation, limiting the duration of nursing shifts and mandating sufficient rest periods 

between shifts would also be of benefit for nurses and the patients they care for. 

10 
Effects of Fatigue and Sleepiness 

Table 3. Evidenced-Based Practice Recommendations Related to Shift Duration and Number of 

Workhours During a Week 

Recommendation Practice Implication 

Schedules that involve working 48 or 60 hours per 

week,193 or working 7 consecutive 12-hour shifts in one 

week in order to have 7 consecutive days off the next 

week194 are unacceptably risky,83 and should be 

prohibited. 

Do not work any more than 48 hours in a 7-day period. 

The continued use of 12-hour shifts cannot be 

recommended given the current working conditions, 

including the almost daily need for nurses to stay beyond 

the end of their scheduled shift, the frequent absence of 

breaks during the workday, and the higher risk of errors 

associated with 12-hour shifts.14, 69, 126

Nurse managers should not schedule nurses for 12-

hour shifts and nurses should not request 12-hours 

shifts. 

If nurses insist on continuing to work 12-hour shifts, 

several measures should be taken to reduce the risks to 

patients and nurses. These steps include reducing the 

number of consecutive shifts to no more than three,83, 104

providing adequate meal and rest breaks,120, 195 revising 

schedules to ensure that nurses have at least 10–12 

hours off between work shifts so that they have adequate 

time for sleep, commuting, and completing their domestic 

responsibilities, and requiring that nurses use their offduty time to get sufficient sleep. 

If you are scheduled to work a 12-hour shift, (1) do not 

work more than three shifts without a day off; (2) insist 

that provisions are made for sufficient staffing to ensure 

that you are able to be free of patient care 

responsibilities for 10 minutes every 2 hours and for 30 

minutes to eat a meal; and (3) insist that you have at 

least 10–12 hours off between shifts so that you can 

obtain sufficient sleep. 

The emphasis on maximizing opportunities for sleep is intentional. Because long workhours 

are often associated with insufficient sleep,25, 36, 196 some authorities believe that fatigue on the 

job is more likely to be associated with a lack of sleep than the number of hours spent 

working.191, 197 Workers who report high workloads, stressful workweeks, or who score higher 

on burnout indexes have shorter sleep times,198, 199 as well as more arousals, greater sleep 

fragmentation, more wake time after sleep onset, lighter sleep, and less deep sleep.200, 201 Fatigue 

and daytime sleepiness associated with stressful working conditions and burnout is believed to 

be a result of insufficient sleep, rather than a direct result of stressful working conditions or 

burnout. 

Although employer support will be required to implement schedule changes, there are several 

strategies that nurses can adopt to improve their ability to remain alert throughout their entire 

shift. Even though the following three fatigue countermeasures were developed mainly for night 

shift workers, the first two recommendations are also appropriate for nurses working other shifts. 

Practice Recommendations for Use of Caffeine 

1. Caffeine should be used therapeutically. Caffeine should not be consumed on a regular basis 

or when alert. Instead, caffeine consumption should occur only at the beginning of a shift or 

about an hour before an anticipated decrease in alertness (e.g., between 3 a.m. and 5 a.m.). 

To reduce the possibility of insomnia, caffeine consumption should stop at least 3 hours 

before a planned bedtime.202

2. Nurses should be allowed to nap during their break and meal periods. Naps should be short, 

e.g., less than 45 minutes, to reduce the likelihood of awakening from deep sleep and 

11 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

experiencing sleep inertia.143 Some nurses may prefer to take a shorter nap, and have a 15-

minute wake up period before they resume patient care.

3. Nurses, particularly those who start their shift at 11 p.m. or midnight, should consider 

napping prior to starting their shift. Not only are nurses who work at night required to be 

awake and vigilant when their body temperature is lowest and their sleep tendency is 

greatest, they are typically awake longer before the beginning of their shift than workers on 

other shifts.203

Table 4. Evidenced-Based Recommendations for Practice Related to Improving Alertness on the 

Job 

Recommendation Practice Implication 

Caffeine should be used therapeutically. Caffeine should 

not be consumed on a regular basis or when alert. 

Instead, caffeine consumption should occur only at the 

beginning of a shift or about an hour before an 

anticipated decrease in alertness e.g., between 3 a.m. 

and 5 a.m. To reduce the possibility of insomnia, caffeine 

consumption should stop at least 3 hours before a 

planned bedtime 

Do not consume caffeine outside of workhours. 

Consume caffeinated beverages only at the beginning 

of the shift or about an hour before an anticipated 

decrease in alertness, e.g., between 3 a.m. and 5 a.m. 

Avoid consuming caffeinated beverages at least 3 

hours before bedtime. 

Nurses should be allowed to nap during their break and 

meal periods. Naps should be short, e.g., less than 45 

minutes, to reduce the likelihood of awakening from deep 

sleep and experiencing sleep inertia. Some nurses may 

prefer to take a shorter nap and have a 15-minute wake 

up period before they resume patient care 

Use breaks and meal periods for a short nap, 

particularly during the night shift. 

Naps should be less than 45 minutes in duration. If you 

are somewhat sluggish when you first awaken, take a 

shorter nap so that you have at least a 15-minute wake 

up period before resuming patient care. 

Nurses, particularly those who start their shift at 11 p.m. 

or midnight, should consider napping prior to starting their 

shift. Not only are nurses who work at night required to 

be awake and vigilant when their body temperature is 

lowest and their sleep tendency is greatest, they are 

typically awake longer before the beginning of their shift 

than workers on other shifts 

If you work nights, especially if you start working at 11 

p.m. or midnight, take a nap prior to starting your shift 

to help you remain alert during the early morning hours. 

Although it may be more difficult to schedule, taking a 

short nap before working a 12-hr night shift, would also 

help improve your alertness during the early morning 

hours. 

Finally, nurses should realize that most people are not accurate judges of how impaired they 

are by fatigue or sleep loss.204, 205 Few adults can perform at high levels for more than 12 

consecutive hours or function adequately with less than 6 hours sleep. Figure 1 illustrates the 

risks associated with combining insufficient sleep with extended shifts and outlines strategies to 

reduce fatigue-related errors. 

12 
Effects of Fatigue and Sleepiness 

Figure 1. Risks Associated With Various Combinations of Sleep Duration, Shift Duration, and Shift 

Time, and Strategies To Mitigate the Effects of Insufficient Sleep and Extended Work Shifts 

Scheduled to work? 

Have you had at 

least 7 hours of 

sleep in the 

24-hours prior to 

starting your shift? 

Yes, and am 

scheduled to work 

< 12-hour shift. 

Yes, and am 

scheduled to work 

a 12-hour shift. 

No, and am 

scheduled to 

work < 12-hour 

shift. 

No, and am 

scheduled to 

work a 12-hour 

shift.

Scheduled to 

work day or 

evening 

Scheduled 

to work the 

night shift? 

Scheduled 

to work the 

day shift? 

Scheduled 

to work the 

night shift? 

Scheduled to 

work day or 

evening 

Scheduled 

to work the 

night shift? 

Scheduled 

to work the 

day shift? 

Scheduled 

to work the 

night shift? 

Lowest Risk of 

Errors. 

Higher Risk of 

Errors. 

Do the following: 

Take regular breaks 

from patient care. 

Nap during break(s) 

and use caffeine 

therapeutically, 

especially on the 

night shift. 

If have < 7 hours of 

sleep, take a nap 

before starting the 

work shift. 

Plus, use naps and 

caffeine to maintain 

alertness. 

Y

Highest Risk of 

Errors: 

Use all of the above 

strategies to mitigate the 

effects of sleep loss, plus 

double check all work.

Research Implications 

More research is needed to understand the effects of fatigue on patient safety. Controlled 

trials are needed to determine optimal work schedules in hospital settings and test fatigue 

countermeasures. Since night shifts cannot be eliminated, the efficacy of fatigue 

countermeasures, naps during break periods, therapeutic use of caffeine, and other measures 

should be tested in hospital environments. Since the use of naps and caffeine have been shown to 

increased alertness during prolonged sleep deprivation and during night shift work, these 

measures should also be evaluated to determine if they would be effective for increasing 

alertness on day and evening shifts. 

Finally, there is no information about the sleep of nurses working outside of hospital 

environments, and only limited information about the workhours of nurses in nursing homes and 

extended-care facilities. Nor is there any information about the sleep and performance of nurses 

who work 24-hour shifts (e.g., nurse-midwives and some advanced practice nurses) or who are 

13 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

14 

 

required to take call. These issues and others need to be examined to improve both the safety of 

patients and the nurses who care for them. 

Although many questions remain unanswered, “We do know enough,” according to L. G. 

Olson and A. Ambrogetti, “to end the worse abuses of the human sleep-wake cycle, and we need 

to see a shift by both hospital employers and the medical [nursing]* profession towards 

addressing this issue”206 (p. 416). The service regulations written during the first two decades of 

the 20th century recognized that people cannot work for long periods of time each day without 

adequate time to sleep. Eighty years later, at the beginning of the 21st century, it is perhaps time 

to acknowledge that nurses cannot provide safe care when they are fatigued, have worked for 

more than 12 consecutive hours, and/or have not had at least 12 to 16 hours off between shifts. 

*

 Material in brackets added by author. 
15

Research Question Research Goal Possible Study Methods What is the optimal schedule for minimizing fatigue among hospital staff nurses? For nurses working in long-term care facilities? 

To evaluate different types of schedules to determine which is the most effective for minimizing fatigue among hospital staff nurses and nurses working in long-term care facilities. 

Controlled clinical trials of different shift durations, nudays off, and types of shiftshift. 

Will the risk of making an error decrease if shifts are shortened to ≤ 10 hours and/or nurses get at least 7 hours sleep? 

To determine if shorter work durations and obtaining adequate amounts of sleep reduce the risk of making an error. 

Clinical trial, with one groushifts, the second group a7 hours sleep, and the thirshorter shifts and obtain a

Since most nurses and managers favor 12-hour shifts despite their well-recognized hazards, how can the culture of individual nursing units be changed to discourage their use? 

To determine what factors favor the continued use of 12-hour shifts and how to alter those factors to make shorter shifts more acceptable to staff nurses and nurse managers. 

Qualitative approaches, in scales to assess unit cultucommitment to improving 

What differentiates those nurses who always obtain at least 6 hours sleep prior to working from those who fail to get at least 6 hours sleep prior to working? 

To identify the characteristics of nurses who are most likely to obtain the minimum amount of sleep necessary to provide care safely. 

Correlation studies and re

Will fatigue countermeasures, e.g., naps during break periods and therapeutic use of caffeine, increase the alertness of nurses working at night? Decrease the risk of making an error? 

To evaluate the efficacy of fatigue countermeasures for increasing the alertness and decreasing the risk of errors when nurses work at night. 

Clinical trial comparing the errors in night shift nurses countermeasures group to assigned to the interventio

Will fatigue countermeasures, e.g., naps during break periods and therapeutic use of caffeine, increase the alertness of nurses working 12-hour shifts? Decrease the risk of making an error? 

To evaluate the efficacy of fatigue countermeasures for increasing the alertness and decreasing the risk of errors when nurses work 12-hour shifts 

Clinical trial comparing the errors of nurses working 1to fatigue countermeasurenot assigned to the interve

Should nurse midwives and other advanced practice nurses be allowed to work 24-hour shifts? 

To determine if 24-hour shifts worked by nurse midwives and other advanced practice nurses are safe. 

Observational study using that used to evaluate the sworked by critical care res

Table 5. Critical Research Questions 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

Conclusion 

The evidence is overwhelming that nurses who work longer than 12 consecutive hours or 

work when they have not obtained sufficient sleep are putting their patients’ health at risk; risk 

damaging their own health; and if they drive home when they are drowsy, also put the health of 

the general public at risk. Nurses, nurse managers, nursing administrators, and policymakers 

need to work together to change the culture that not only allows, but often encourages nurses to 

work long hours without obtaining sufficient sleep. 

Key Terms and Definitions 

Table 6. Key Definitions 

Term Definition 

Insufficient sleep A condition that results from sleeping less than needed. Healthy adults who obtain 

enough sleep do not require an alarm clock to awaken them in the morning, do not 

have difficulties with remaining alert after lunch or during a boring lecture, and do not 

sleep in on weekends. 

Wrist actigraphy Wristwatch-sized instrument used to record frequency and amplitude of wrist 

movements. Used to distinguish sleep from waking states. 

Sleep debt The difference between the amount of sleep you need and the amount you obtained. 

The larger the sleep debt, the more likely you are to fall asleep during the daytime. 

Polysomnographic 

recorders 

Recording equipment used to record sleep. Equipment records 

electroencephalograms (EEG), electro-oculograms (EOG), and electro-myograms 

(EMG) needed for staging sleep. 

Shift work sleep disorder A sleep disorder effecting individuals who work at night. Individuals with this disorder 

have difficulty remaining awake during their work shift and have trouble sleeping after 

working at night, yet have no trouble sleeping at night or staying awake during the 

day on their days off. 

Search Strategy 

Relevant papers for this review were identified from three databases (MEDLINE,® 

CINHAL,® and PsychLit) using the period 1990–2006. Several older, classical works were also 

cited. Hand searches were also performed examining journals such as the Journal of Sleep 

Research and Sleep. Only those papers that focused on the effects of chronic partial or total sleep 

deprivation for a single night, extended work shifts, and strategies to reduce fatigue-related 

errors and accidents were included in this review. Search terms included “caffeine,” “chronic 

partial sleep deprivation,” “fatigue,” “fatigue countermeasures,” “extended work shifts,” 

“napping,” “overtime,” “performance,” “resident physicians,” “registered nurses,” “rest breaks,” 

“sleep loss,” “sleep restriction,” “staff nurses,” “total sleep deprivation,” and “vigilance.”

Author Affiliations 

Ann E. Rogers, Ph.D., R.N., F.A.A.N., associate professor, University of Pennsylvania 

School of Nursing, and the Center for Sleep and Respiratory Neurobiology, University of 

Pennsylvania School of Medicine. E-mail: aerogers@nursing.upenn.edu. 

16 
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Evidence Table 1. Effects of Insufficient Sleep on Patient Safety and Health of Individuals 

26

Source 

Safety Issued Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measures 

Study Setting & Study Population 

Study Intervention K

Belenky 2003161 Chronic sleep restriction Randomized controlled trial (2) Randomized controlled trial (2) Vigilance, 

objective and subjective sleepiness (3) 

69 healthy volunteers (16 women, 50 men) ages 24–62 

Subjects’ sleep restricted to 3 hr, 5 hr, 7 hr, or 9 hr/night for 7 nights 

Wrepdlelerecthpimpw(9 

Harrison 1997162 One night’s sleep loss Randomized controlled trial (2) Cross-over design (2), Verbal communication 

(3) 

9 healthy college students 

Treabpcmfla

Pilcher 199622 Sleep loss Meta-analysis (1) Meta-analysis (1) Effects of sleep loss on 

cognition, motor performance, and mood (3) 

19 studies and 1,932 participants 

Spocpsdsclash
27

Source 

Safety Issued Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measures 

Study Setting & Study Population 

Study Intervention K

Philibert 2005150 Sleep loss and cognitive function, 

memory and vigilance 

Meta-analysis (1) Meta-analysis (1) Effects 

of sleep loss among physicians on cognitive function, memory and vigilance (3) 

60 studies published between 1971 and 2004 involving 959 physicians and 1,028 nonphysicians 

Cpsepdescec

Phillip 200432 One night’s sleep 

loss 

Randomized trial (2) 

Cross-over design (2) Reaction time, subjective sleepiness and performance ratings (3) 

10 younger (20–25 years) and 10 older (52–63 years) drivers 

Rin saresuresinpwb

Ayas 2003 (a)56 Insufficient sleep Time series (7) Longitudinal study (3), self-reported sleep 

duration and risk of DM (1) 

70,260 women ages 45–65 years who were enrolled in the Nurses Health Study 

Tonthms
28

Source 

Safety Issued Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measures 

Study Setting & Study Population 

Study Intervention K

Gangwisch 200553 Sleep restriction Time series study (7) Cross-sectional and longitudinal examination 

(4) of sleep duration and weight gain over a 10-year period (2) 

Participants in the NHANES I study, 9,588 participants in the cross-sectional study and 6,981 participants in the longitudinal study 

S

damywhdhaino

Gottlieb 2005168 Chronic sleep restriction Cross-sectional study (4) Cross-sectional study (5) Usual sleep time, fasting 

glucose levels, blood glucose levels 2 hours glucose challenge (3)

Participants in the Sleep Heart Health Study (722 men and 764 women) 

Shapim

Kripke 200229 Chronic sleep 

restriction 

Cross-sectional study (4) 

Survey (5) Participants were 30–100 years of age, sleep durations and morbidity and mortality rates over a 6-year period (1) 

1.1 million participants from the American Cancer Society’s Cancer Prevention II Study. 

Maoleloa7 

Singh 200554 Sleep restriction Cross-sectional 

study (4) 

Survey (5), total sleep time in the 2 weeks prior to survey, and body mass index (BMI) (3) 

3,158 randomly selected adults in the metropolitan area of Detroit, MI 

Ooswsahaleino
Evidence Table 2. Extended Work Hours 

29

Source 

Safety Issued Related to Clinical Practice 

Design Type 

Study Design, Study Outcome Measures Study Setting & 

Study Population 

Study Intervention K

Arnedt 2005174

On-call schedules and performance 

Nonrandomized trial (3) 

Nonrandomized controlled trial (l3) 60-minute test battery consisting of sustained attention, vigilance, simulated driving performance, and selfreports of performance (3). 

34 pediatric residents at a university hospital in the northeastern region of the U.S. 

Residents tested in four conditions: (1) after a night of heavy call (on call every 4th to 5thnight), (2) a night on a light call schedule (call is less frequent than heavy call), (3) after a night of light call and enough alcohol to obtain a blood alcohol level of 0.04–0.05, and (4) after a night of heavy call plus alcohol

PnqaRsc4asa 

Fletcher 2004169

Number of hours worked 

Systematic Review (11) 

Literature review (6) Reviewed 7 studies between 1966 and 2004 related to reducing resident work hours. Outcomes included mortality, adverse events, and medication errors (1). 

R

ewimNclacc
30

Source 

Safety Issued Related to Clinical Practice 

Design Type 

Study Design, Study Outcome Measures Study Setting & 

Study Population 

Study Intervention 

Key 

Landrigan 200435

Number of hours work 

Nonrandomized trial (3) 

Nonrandomized trial (3) Number of serious medical errors observed by trained observers in ICU (2), raters blinded to work schedules 

20 critical care interns at large university teaching hospital 

Traditional call scheduled with extended hours and every third night call, and a restricted schedule that reduced work shifts to 16 hours 

Interseriothe tdurinscheseriodiagsignithe tcomsche

Akerstedt 2002178

Number of hours worked, and overtime 

Longitudinal, descriptive study (7) 

Observational study with controls (4) Phone interviews, fatal occupational accidents (3) 

47,860 Swedes interviewed over a 20-year period about issues related to work and health 

TheroccuPredgendthe pworkstatuor phdid nfatal 

Dembe 2005207 

Number of hours worked, overtime 

Time series (7) Survey (5), occurrence of 

injury (3) 

10,793 Americans with a variety of occupations who participated in the National Longitudinal Survey of Youth between 1987 and 2000 

Workwas highjobs ≥12 assoincrehr/whazaincrefashnumweekrates of jogend
31

Source 

Safety Issued Related to Clinical Practice 

Design Type 

Study Design, Study Outcome Measures Study Setting & 

Study Population 

Study Intervention 

Key Fin

Folkard 200383

Work hours, shift work and safety 

Meta-analysis (1) Meta-analysis (1). Risks 

across different shifts, risks over successive shifts, risks over hours of duty, risk as a function of breaks (3) 

26 studies Risk of i

fashion lowest rthe highwas a sbetween was relasubstanmost of across swas 6% 17% hig

higher o

increaseafter 8th 

the 12th 

during tinjury rosuccesshad douperiod bphenomshifts anperiod b

Sparks 2003208 Weekly workhours, ill 

health 

Meta-analysis (1) Meta-analysis (1) Weekly 

workhours, health problems (3) 

21 studies There w

0.13 betand ill h

Van der Hulst 200379 Long work hours and health Systematic literature review 

(1) 

Systematic literature review (1) workhours, adverse health effects (3) 

27 empirical studies Long wo

with adv(cardiovdisability changesbehavio

Yang 200680 Long workhours 

and hypertension 

Cross-sectional study (4) 

Survey (4), workhours/week and hypertension 

24,205 working adults living in California 

After cohealth aindividuhours/wrisk of dthan tho
Evidence Table 3. Fatigue Countermeasures 

32

Source 

Safety Issued Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measures 

Study Setting & Study Population 

Study Intervention K

SmithCoggins 1997116

Maintenance of vigilance, fatigue countermeasures program 

Nonrandomized controlled trial (3) 

Nonrandomized controlled trial (3) Ambulatory polysomnography recordings during main sleep period, daily performance testing, and daily subjective ratings of sleep, mood, and intervention use (3) Tested on both day and night shifts. 

6 emergency room physicians 

Measures obtained at baseline, after a placebo intervention, and after the implementation of a fatigue countermeasures program 

Inamimpaw

Lilley 2002133 Fatigue, accidents 

and rest breaks 

Noncomparative study (8) 

Survey (5) Payment method, ethnicity, injury, fatigue, sleep duration, work duration, breaks and their duration (3) 

367 logging and silviculture workers in New Zeeland 

Pbfaw

Neri 2002129 Maintenance of 

Vigilance, rest breaks 

Randomized controlled trial (2) 

Randomized controlled trial (2) Continuous recordings of EEG, subjective ratings of sleepiness, psychomotor vigilance testing (reaction time) (3) 

28 pilots, flight simulator 

Treatment group received 5 short breaks spaced hourly during flight, control group received 1 break in middle of simulated night flight 

Tbsleam

Rogers 2004126 

Errors and rest breaks 

Noncomparative study (8) 

Survey (5) Daily reports of break duration, patient care responsibilities during break and meal periods, errors and near errors (3) 

393 randomly selected full-time hospital staff nurses 

NnbrereaMmwddp
33

Source 

Safety Issued Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measures 

Study Setting & Study Population 

Study Intervention K

Tucker 2003131 Injuries and rest breaks Noncomparative study (8) Retospective analysis of accident data over a 3-

year period (4), number of injuries in each 30-minute interval that preceded a break (every 2 hours) (3) 

1,954 employees at an auto assembly plant in the UK 

R3pbbmb

Driskell & Mullen, 2005209 

Use of napping to improve performance and reduce fatigue 

Meta-analysis (1) Meta-analysis (1) 

Evaluated the effect of naps on performance, the effect of the nap duration, the effect of the postnap interval (3) 

12 studies N

pfacp

Gillberg 1996184

Maintenance of vigilance, napping during work period 

Randomized controlled trial (2) 

Randomized controlled trial (2) Performance measures, reaction-time tests, and EEG/EOG recordings before, during, and after drive (3) 

9 sleep-deprived truck drivers, driving simulator 

Subjects assigned to one of three conditions: (1) day drive of 90 min, (2) night driving with 30-min rest period, and (3) night drive with 30-min nap 

EshaSsthNpp

Gillberg 1996210 

Maintenance of vigilance, napping during daytime 

Randomized controlled trial (2) 

Randomized controlled trial (2) Cross-over repeated measures design. Karolinska Sleepiness Scale, visual performance task, and continuous EEG/EOG recordings (3) 

8 healthy young males, laboratory setting 

Sleep restricted to 4 hours at night, randomly assigned to either nap (20 min during midday) or no nap condition 

Nsppn

Harma 1989203

Maintenance of vigilance, napping prior to shift 

Noncomparative study (8) 

Survey (5) Individual characteristics, shortterm memory, alertness (3) 

146 nurses and nursing assistants 

Ppsre
34

Source 

Safety Issued Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measures 

Study Setting & Study Population 

Study Intervention K

Purnell 2002134

Maintenance of Vigilance, napping during night shift 

Randomized controlled trial (2) 

Randomized controlled trial (2), counterbalanced cross-over design, performance on neurobehavioral test battery, subjective fatigue, drowsiness driving home after a 12-hour night shift (3) 

Worksite in New Zealand, 24 male aircraft maintenance engineers 

During experimental week, subjects were given an opportunity to take a 20-minute nap at work between 1 and 3 a.m.; were not allowed opportunity to nap during control week. 

2imreosSledwd

Rosekind 1994140

Maintenance of vigilance, napping during work shift 

Randomized controlled trial (2) 

Randomized controlled trial (2) vigilance performance testing, ambulatory physiological monitoring of sleepiness (3) 

Regularly scheduled trans-Pacific airline flights 

Intervention group allowed to take a 40-minute planned nap during cruise over water; control group not allowed a nap 

Mmvnnsto ndflcemlagpanp
35

Source 

Safety Issued Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measures 

Study Setting & Study Population 

Study Intervention K

Sallinen 1998138

Maintenance of Vigilance, napping during night shift 

Randomized controlled trial (2) 

Randomized controlled trial (2), efficacy of naps during night shift evaluated using visual reaction times, subjective ratings of sleepiness, and physiological sleepiness (3) 

14 experienced male shift workers, simulated work shift in laboratory 

Subjects randomly assigned to take either a 30-minute or 50-minute nap at 1 a.m. or 4 a.m. Control condition was a shift without a nap. 

NreessbnSsthlam

Bonnet 2005211 

Maintenance of vigilance, sleep restriction, and use of stimulants 

Systematic literature review (11) 

High-quality systematic literature review (1) related to the safety and efficacy of five different stimulants 

239 papers, most were double-blind clinical trials 

Rindmuas

De Valck 2001144

Maintenance of vigilance, slowrelease caffeine 

Randomized controlled trial (2) 

Randomized controlled trial (2) Cross-over design with sleep restricted subjects (4.5 hours of 7.5 hours time in bed) completed a 45-minute driving task, POMS, and Stanford Sleepiness Scale (3) 

12 subjects ages 20–25 years, driving simulator 

Subjects randomly assigned to take 300 mg sustainedrelease caffeine tablet or placebo after 4 hours sleep 

Cladlipima

De Valck 2003147

Maintenance of vigilance, slowrelease caffeine, and a nap 

Randomized controlled trial (2) 

Randomized controlled trial (2) Cross-over design with sleep restricted subjects (4.5 hours of 7.5 hours time in bed) completed a 45-minute driving task, POMS, and Stanford Sleepiness Scale (3) 

12 subjects ages 20–25 years, driving simulator 

Subjects randomly assigned to take a 30-minute nap, 300 mg slow-release caffeine tablet, or placebo after 4 hours sleep 

Bccsreloth
36

Source 

Safety Issued Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measures 

Study Setting & Study Population 

Study Intervention K

Gill 2006152 Maintenance of 

vigilance, modafinil 

Randomized controlled trial (2) 

Randomized controlled trial (2) Cognitive performance, subjective alertness on night shift (3) 

25 emergency room physicians 

Cross-over design used, all subjects randomly assigned to either modafinil or placebo group. After a 2-week washout period, received either placebo or modafinil. 

Aimaafuda

Schweitzer 2006146

Maintenance of vigilance, napping, and caffeine 

Randomized controlled trial (2) 

Randomized controlled trial (2) tests the efficacy of napping, caffeine, and the combination of napping and caffeine in laboratory study. Crossover design (2) for field portion of study. Outcomes included maintenance of wakefulness testing and psychomotor vigilance task (3) 

Laboratory study 68 healthy individuals, field study, 53 shift workers (nights and evening shift) 

Laboratory study included the following treatments: (1) an evening nap before the first 2 of 4 night shifts, plus placebo; (2) caffeine taken nightly; and (3) the combination of evening naps and caffeine. Field study tested subjects in both of the following conditions: (1) an evening nap prior to the first two of 4 night shifts, plus caffeine taken nightly; and (2) no placebo and no nap group. 

LincaTaeinnimp
37

Source 

Safety Issued Related to Clinical Practice 

Design Type Study Design, Study 

Outcome Measures 

Study Setting & Study Population 

Study Intervention K

Wesensten 2005148

Maintenance of vigilance, caffeine, dextroamphetamine and modafinil during prolonged sleep deprivation 

Randomized trial (2) 

Randomized trial (2) Performance testing, Stanford Sleepiness Scale, modified Maintenance of Wakefulness Test, and test of executive functioning 

48 healthy young adults, laboratory 

Subjects sleep deprived for 85 hour then given 600 mg caffeine, dextroamphetamine 20 mg, modafinil 400 mg or placebo 

Cdmemfudd

LeDuc 2000160

Maintenance of vigilance, exercise 

Randomized trial (2) 

Randomized trial (2), cognitive testing, subjective alertness, mood, performance testing, and maintenance of vigilance testing (3) 

12 aviators Subjects sleep 

deprived then assigned to the rest condition (10 minutes) or exercise condition 

N1pim(35inE