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Fatigue & Understaffing: A Threat to Patient Safety?

The importance of adequate nurse staffing in achieving quality patient care was a principal finding in the landmark report of the Institute of Medicine’s (IOM) Committee on the Adequacy of Nurse Staffing in Hospitals and Nursing Homes. Two additional studies released in March 2011 further highlighted the importance of higher nursing staff levels to patient outcomes, and both studies present evidence that higher nurse staffing levels improve patient outcomes, often saving lives (Bouchard, 2011).

According to the American Nurses Association (ANA), these studies directly link patient safety to adequate nurse staffing levels. While insufficient nurse staffing has been linked to poorer patient outcomes, lengthened hospital stays and increased chance of patient death (American Nurses Association [ANA], 2013).

The RN Safe Staffing Act of 2011 requires that Medicare participating hospitals implement staffing plans for each nursing unit and shift. The act requires the committee in charge of staffing to be comprised of direct-care nurses by at least 55%, and that staffing considerations include each unit’s unique characteristics and needs (ANA, 2013). The Act also establishes adjustable minimum numbers of RNs for each unit, ensuring that staffing plans are based upon patient numbers and the patient acuity, as well as the level of education, training and experience of the RNs and support staff. A provision of the Act ensures that staffing levels are in compliance with recommendations by specialty nursing organizations, and requires healthcare organizations to avoid assigning RNs to units on which they are not trained or experienced. The bill also includes compliance provisions that require reporting of staffing information and data that can be used to establish a link between nurse staffing and patient acuity (ANA, 2013).

In addition to inadequate staffing levels, nurse fatigue appears to play a major role in patient safety. According to a 2013 survey commissioned by Kronos Inc., nurse fatigue is “pervasive” in the healthcare industry and can be directly related to errors and poor quality care (Ray-Ghosal, 2013). In the study, many nurses were concerned about their ability to perform safely, with two-thirds of RN’s reporting that they had nearly made a mistake at work due to fatigue; more than a quarter admitted to having made a fatigue-related error (Bird, 2013).

Released in March 2013 at the American Organization of Nurse Executives (AONE) Conference in Denver, the "Nurse Staffing Strategy," pointed out that nurse fatigue not only negatively affects operational costs, but patient and employee satisfaction as well. According to the research findings, more than half of the nurses involved in the study (54%), felt they had an excessive workload, and 96% reported being tired at the beginning of their shift. An astounding 65% said their hospitals do not have policies regarding cumulative days of extended shifts (Bird, 2013). Separate research published in The Journal of the American Medical Association (JAMA) found that nurse understaffing in neonatal intensive care units (NICU) leads to higher infection rates among very low-birth-weight babies (Bird, 2013).

The evidence is clear: Nurse staffing and fatigue directly impact patient care and safety. As patient advocates, nurses have a responsibility to ensure that their patient load is realistic, manageable and most importantly, safe for the patients. Nurses also have a responsibility to ensure that their fatigue is recognized and addressed before it becomes a safety concern. 


American Nurses Association [ANA], (2013). Safe Staffing Saves Lives: ANA's National Campaign to Solve the Nurse Staffing Crisis. Bird, J. (2013). Survey: Nurse understaffing, fatigue threatens patient safety. FierceHealthcare. com.  Bouchard, S. (2011). Studies show higher nurse staffing levels benefit patients. Healthcare Finance  Clarke, S. & Donaldson, N. (2008). Nurse Staffing & Patient Care Quality and Safety, Chapter 25, Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD. Ray-Ghosal, I. (2013). Kronos Survey Reveals Nurse Fatigue is Pervasive in the Healthcare Industry and Directly Linked to On-the-Job Errors. Kronos Press Release, March 20, 2013.