Health care workers experience demanding work environments and rotating shift schedules that may take a toll on their health. Registered nurses (RNs) working in hospitals are at high risk of experiencing occupational fatigue due to hectic and nonstandard work schedules, according to a study published in The Journal of Nursing Administration.

Occupational fatigue not only impacts RNs’ health and well-being, but also affects patient safety and the hospital organization as a whole, noted the researchers. Fatigue risk management systems have been proposed as a strategy for addressing this issue and may be a key component in monitoring changes in fatigue levels among employees.

One main factor in the development of occupational fatigue is lack of sleep, according to the researchers. Nurses often work 12-hour shifts, which increases their risk of fatigue because of sleep deprivation and puts their personal health at risk. “Fatigue resulting from insufficient and poor-quality sleep can negatively affect cumulative daytime performance, including reduced ability to be alert and vigilant and loss of consciousness in critical situations,” they noted.

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Occupational fatigue is identified “as a complex multidimensional condition that occurs when nurses are exposed to excessive work demands and various stress factors with insufficient recovery,” the authors explained. “Thus, to establish strategies for effective fatigue management, monitoring sleep is also important.”

April N. Kapu, DNP, APRN, ACNP-BC,

“As a critical care NP, I often worked three or four 12- to 14-hour shifts in a row, sometimes more,” said April N. Kapu, DNP, APRN, ACNP-BC, FAANP, FCCM, FAAN, president of the American Association of Nurse Practitioners (AANP). “It would take me at least a day and a couple of good nights’ sleep before I could recover.” Falling asleep and maintaining sleep can also be challenging before or during shifts because of the demands of the job. 

Dr Kapu noted that a person never knows how much sleep they really need until they need it. “In the health care field, it is easy to run on empty as you are taking care of everyone else. Sleep is an essential component of our personal energy maintenance plan. It is important to take note of our individual sleep patterns and what helps us sleep better and what doesn’t,” she said.

Study Design

To study nurses’ fatigue levels and sleep measures during 12-hour shifts, the investigators used self-reported measures of fatigue along with objective and subjective sleep measures. The study included 29 direct care RNs who worked 2 consecutive 12-hour day shifts (7:00 AM-7:30 PM) following at least 24 hours off. The participants ranged in age from 23 to 48 years (mean age, 29.7 years).

Data were collected from April 2012 through May 2017 and from September 2018 through January 2019. Participants were asked to fill out a survey assessing their fatigue levels during each data collection shift (roughly every 4 hours) at the start of (T1, 7:00 AM), during (T2, 11:00 AM, and T3, 3:00 PM), and at the end of each consecutive shift (T4, 7:30 PM).

Fatigue levels were measured using the Brief Fatigue Inventory (BFI) 17 and the Swedish Occupational Fatigue Inventory (SOFI); sleep data were collected using actigraphy (Philips Actiwatch Spectrum).  Data were collected for 58 shifts. Nurses left work after their shift ended only 47% of the time, indicating that many nurses work past their 12-hour shift, according to the study authors.

What Was Found

Fatigue levels started to escalate 4 hours after shifts started, and highest levels were reported at 7:30pm.

The study findings indicated that during the first shift, BFI, SOFI–lack of energy, and SOFI–physical exertion measures were lowest during T2 and reached the highest during T4. However, motivation, sleepiness, and physical discomfort were highest at T1. “SOFI–sleepiness, SOFI–lack of motivation, and SOFI–physical discomfort measures on the first shift were the lowest at T2 and then increased, but the highest mean values were reported at T1,” the researchers reported.

During the second shift, mean values of the BFI and SOFI–sleepiness were lowest at T2, then reached the highest at T4. Mean values of SOFI–lack of energy, SOFI–lack of motivation, SOFI–physical discomfort, and SOFI–physical exertion measures increased steadily from T1 to T4, with T4 being the highest.

Nurses’ lack of sleep the night prior to a shift was related to higher fatigue levels during the next shift and the subjective quality of sleep the night before the second shift was higher in comparison to the night before the first shift.

Health care organizations should facilitate work schedules to ensure that nurses have sufficient recovery between shifts and help nurses manage their sleep and fatigue levels, the authors suggested. “Nurses must be keenly aware that insufficient and poor-quality sleep before work and fatigue during work without adequate recovery can threaten not only their health but also the safety of their patients,” the researchers concluded.

Dr Kapu noted that it takes time, patience, and self-awareness to develop an effective sleep routine. It is crucial for NPs and nurses to develop these habits to better meet the rigorous demands of working in a hospital setting, she added.


Cho H, Brzozowski S, Arsenault Knudsen EN, Steege LM. Changes in fatigue levels and sleep measures of hospital nurses during two 12-hour work shifts. J Nurs Adm. 2021;51(3):128-134. doi:10.1097/NNA.0000000000000983