Recommendation 1.1

Governments at both national and provincial levels promote the management of fatigue in health-care work environments by:

1. Providing sufficient economic and human resources within the work environment to prevent and mitigate fatigue.
2. Providing funding to support mandatory education for practicing nurses, nurse managers, nursing students and nurse educators about the causes of fatigue and its negative impacts on patients and nurses.
3. Providing funding to ensure that adequate physical infrastructure is available to support areas for nurses to rest during scheduled breaks. This means including designated space for rest in all new building designs and providing funding to renovate existing facilities.
4. Increasing nursing school enrolment and funding to so that there will be sufficient numbers of graduates in the future to ensure appropriate nurse to patient ratios in health-care settings.
5. Providing financial support to nursing faculties to manage increased enrolment in graduate nursing programs

Recommendation 2.1

Researchers partner with governments, professional associations, regulatory bodies, unions, health-service organizationsand educational institutions to conduct research regarding the relationship between fatigue, workload, work hours and the amount of sleep needed to provide safe patient care. The goals are to: (a) increase understanding of the relationship between nurse fatigue and patient safety; (b) identify measures to decrease fatigue; and (c) reduce the impact of fatigue on patient and nurse safety. Researchers work together across professions to achieve the above goals through studying:

1. Hours worked, 12-hours shifts, on-call patterns and intervals between shifts worked by nurses at all levels (e.g. staff nurses, managers, nurse practitioners, nurse midwives, etc., in a variety of health-care settings).
2. The gap in provincial infrastructure, to accurately monitor nurses’ working hours, as many nurses hold positions in multiple organizations across health-care sectors.
3. The prevalence and incidence of fatigue based on gender, marital status, lifestyle and age.
4. The efficacy of programs to determine, assess and mitigate fatigue in health-care settings.
5. The nature of mitigating factors influencing fatigue in the workplace, including part-time employment and nurses working multiple jobs.

Recommendation 3.1

Accreditation bodies develop and implement standards in the accreditation process that address a culture of safety, including the prevention and mitigation of nurse fatigue, and incorporate the recommendations contained in this guideline.

Recommendation 4.1

Occupational health and safety educational programs include formal and informal education sessions that address:

1. recognizing and preventing fatigue
2. the factors that contribute to fatigue
3. the implications of nurse fatigue on patient safety, nurse well-being and organizational well-being
4. sleep hygiene
5. utilizing self-assessment practices for fatigue

Recommendation 4.2

Academic settings address the issue of nursing fatigue in the curriculum by:

1. incorporating content related to nurse fatigue in the curriculum for nursing students, preceptors, professors and other educators
2. establishing a method of evaluation that feeds back into the process to determine if student nurse fatigue and nursing faculty fatigue in the academic setting and workplace have been reduced

Recommendation 4.3

Organizations and academic settings:

1. incorporate information regarding fatigue prevention and recognition strategies into orientation programs for staff, nursing students and preceptors
2. enhance leadership courses to address issues related to fatigue
3. promote research to assist health-care organizations in implementing and evaluating strategies to address nurse fatigue

Recommendation 5.1

Professional associations, regulatory bodies and unions promote practices that result in preventing and mitigating fatigue for nurses and other health-care professionals that contribute to healthy work environments.

Recommendation 5.2

Professional associations and unions collaborate, advocate for and promote a workplace culture that recognizes the impact of fatigue on both patient safety and nurses’ overall health and well-being.

Recommendation 5.3

Nursing regulatory bodies develop standards of practice that recognize the impact of fatigue on patient safety and nurses’ overall health and well-being.

Recommendation 5.4

Professional associations, regulatory bodies and unions promote the education of nurses regarding their professional responsibility related to managing personal fatigue and mitigating the impact of fatigue on safe, quality patient care.

Recommendation 5.5

Professional associations, regulatory bodies and unions advocate for safe work environments with appropriate staffing models that include adequate registered nursing staffing to address workload, overtime issues and scheduling practices that minimize fatigue.

Recommendation 5.6

Professional associations, regulatory bodies and unions support and encourage a healthy work environment for all health-care professionals.

Recommendation 5.7

Regulatory bodies set practice standards and guidelines applicable to nurses and employers to ensure quality practice environments.

Recommendation 5.8

Unions, professional associations and nursing regulatory bodies encourage nurses and organizations to identify, document and collaboratively address unsafe staffing conditions.

Recommendation 6.1

Organizations and academic centres promote a culture that recognizes nurse fatigue as a risk to patient and nurse safety that must be addressed by comprehensive fatigue prevention and management programs that include:

1. educating staff and leadership on fatigue management
2. developing mechanisms to document fatigue and analyze its relationship to overtime hours worked, medication errors, and patient and staff outcomes
3. providing fatigue assessment strategies through orientation and other professional development opportunities
4. support services, such as wellness initiatives and Employee Assistance Programs, to assist with contributors to fatigue

Recommendation 6.2

Organizations plan, implement and evaluate staffing and workload practices that create adequate staffing to reduce workload, in order to mitigate nurse fatigue and ensure nurse and patient safety.

Recommendation 6.3

Organizations implement a safe scheduling policy that includes no more than 12 hours scheduled within a 24-hour period, and no more than 50 hours scheduled per seven-day work week.

a) Scheduling for nights should not involve more than three consecutive 12-hour night shifts and should include a longer interval of “off duty” time between blocks of shifts to recover.

Recommendation 6.4

Organizations develop and implement a policy – in consultation with nursing unit councils, the occupational health/ wellness department, scheduling committees, unions and regulatory bodies – that sets limits regarding the amount of overtime worked by nurses.

Recommendation 6.5

Organizations develop a policy that supports rest and sleep periods during scheduled breaks. Organizations furthermore create a safe, secure area where nurses can have uninterrupted (excluding emergencies) rest and sleep periods. Individual nurse retain professional accountability and responsibility to respond to emergencies.

Recommendation 7.1

All employees, physicians, volunteers and students should:

• perform a self-assessment prior to starting and during a work shift to ensure their fitness to work and provide safe provision of care
• ensure adequate recovery time prior to starting a shift
• take entitled breaks and support colleagues to do the same; and limit overtime hours worked

Recommendation 7.2

All employees, physicians, volunteers and students should take responsibility for identifying and reporting unsafe conditions (e.g. fatigue) in accordance with professional practice standards and hospital policy, without fear of reprisal.

Recommendation 7.3

All employees, physicians, volunteers and students should take responsibility for maintaining optimal personal health and well-being, including:

• participating in physical activity outside the work setting
• ensuring adequate nutritional intake
• ensuring adequate rest and sleep between shifts
• communicating shift preference where there are known personal impacts related to specific shift patterns
• responsible self-scheduling in settings that participate in self-scheduling