Nurse feedback is being sought on the first draft National Code of Practice for Managing Fatigue and Shift Work in Hospital-Based Nursing built on a survey showing high numbers of nurses getting too little sleep.

The findings indicate a ‘culture change’ is needed to reduce public hospital nurse fatigue and improve nurse and patient safety, says the code co-author Professor Philippa Gander, as the majority of nurses reported usual sleep shorter than what’s recommended for health safety and wellbeing.

Gander says fatigue resulting from shift work and extended hours can degrade patient care, also increase the risk of clinical error, workplace injuries to nurses, and drowsy driving accidents, as well as increasing nursing turnover and health care costs.

The draft code out for consultation is part of the major Health Research Council-funded Safer Nursing 24/7 project. The three year project, led by Gander in league with nurses’ union NZNO, was launched in 2016 with an online survey of shift working nurses as the first step to better managing nurse fatigue.

The 2016-17 survey of public hospital nurses – working in six practice areas chosen for having a high likelihood of fatigue – attracted 1885 registered nurse and enrolled nurse participants.

The full survey findings are yet to be released but the 43-page draft code document released by Gander, Dr Karyn O’Keeffe and the rest of the research team includes findings that:

  • The majority of 1885 survey participants reported usually getting less than 7 hours sleep a night (recommended sleep for adults is 7-9 hours per night)
  • The least likely of the six practice areas to get 7 hours a sleep were inpatient mental health nurses (60% underslept) and the most likely were ICU/CCU (about 42% underslept)
  • Only 2 per cent of the nurses reported usually sleeping longer than 9 hours
  • About 55 per cent of surveyed nurses reported never or rarely getting enough sleep (compared to 38 per cent of the general adult population aged 30-59 years)
  • More than 70 per cent reported never or rarely waking refreshed (compared to just over 45 per cent of the general adult population)
  • 32 per cent of nurses reported that since becoming a nurse they had fallen asleep driving home from work
  • Nearly two-thirds (65%) reported having felt close to falling asleep at the wheel in the last 12 months
  • About 73% of nurses had been able to take breaks in their shifts in the previous seven days and the same the week before that; but inpatient mental health nurses were the least likeliest to get the chance to take a break (64% in previous seven days and 60% the week before that)
  • More than 80 per cent (83%) indicated they did not have access to healthy food at all hours.

The survey findings have been used – along with advances in knowledge about the impact of shift work on the circadian ‘master’ body clock, the associated health risks and improvements in safety management systems – to develop a code to help DHBs better identify, manage and mitigate nurse fatigue and the resulting safety hazards.

Gander and fellow Massey Sleep/Wake Centre researcher Dr Karyn O’Keeffe, say fatigue is inevitable in hospital nursing because of the requirement to provide care 24/7 but  – with a culture change and the new draft code – district health boards could develop a fatigue and shift work management system that reduces the risk of fatigue being a safety hazard for both nurses and their patients.

The draft code does not recommend absolute restrictions on nurses’ work patterns, for example set maximum safe shift lengths, numbers of consecutive shifts, or minimum breaks between shifts. Instead it provides a fatigue hazard assessment matrixfor evaluating weekly work patterns, based on six variables relating to work patterns and two variables relating to sleep.

The matrix was developed and validated using the 2016-2017 national survey of DHB nurses to check how accurate it was at predicting fatigue levels of nurses and the three main fatigue-related outcomes: excessive sleepiness, having felt close to falling asleep while driving in previous 12 months and recalling a fatigue-related clinical error in the last six months.

The matrix and draft Code of Practice are now out for consultation until March 10 to get wider nurse expertise feedback on refining the code to make it as useful as possible.  Gander and O’Keeffe said once it had received feedback and finalised the Code it hoped to pilot it in a major public hospital.

The document can be downloaded and feedback provided at the project’s website along with information on fatigue, sleep, shift work, the body clock and fatigue management.

Table 1: Fatigue hazard assessment matrix for DHB nurses (from draft Code of Practice)


Risk Factor Lower fatigue

Score O

Significant fatigue

Score 1

Higher Fatigue

 Score 2

1.     Total hours worked ≤ 40hr 40hr to 48hr  



2.     Shift extensions ≥ 30 min None ≤50% of days



>50% of days



3.     Breaks <9h between shifts 0 1 >1

4.     Number of nights


0 1-2 >2
5.     Number of breaks ≥ 24h between shifts ≥2 1 0
6.     Roster change no Roster change requested Roster change not requested
7.     Number of nights sleep (2300-0700) 6-7 nights 4-5 nights 0-3 nights
8.     Number of nights got enough sleep to be fully rested 6-7 days 4-5 days 0-3 days




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