The committee agrees that nurses’ work processes and workspace need to be designed to make them more efficient, less conducive to the commission of errors, and more amenable to detecting and remedying errors when they occur. In addition, limiting the number of hours worked per day and consecutive days of work by nursing staff, as is done in other safety-sensitive industries, is a fundamental patient safety precaution. It is also essential to foster collaboration of nursing staff with other health care personnel in identifying high-risk and inefficient work processes and workspaces and (re)designing them for patient safety and efficiency. Redesign of patient care documentation practices, however, cannot be accomplished solely by nursing staff and internal HCO efforts. Because many documentation practices are driven by external parties, such as regulators and oversight organizations, these organizations will need to assist in the redesign of those practices.

This chapter reviews the evidence on the design of nurses’ work hours, work processes, and workspaces, primarily as they relate to patient safety, but also with respect to efficiency (which, as noted above, is a contributory factor in safety). We present findings and recommendations derived from this evidence on designing these elements of the nursing environment so as to enhance safety.


This section reviews the evidence related to the design of nurses’ work hours: the effect of fatigue from shift work and extended work hours on work performance, the relationship between nurse work hours and the commission of errors, and data on hours worked by both hospital and nursing home nursing personnel. The committee’s responses to this evidence in the form of conclusions and a recommendation are then presented.

Effect of Fatigue from Shift Work and Extended Work Hours on Work Performance1

Fatigue results from continuous physical or mental activity, inadequate rest, sleep loss, or nonstandard work schedules (e.g., working at night). Whatever the origin of physical or mental fatigue, it is accompanied by a subjective feeling of tiredness and a diminished capacity to do work. The effects of fatigue include slowed reaction time, diminished attention to detail, errors of omission, compromised problem solving (Van-Griever and


This section incorporates content from a paper on “Work Hour Regulation in Safety-Sensitive Industries” commissioned by the committee and included in this report as Appendix C.

The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement