Compared to other high-risk industries, healthcare has one of the highest incidence rates of occupational injuries and illness with rates in the U.S. per 100 workers reported at 4.3 for healthcare, 3.3 for manufacturing, and 4.6 for transportation. [1] A contributor to injury among nurses, [2] other healthcare workers, [3] and patients [4] is occupational fatigue. Occupational fatigue is a subjective human experience and has been described as a physical and/or mental depletion of energy resulting from a lack of sleep and/or high demands at work. [5–8] Among nurses in the hospital setting, it can arise from multiple occupational sources to which nurses are regularly exposed, such as long work hours (i.e., 12-hour shifts), [9,10] quick returns (<11 hours between shifts), [11] working night shift, [10] and the heavy physical activity and mental workloads associated with providing patient care. [7, 12] In addition, the pediatric acute care setting poses a unique work environment, which may exacerbate nurse fatigue. Specifically, pediatric healthcare providers experience high stress levels from working with a sick and vulnerable patient and family population. [13] Since children need extra time to prepare for the care they are receiving, nurses can experience added stress and heavier workloads as they try to accommodate for this extra time. [14] Despite the multiple organizational factors associated with nurse occupational fatigue and subsequent risks posed to worker and patient safety, fatigue is rarely recognized as a reportable occupational hazard in healthcare.

While leaders in the industry have acknowledged occupational fatigue among nurses is a safety threat to patients and the healthcare workforce, the management of fatigue in healthcare settings is fraught with obstacles. [15, 16] Experts in the field of occupational fatigue recommend implementing fatigue risk management systems. [17, 18] A fatigue risk management system is a multi-layered safety approach, and should be a shared-responsibility between the worker and employer: (a) employers give workers adequate time off to sleep; (b) workers take the time to sleep; (c) employers and employees use detection/monitoring systems for reporting and mitigating fatigue-related behavioral symptoms; and (d) employers regularly evaluate the fatigue risk management system and reported errors and incidents for root causes of fatigue.[17] Unfortunately in healthcare, implementing early controls for managing occupational fatigue risks, such as providing enough time off for sleep, is not always possible due to worker shortages and/or surges in public need for healthcare. As a result, nurses and other healthcare providers may need to work long hours for multiple days to meet public health needs, placing them at continued risk for fatigue related injuries and accidents. [19]

Specific obstacles also exist in reporting fatigue-related behavioral symptoms in healthcare safety programs. Barriers range from the difficulties of measuring the multidimensional, subjective, and temporal symptoms of fatigue,[7, 15] determining the most efficient reporting process, [7] and a lack of non-punitive reporting systems [17, 20] which may reduce worker willingness to report.[21] Even with a non-punitive reporting system in place, nurses and other healthcare workers are reluctant to report events that may indicate culpability.[22] Additionally, nurses often perceive fatigue as an inevitable part of working in healthcare, [22, 23] and work recovery as a nurses’ responsibility to occur outside of the hospital.[22, 24] Evidence suggests rather than reporting fatiguing work conditions (i.e., long work hours, rotating shifts) as safety hazards, nurses feel reasonable solutions would be to leave their jobs and/or profession, [25] increasing organizational costs due to nurse turnover.[26] Such beliefs can present major barriers to reporting fatigue as a workplace hazard. Consequently, there is not a clear determination on how or if nurses would report fatigue and associated factors while at work.

Fatigue reporting is not unique in facing barriers. Healthcare injury surveillance systems have long been plagued with not effectively capturing the full scope of injuries and incidents in the adult and pediatric acute care setting. [27, 28] Influential characteristics on reporting include the ease of making a report, time constraints, comprehensive training on how/when to use the system and the presence of subsequent follow-up. [27] A recent intervention at a pediatric hospital using an active reporting system (where workers were asked to narratively report injuries) demonstrated increased reporting of physical and psychological injury or near-misses compared to passive injury surveillance. [28] While healthcare worker reports were physical and psychological in nature, it is unknown whether this successful reporting method also was effective at capturing reports of occupational fatigue among pediatric nurses.

This secondary analysis study was designed to investigate whether pediatric nurses would report fatigue and associated outcomes via DVR when using an active reporting system. While not prompted to talk about occupational fatigue, approximately 30% of nurses in this study did report on their fatigue status pre and/or post shift. Nurses reported not only their fatigue and related symptoms, but also contributing factors (individual and work-related) and adverse outcomes, such as physical and mental manifestations. In addition, nurses stated when they were not fatigued, describing what buffered fatigue symptoms and favorable outcomes such as a readiness to work and having a positive outlook on their day. As a result, this study highlights pediatric nurses will report on occupational fatigue, when given the opportunity. It also suggests what is reported is fairly accurate, since findings of this study align well with what is known about occupational fatigue symptoms, contributors and outcomes among nurses in adult [42, 43] and pediatric care settings. [9,44]

Workplace stress in the form of shift work characteristics (i.e., long shifts, overtime, night shift) and heavy workload were all factors reported by nurses in this study as contributing to occupational fatigue. Of note, the socio-demographic results indicate nurses are working less than 40-hours per week. This supports the qualitative findings that work hour stressors are related to working beyond scheduled work hours (i.e., staying late to finish work), as opposed to extensive cumulative weekly work hours. Shift work characteristics and heavy workloads have also been identified as major contributors to medication errors [4] and occupational injuries in healthcare and motor vehicle accidents from drowsy driving among nurses. [45, 46] The impact of patient care errors and occupational injuries from fatigue are significant. For example, medical errors can have devastating effects on both patients and healthcare workers. [47] Healthcare workers who commit errors can experience severe psychological impact, effecting their heath and ability to continue their work as healthcare providers. [47, 48] The negative downstream effects of occupational fatigue, such as worker injury, adverse health outcomes, and worker death, are financially costly to the economy. [49] Specific to the pediatric nurse population, acute fatigue has been associated with nurse absences, an added cost to healthcare facilities. [44] Despite considerable risks, this study demonstrated nurses recognized their fatigue symptoms at not just the end, but also the start of their shifts. Beginning work already fatigued could place nurses, their coworkers, and patients at higher risk for adverse outcomes.

Conversely, some nurses in this study reported the antithesis of fatigue, along with a positive psychological outlook and a readiness to work, even when the workload was anticipated to be high. Specifically, nurses reported work readiness when they felt they had quality sleep and/or adequate recovery time from work. Reducing nurse fatigue may lower the spillover effects of work, resulting in greater wellbeing, benefitting not only the nurse but help to stabilize the nursing workforce. In a study with 637 nurses, those with extreme fatigue had lower wellbeing scores, indicating symptoms of distress, lack of meaning in work, and dissatisfaction with work-life balance. [50] Nurses with lower wellbeing scores had a higher likelihood of intent to leave the bedside. Because of these downstream effects, acknowledging what helps nurses to feel refreshed is quite significant and should not be understated. Reducing nurse fatigue and ensuring a readiness to work aligns with the goals of the Total Worker Health^® approach to occupational health and safety. The National Institute for Occupational Safety and Health’s (NIOSH) Total Worker Health^® program urges employers to expand views of worker health and safety by incorporating policies, programs, and procedures to not only mitigate work-related hazards but also promote wellbeing. [51] Having nurses who feel refreshed and physically and mentally prepared to provide patient care could benefit society and the healthcare industry, mitigating potential adverse outcomes associated with lack of readiness to work. [52]

If the associated societal costs of occupational fatigue among nurses is so significant, why does fatigue reporting and risk mitigation in healthcare continue to be elusive? Even though some nurses self-detected and reported feeling fatigued in this study, certain barriers persist. Specifically, some nurses were unsure whether fatigue was appropriate to share in the context of injury reporting, highlighting the continued stigma and cultural barriers to reporting fatigue symptoms in healthcare. [22–25] In the 2022 U.S. Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture, almost half of pediatric healthcare workers perceived error and injury reporting as punitive [53] with similar results found among healthcare workers in adult setting [54] suggesting a wide-spread issue in the healthcare industry. To overcome these barriers, healthcare organizations would benefit from transforming error and injury reporting to non-punitive systems and foster an organizational culture emphasizing fatigue risk detection or screening as a standard shift practice to enact proactive fatigue countermeasures (e.g., caffeine, napping). Fatigue risk detection and screening has been effectively used in a variety of other high-risk industries. [21] Additionally, experts in the field have highlighted the need for healthcare leaders to drive a shift towards inclusion of occupational fatigue in patient and worker safety culture. [43, 55]

Healthcare industries also may benefit from raising the significance of fatigue detection and reporting among nurses and other healthcare workers. This can be accomplished by providing training to managers and staff on the risks associated with fatigue and how to best mitigate risks. A review of fatigue risk mitigation training among shift workers demonstrated multiple benefits, including improved patient safety and worker health and safety across outcome measures of sleep, burnout and stress, and acute fatigue. [56]

For this study, qualitative data successfully captured reports of nurse occupational fatigue. Previous research indicated healthcare workers in the pediatric setting prefer reporting injuries through active systems via narrative recording devices, demonstrating a 40-fold increase of injury reporting. [28] While evidence suggests self-reporting fatigue may not always be an accurate measure due to associated impaired cognition, [57, 58] the importance of capturing occupational fatigue through reporting and surveillance cannot be understated. Nurse leaders, managers, and nurses often recognize the problems surrounding fatigue, yet broader healthcare leadership may not [15, 16] and surveillance data could demonstrate the need for interventions. Furthermore, without occupational fatigue surveillance, the extent of the hazard risk, including how often and how many nurses are working while fatigued, may not be accurately captured. As a result, the true impact of fatigue risk mitigation interventions may not be recognized.

While this study confirms pediatric nurses will report fatigue and previous research supports an active reporting system increases injury and illness reporting,[28] some approaches to fatigue risk management in healthcare have averted nurse reporting due to concerns of overburdening nurses.[59] Recently published study results [7] described success with a passive fatigue prediction model as a tool for managing occupational fatigue drawing in data already collected in some healthcare settings (e.g., patient acuity, admission/discharge counts) as opposed to relying on screening or fatigue detection measures. Similarly, Gander et al. [60] developed scheduling matrices effective at predicting nurse fatigue and risks for errors. While both studies demonstrated promising interventions in adult care settings, questions of the generalizability across hospitals and the pediatric setting remain. Considering the suggested multi-layered system approach to fatigue risk management, [17] finding a way to integrate active nurse reporting with other fatigue prediction strategies may provide realistic options for a wider variety of healthcare settings. In addition, working towards a safer healthcare work environment should encompass efforts to assess and mollify the sources of heavy work demands that not only contribute to occupational fatigue but have been noted to restrict fatigue reporting. [59]

This secondary analysis of qualitative data using a descriptive design revealed that a sample of pediatric nurses recognized and reported occupational fatigue in an active injury reporting system. Moreover, the nurses were able to recognize pre-existing stressors coinciding with fatigue symptoms, outcomes of fatigue, and the buffers that may reduce negative effects of fatigue. Results underscore the need for additional research to be completed regarding the best way to report occupational fatigue among healthcare workers using technologies such as DVR, and how to mitigate consequences of fatigue. Organizations should also consider incorporating fatigue as a reportable injury, improving their workplace culture to destigmatize injury reporting, and enhancing the error assessment process.