Fatigue Worker health and wellness

Waking up to the risks of workplace fatigue

More than 1 in 10 injuries on the job may be linked to insufficient sleep, experts say

Image: kali9/iStockphoto

For many people struggling to cope with the pressures of life in a 24/7, on-demand world, sleep gets relegated to the bottom of their to-do list. Sleep is sacrificed to squeeze in an extra hour of productivity, or because rest time is equated with wasted time.

“In America, we have a long-standing culture of thinking, ‘I’ll sleep when I’m dead,’ or ‘Sleep is for lazy people,’ or ‘People who value rest are not as ambitious,’” said Emily Whitcomb, senior program manager, fatigue initiative, at the National Safety Council. “We have a history of incentivizing people who work long hours with extra pay, promotions and recognition.”

The failure to prioritize rest is a growing concern and taking a toll on U.S. workers.

“A large percentage of the U.S. workforce is fatigued on the job,” said Claire Caruso, a research health scientist at NIOSH.

Adults need seven to nine hours of sleep a night, according to the National Sleep Foundation and the American Academy of Sleep Medicine. However, data from the National Health Interview Survey published in the journal Sleep shows that about 30% of U.S. civilian workers got less than six hours of sleep a night in the mid-2000s – up from 24% in the 1980s. Data from 2010 published in a Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report in 2012 shows those percentages were even higher in certain industries, and especially among night shift workers:

  • 34.1% of workers in the manufacturing industry
  • 44% of all night shift workers
  • 52.3% of night shift workers in health care and social assistance
  • 69.7% of night shift workers in transportation and warehousing

Chronic fatigue is more than just a quality-of-life issue. “It’s estimated that about 13% of workplace injuries can be attributed to employees with sleep problems, and 21% of fatal crashes may involve a drowsy driver,” Whitcomb said. “There’s really no shortage of research out there that shows us a tired worker is more likely to be involved in an incident or get hurt at work.”

Despite all the research, how has such a significant risk factor gotten so little attention in the workplace? One reason is a simple lack of data.

“When employers fill out paperwork for an incident in the workplace, most are not asking about fatigue, how much sleep the person got or how many hours they worked in the last couple of days,” Whitcomb said. “So, while we know it’s a significant contributing factor to a good portion of workplace injuries and incidents, it’s hard for us to conceptualize just how big the problem is.”

This is your brain on too little sleep

Sleep is easily mistaken for time spent doing nothing, but experts describe it as an active process that plays a crucial role in our ability to function mentally and physically.

“Fatigue builds up with each hour we stay awake and dissipates as we sleep,” said Indira Gurubhagavatula, associate professor of medicine at the University of Pennsylvania Veteran’s Administration Medical Center and chair of the Public Safety Committee at AASM.

Physical symptoms of fatigue include yawning, difficulty focusing the eyes, upset stomach, headache, loss of muscle coordination, an increased risk of dropping things, and stumbling and falling. Cognitive effects include impaired memory, attention, judgment and concentration; difficulty processing complex data, making decisions and regulating emotions; and greater distractibility and risk-taking behavior.

“The effects of fatigue are very similar to the impairment caused by excessive alcohol,” Gurubhagavatula said. “One study has equated performance after 18 hours of being awake with performance while having a blood alcohol concentration of 0.05%, which is considered legally drunk in many states.”

Even mild, everyday fatigue can affect workplace safety and performance.

“Most employers underestimate how little sleep deprivation is necessary to result in detrimental outcomes,” said Christopher Barnes, associate professor of management at the University of Washington Foster School of Business, who studies fatigue and human sustainability in organizations. “For example, my research indicates a 5.6% increase in mining injuries 
following the change to daylight saving time in the spring. That is less than an hour of sleep deprivation, and it produces a meaningfully harmful effect on employee safety.”

Equally troubling is the likelihood that workers won’t recognize their impairment. “Studies have shown that we are not good at assessing our level of fatigue,” Gurubhagavatula said, “and our awareness of the risks is clearly insufficient, given the data about fatigue-related driving accidents alone.”

The long-term effects on workers’ overall health and well-being can be just as concerning as the short-term safety implications, she noted. These include obesity, diabetes, hypertension and heart disease, as well as early mortality.

Tips for night shift workers


Indira Gurubhagavatula, associate professor of medicine at the University of Pennsylvania Veteran’s Administration Medical Center and chair of the Public Safety Committee at the American Academy of Sleep Medicine, offered the following advice for safety professionals to share with employees who work extended or nontraditional hours:

  • Discuss your sleep needs with your family and friends to ensure everyone at home is on board and supportive.
  • Consider breaking up your daily sleep into two periods, if that allows you greater flexibility to attend to personal responsibilities. Naps can also be helpful, especially right before a shift, during a shift (if possible) and just before the ride home.
  • Judicious use of caffeine can be helpful, but limit or avoid caffeine consumption late in your shift so it doesn’t interfere with your ability to sleep once you arrive home.
  • Maintain good sleep habits:
  • Avoid smoking
  • Limit alcohol consumption
  • Exercise regularly
  • Choose healthy foods
  • Keep regular bed and wake-up times
  • Maintain a consistent bedtime routine.
  • Keep your bedroom dark, cool, quiet and comfortable
  • Turn off phones and electronics before sleeping

What drains workers’ batteries?

In its 2012 guidance statement on the issue, the American College of Occupational and Environmental Medicine defined fatigue as “the body’s response to sleep loss or to prolonged physical or mental exertion.” Circumstances that lead to the condition can usually be traced to a mix of personal factors – family commitments (child care or elder care), medical issues (sleep disorders, other chronic health disorders or certain medications) or simple failure to prioritize rest – and work conditions such as long commutes or multiple jobs, as well as:

Shift work. Humans are biologically hardwired to be active during the day and sleep at night, and disruptions to that natural order are costly. “Shift workers are expected to sleep during times when their biological rhythm drives them to stay awake and work at times when they have a profound urge to sleep,” Gurubhagavatula said. “Instead of seven hours per night, they average closer to 5.5 hours.”

A study by the Liberty Mutual Research Institute for Safety, published in the American Journal of Industrial Medicine in 2006, found that compared with morning shifts, workers with afternoon shifts had a 15.2% increased risk of injury, while those on night shifts had a 27.9% greater risk. Gurubhagavatula pointed out that night shift workers also have a higher incidence of car crashes (especially during their ride home), as well as serious long-term health outcomes such as obesity, diabetes, cardiovascular disease and cancer.

Long hours. The Liberty Mutual study also found the likelihood of injury grows once a worker’s shift exceeds the eight-hour mark, with a 13% increased risk at 10 hours and a 27.5% increased risk at 12 hours. Longer shifts have been linked to errors in decision-making and lack of attentiveness, said L. Casey Chosewood, director of the Office for Total Worker Health at NIOSH. “So our recommendation has long been that shifts of more than 10 hours should be minimized.”

Still, about 20% of the population works more than 48 hours a week, and roughly 7% works more than 60 hours, Chosewood said, adding, “You just cannot recover adequately if you’re spending excessive time at work.”

Demanding or stressful work. Physical exertion is taxing, but extended mental concentration can be equally fatiguing, particularly in occupations such as critical care nursing, public safety or long-haul truck driving. “We know that the need for constant vigilance is a significant source of stress,” Chosewood said. “We have increasing evidence that workplace stressors that are part and parcel of long hours and fatigue are a risk factor not only for acute injury, but also for the development of chronic diseases.”

Elements of a fatigue risk management system

According to the American College of Occupational and Environmental Medicine’s 2012 guidance statement, “Fatigue Risk Management in the Workplace,” a fatigue risk management system may include:

  • A fatigue management policy
  • Risk management, including collecting information on fatigue as a hazard, analyzing its risk and creating controls to mitigate that risk
  • A reporting system for employees
  • Incident investigation
  • Management training and education for employees, management and even their families
  • Sleep disorder management
  • A process for the internal and external auditing and continuous improvement of the FRMS

Finding solutions

The prevalence of fatigue may lead to the perception that it’s an inevitable part of living and working in the modern world. However, as awareness grows, organizations, government agencies and employers are taking on this problem and finding solutions. Recommended strategies include:

Establishing a fatigue risk management system. “A fatigue risk management system is a set of policies, practices and programs that you incorporate into an existing safety management system in order to effectively manage fatigue in the workplace,” Whitcomb said.

An FRMS often dovetails with existing programs, so establishing one may be easier than it might seem.

“Fatigue is a predictable and manageable safety risk we identified in our business that, like other risks, had to be understood and proactively managed,” said Brian Beauvais, health and safety manager at Alyeska Pipeline Service Co., which has implemented an FRMS and seen safety performance improve as a result. “We quickly discovered we already had a number of these elements in place in other programs and only needed to align them. We made it part of things we were already doing, such as our safety program, our health and wellness program, and our occupational health and safety program.”

Providing education and screening. “Ensure that the whole organization is aware of the need for sleep and the hazards, health risks and performance impairments associated with fatigue,” Gurubhagavatula said. She also suggests screening for sleep disorders as part of this effort, citing the example of Schneider National, whose program to screen and treat truck drivers for obstructive sleep apnea helped decrease the risk of crashes and boost employee retention.

Focusing on worker schedules. “Limiting shift work and long hours to the extent possible is where you’re going to get the biggest bang for your investments,” Chosewood said. If night shifts or long hours can’t be avoided, some adjustments can help lighten the burden on employees.

“Depending on the workload, 12-hour days may be tolerable with more frequent interspersed rest days,” Caruso said. “During the evening and night, shorter shifts are better tolerated than longer shifts.”

Other scheduling goals include:

  • Minimizing overtime – especially forced overtime.
  • Avoiding permanent placement on night shift and keeping consecutive night shifts to a minimum. (The Liberty Mutual study found that workers’ injury risk grew with each consecutive night shift, from 6% higher on the second night to 17% and 36% greater on the third and fourth nights, respectively.)
  • Offering workers as much choice as possible. “If you need the work done but it doesn’t matter if someone starts at 10 p.m. versus 2 a.m., give the worker the flexibility to pick their own start and stop time,” Chosewood said.
  • Scheduling demanding tasks when workers are most alert, such as during the first half of a long shift or night shift.
  • Giving workers adequate time between shifts – Chosewood recommends a minimum of 18 hours – and scheduling in rest days. “Plan one or two full days of rest to follow five consecutive eight-hour shifts or four 10-hour shifts,” Caruso said. “Consider two rest days after three consecutive 12-hour shifts.”
  • Making sure workers take frequent breaks during each shift – especially when they put in longer hours, work nights or perform demanding tasks.

If this sounds daunting, Chosewood suggests a schedule design consultation with a human factors or macroergonomics specialist. “A one-time consultation would be affordable even for a small or midsized business,” he said.

Addressing environmental stressors. Make sure working conditions aren’t adding difficulty to the shift. For example, provide adequate lighting, maintain comfortable temperatures, reduce noise and ensure workers have access to food.

Fatigue monitoring systems: ‘Pros and cons’

The promise of technology to sound the alarm when workers become fatigued is gaining attention. Originally used in the mining industry, fatigue monitoring systems are moving into other industries (such as transportation) where vigilance is essential. Typically relying on dashcams or wearable devices to measure eye movements or other physiological indicators of fatigue, these systems raise significant questions of worker privacy that will need to be addressed before they gain widespread use.

“We see pros and cons to fatigue monitoring systems,” said L. Casey Chosewood, director of the Office for Total Worker Health at NIOSH. “If employers choose them, workers should be given a voice on what kind of monitoring is done and how it is used.”

Invest in rest

When resources are thin or shift schedules are difficult to change, safety professionals hoping to implement these strategies may expect some pushback from employers. To gain buy-in, experts suggest highlighting the following points:

Managing fatigue is a legal responsibility. “Employers must implement measures to monitor and limit worker exposures to health and physical hazards in the workplace, as required by the Occupational Safety and Health Act,” Caruso said. Federal and state regulators for some industries also require some form of fatigue mitigation, such as capped work hours and established minimum rest periods between shifts.

Managing fatigue is good business. It’s easy to assume that increasing work hours will maximize productivity. “It is harder to envision the loss in productivity from a few hours of sleep deprivation,” Barnes said. “Many employers just assume that high motivation will offset the effects of sleep deprivation, but that ignores the biological realities. To compound the situation, employers often think in terms of the quantity of performance, but forget about how sleep deprivation can undermine the quality of performance as well.”

When workers are fatigued, performance and productivity can suffer a number of ways, including:

  • Higher levels of absenteeism, presenteeism and tardiness.
  • Higher rates of incidents, errors and do-overs.
  • Increased likelihood of unethical or unprofessional behavior.
  • Decrease in engagement and helpful behaviors.
  • Increases in the time needed to complete tasks.

Fatigue is expensive.A study from RAND Corp., published in 2016, estimated that insufficient sleep costs the U.S. economy $411 billion a year. Beyond the costs of diminished performance and productivity, experts pointed to fatigued workers’ greater use of health care resources, as well as higher workers’ compensation and other insurance rates.

It may be helpful to support these points with organization-specific data. “When you’re doing an incident report, ask questions about work-rest history,” Whitcomb said. “‘How many hours of sleep did they get in the last couple of days? How many hours were they working in the last couple of days? When on the shift did the incident occur?’ I would venture to guess that you’ll find a pattern that suggests these incidents and injuries are occurring in employees who were tired.”

Whitcomb also recommended NSC’s fatigue cost calculator (available at nsc.org/tiredatwork), which allows users to estimate how much fatigue is costing their organization.

“The evidence is clear that employees are maximally effective when they get the sleep they need,” Barnes said. “So organizations which strive to structure environments in order to maximize the sleep and wellness of their employees will reap the benefits.”

New toolkit available

The National Safety Council has developed a fatigue risk management toolkit, including policy templates, training materials and educational materials for the worksite. Set to launch at the NSC 2019 Congress & Expo in San Diego, the toolkit is available for download at nsc.org/fatigue.

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