Managing fatigue as part of a safety culture – a blog from Nancy Redfern, Emma Plunkett and Roopa McCrossan

Summary

In a series of blogs for the hub, we will be highlighting the impact fatigue has on staff and patients. In their first blog, Emma Plunkett and Nancy Redfern, part of the Joint Working Group on Fatigue, shared how they became involved in investigating night shift fatigue, setting up the Joint Working Group on Fatigue and the aims of the #FightFatigue campaign.

In this second blog, Emma and Nancy are joined by Roopa McCrossan to highlight how tiredness can impact on our performance, the patient and staff implications of fatigue, and the actions that need to be taken not only at an organisational level to improve culture, but the effort required at national level too.

Content

The impact of tiredness on performance

Tired from work? No matter what your job, work can sometimes wear us out and leave us feeling drained and weary. For those of us that work in healthcare, this can have huge impacts on the care we are able to deliver to our patients. Our workloads are heavy, stressful and often involve complex decision making, compounded by a shortage of staff and a lack of support in the workplace. 

On top of this, there are the usual out of work demands: family, social, studying and keeping fit to name but a few. With more and more things needing attention in our waking hours, sleep has a tendency to fall down the list of priorities. Many healthcare workers are chronically sleep restricted and don’t routinely get their required 8 hours’ sleep. Early starts and night shifts only serve to make matters worse. In fact, chronic sleep restriction reduces our subjective feelings of drowsiness, so we may miss the important warning signs that our performance is deteriorating.

There’s good evidence that as we tire our performance get worse. It’s harder to make complex decisions or perform complicated tasks, manage our emotions and interact empathically with colleagues. Staff have less respect for sleep deprived managers. Our vigilance, short term memory, and mood suffer; we are more impulsive, poorer at assessing risk and less effective at teamwork.[1] And we are more accident-prone, sometimes with tragic consequences. Doctors, nurses, midwives – all have died driving home tired. 

The patient safety implications

Sleep restriction also impacts on the care we deliver to patients. GPs prescribe more antibiotics when they have been working long hours without a break, surgeons are slower at operating, and patients anaesthetised later in the day have higher rates of postoperative pain, nausea and vomiting than those on morning lists. At the end of a long shift, neonatal ICU clinicians are less meticulous about hand asepsis.[2] Tired practitioners make more errors prescribing and dispensing drugs at night, and patients operated on out-of-hours have an increased risk of unexpected death. Patients of nurses working shifts longer than 12 hours have higher rates of mortality and morbidity.[3, 4]

Staff wellbeing

It’s not only the patients that may come to harm, night shift workers themselves have a higher risk of several diseases, including cardiovascular disease, type 2 diabetes, mental health problems, accidents, injuries and some forms of cancer.[5–8] Our bodies are not designed to be awake at night. As well as the brain’s internal body clock controlling our circadian sleep rhythm, many of our cells function differently at night. The pancreas goes into a tailspin if we eat a large meal in the middle of the night; digestion, blood sugar control, muscle strength and cognitive function are all diurnal (day-active). These systems don’t respond when we change from day to night shift. No matter how hard we try, we are unable to shift the phase of our internal clock to match our work demands, so we may be sleepy during night shifts and struggle to sleep in the day.

What can we learn from other industries?

Every other safety-critical industry realises that employee fatigue is a problem and has ways of recognising and mitigating its impact. But for some reason, healthcare does not. It’s a legal requirement for other 24/7 industries, such as airlines, road haulage and nuclear, to have a formal fatigue risk management system as part of the work culture. So what can we learn from them?

The first thing is education: ensuring everyone in an organisation understands the risks of fatigue and the importance of prioritising our sleep –  so-called ‘good sleep hygiene’. 

At work we need easily accessible facilities in quiet dark safe areas where we can nap during breaks. Even a 20 minute ‘power nap’ makes us safer.

We need a culture that encourages staff to take breaks and to nap. 

We also need to minimise the amount of work we do between 3 and 6am, the circadian nadir, perhaps changing the time we traditionally give 6 hourly medicines from midnight and 6 am, where drug errors are more common at these times, to 1 am and 7 am. Where activity cannot be avoided, we need to look out for each other; double check what we are doing with a colleague and have some experienced staff on each shift who can support our thinking in fast-moving situations. 

Most of all we need to talk about fatigue, to find out who is already tired when we come to work and recognise that fatigue-aware cultures make healthcare safer, for staff and for our patients.

What can organisations do to improve their culture?

Organisations can take steps to improve their culture, including:

• Putting fatigue on the risk register.
• Improving facilities with sofa beds in staff rooms.
• Raising awareness of fatigue amongst medical and nursing staff, particularly in acute medical disciplines, such as anaesthesia, obstetrics, critical care and emergency medicine.

But rather than work piecemeal, we need a national effort; governments should require all healthcare organisations to have fatigue on the risk register, and to demonstrate how they are mitigating the impact of long hours and nightshift work. Driving to and from work should become part of ‘driving for work’ –  the regulatory framework that covers lorry drivers and train drivers – so that the employer has a stake in the employee getting home safely. The employee would then get a power nap during a shift, which is known to drastically reduce the chance of having 'microsleeps' at the wheel. 

In a healthcare system that’s under huge strain, taking fatigue seriously is an easy win, it will make patients and staff safer and provide a much-needed boost to morale and wellbeing.

References

1. Kayser KC, Puig VA, Estepp JR. Predicting and mitigating fatigue effects due to sleep deprivation: A review. Front Neurosci 2022; 16. doi: 10.3389/fnins.2022.930280.
2. Rittenschober-Böhm J, Bibl K, Schneider M, et al. The association between shift patterns and the quality of hand antisepsis in a neonatal intensive care unit: An observational study. Int J Nurs Stud 2020; 112:103686. doi: 10.1016/j.ijnurstu.2020.103686.
3. Gurubhagavatula I, Barger L, Barnes C, et al. Guiding Principles For Determining Work Shift Duration And Addressing The Effects Of Work Shift Duration On Performance, Safety, And Health. Sleep 2021; 44(11). doi: 10.1093/sleep/zsab161.
4. Linder JA, Doctor JN, Friedberg MW, et al.. Time of day and the decision to prescribe antibiotics. JAMA Intern Med 2014; 174(12):2029-31. doi: 10.1001/jamainternmed.2014.5225.
5. Papantoniou K, Castaño-Vinyals G, Espinosa A, et al. Shift work and colorectal cancer risk in the MCC-Spain case-control study. Scand J Work Environ Health 2017; 43(3): 250-259. doi: 10.5271/sjweh.3626.
6. Park J, Shin SY, Kang Y, Rhie J. Effect of night shift work on the control of hypertension and diabetes in workers taking medication. Ann Occup Environ Med 2019; 31(27): e27. doi: 10.35371/aoem.2019.31.e27.
7. Patterson PD, Weiss LS, Weaver MD, et al. Napping on the night shift and its impact on blood pressure and heart rate variability among emergency medical services workers: study protocol for a randomized crossover trial. Trials 2021; 22(1): 212. doi: 10.1186/s13063-021-05161-4.
8. Ponsin A, Fort E, Hours M, Charbotel B, Denis MA. Commuting Accidents among Non-Physician Staff of a Large University Hospital Center from 2012 to 2016: A Case-Control Study. Int J Environ Res Public Health 2023; 17(9): 2982. doi: 10.3390/ijerph17092982.

Further resources on fatigue

• Why we need to manage fatigue in the NHS – a blog from Nancy Redfern and Emma Plunkett
• Association of Anaesthetists fatigue resources.
• Fatigue resources on the hub.

About the Author

Nancy Redfern is a consultant Anaesthetist in Newcastle upon Tyne, with interests in obstetric and neuroanaesthesia. Her long-term non-clinical interests include staff wellbeing, fatigue, mentorship, education, and workforce. As Honorary Membership Secretary and Vice President of the Association of Anaesthetists of Great Britain and Ireland she worked with a small team who started the work on fatigue and established mentoring at the Association. She now co-chairs the national joint fatigue working group, which works to improve understanding and management of work-related fatigue. As part of this she is involved in research on implementation of safe fatigue risk management in acute hospital settings and speaks widely on wellbeing issues. She is also a member of the Workforce, Working conditions and Welfare group of the European Board where she has led a study on the impacts of fatigue on trainee and consultant anaesthetists throughout Europe. She advises the European Patient Safety Foundation about managing staff fatigue.

Emma Plunkett is a consultant anaesthetist at University Hospitals Birmingham and Birmingham Women’s Hospital. Her clinical interests are obstetric anaesthesia and peri-operative medicine. Her non-clinical interests are around ways we can support staff wellbeing and help them to perform at their best. She currently co-chairs the Joint Fatigue Group - a partnership between the Association of Anaesthetists, RCoA and FICM to improve the culture around fatigue - and co-authored the national surveys of fatigue in anaesthetists and the #FightFatigue resources. She is a trained mentor, leads the wellbeing group in her department and has introduced positive reporting systems (Learning from Excellence) where she works. 

Roopa McCrossan is a Consultant Anaesthetist at South Tees Hospitals NHS Foundation Trust and former Chair of the Association of Anaesthetists Trainee Committee. Her clinical interests are obstetric anaesthesia and neuroanaesthesia. She is based in Newcastle-upon tyne and has a strong interest in fatigue, staff wellbeing, tackling workplace bullying and LTFT training. Roopa is one of the founding members of the Joint Fatigue Working Group (AAGBI, RCOA, FICM) and has published research on fatigue and it’s impacts on the workforce. She is heavily involved with the #FightFatigue campaign and speaks nationally and internationally about this topic.

The #FightFatigue campaign aims to educate healthcare professionals about the effects of workplace fatigue and provide strategies with which to manage it. The fatigue group have won the RCOA Humphry Davy medal and the BMJ team of the year award 2020 for workforce and wellbeing in recognition of their work.