In a series of blogs for the hub, Emma Plunkett and Nancy Redfern, part of the Joint Working Group on Fatigue, will highlight the impact staff fatigue has not only on the staff themselves but also on patient safety, and why healthcare needs a robust fatigue risk management system like other safety-critical industries.
In their first blog, Emma and Nancy share how they became involved in investigating night shift fatigue after the death of a colleague driving home tired. They discuss how they set up the Joint Working Group on Fatigue and the aims of the #FightFatigue campaign.
Our story started with a tragedy. We all knew the feeling of overwhelming tiredness after a busy night shift but, until one of our anaesthetic trainees died driving home tired, we had just thought of it as an occupational hazard. As we investigated the problem, we realised that other safety-critical industries, such as airline, electric and rail, had formal ways of managing night shift fatigue. We needed to do the same.
Evidence of the effects of fatigue
We started with a survey of all trainees in anaesthesia in the UK, partly to raise awareness of the impact of fatigue and partly to find out how common driving accidents were. Alarmingly, 57% of trainees described having an accident or near miss driving home. The robust response rate and the scale of the issue identified led to publication of our findings in the journal Anaesthesia. What had previously been anecdotal accounts was now evidence.
As soon as this was published, the consultants said ‘me too’, so we surveyed them.
91% of the consultants reported experiencing work-related fatigue with 50% expressing that this had a negative impact on their physical and psychological wellbeing. A concerning 45% had had an accident or near miss driving home after a long shift or a night on call at some point in their career.
Although both groups recognised they were very tired, many felt they had no choice but to drive as there were no facilities to rest in the hospital during or after a night shift. And three-quarters of them used their car to get to and from work.
Our working patterns have changed massively in recent years. The introduction of the European Working Time directive meant that trainees moved to 12-hour shifts and managers removed the on-call rooms in many hospitals. Consultants often do 12-hour days and spend many hours working alone, sometimes followed by a night on call. Relentless growth in our workload, gaps in rotas and lack of staff all make shifts busier and contribute to high levels of fatigue in healthcare staff.
Realising the size of the problem, we established a joint working group on fatigue, with the Association of Anaesthetists, the Royal College of Anaesthetists (RCoA) and the Faculty of Intensive Care medicine. We designed some educational material, posters and teaching materials, and started to do talks and workshops wherever and whenever we were invited. The #FightFatigue campaign was underway.
Introducing the 20-minute power nap
But there was no point in just talking; people also needed somewhere to rest near where they work. Research into other industries showed that as little as a 20-minute power nap might prevent ‘microsleeps’ – the few seconds’ lack of awareness of our surroundings that probably killed the trainee driving home. Other impacts of fatigue, on logical reasoning, vigilance, flexibility of thinking and creativity, memory and learning, and empathy, might also be improved by a power nap.
Some organisations bought sofas that could be turned into couches to nap on in the coffee room, others got sleep pods. The BMA published a fatigue and facilities charter. During the pandemic, they also provided funds for hospitals to buy roll out chairs and sofa beds to help staff rest. A few hospitals spent the money Sir Tom Moore raised by walking round his garden on rest facilities.
We wanted to track whether these initiatives had led to sustained change. The General Medical Council conducts an annual National Training Survey of all junior doctors and educational supervisors, so we approached them to ask to have questions on fatigue included in this. With the support of the RCoA, trainees in anaesthesia have been asked questions related to fatigue since 2018.
Although there is still room for improvement, it has been encouraging to see a trend towards better support for breaks, fewer trainees feeling too tired to drive and improved availability of education on fatigue and shift working.
Providing education and facilities is a good first step, but real change depends on leadership and a supportive night shift culture. It’s not enough to know how to manage fatigue; we all have to put our knowledge into practice, even on busy shifts, and this depends on the team. We were awarded some funding from the Health Foundation and conducted a project in one hospital labour ward, identifying what the specific risks of staff fatigue are for our staff and strategies to mitigate them.
Our latest venture is to encourage other departments to put fatigue on the risk register, with proactive elements to try and prevent fatigue and reactive elements so that staff are managed well if they are critically tired.
Looking to other industries
Other organisations are also interested in our work. We were thrilled to be contacted by the Healthcare Safety Investigation Branch (HSIB), the equivalent of the Air Accident Investigation Branch who review serious incidents. They too felt that staff fatigue deserves more attention. Next we need to get patients involved. There must be lots of people who have worked in airline, nuclear, rail or petrochemical industries who would expect a robust approach to staff fatigue, who can help us persuade hospitals and governments that healthcare deserves what other industries have.
This hasn’t been a project with targets and timelines. Rather, we know where we want to get to – to have robust fatigue risk management systems in healthcare similar to those in other safety-critical industries. We haven’t got the power to do this, all we have is influence. I describe it as tipping out the pieces of a large jigsaw puzzle; some pieces are the right way up, some go together, but there’s a lot of turning over pieces and trying things out. Whenever an opportunity presents itself, we try and take it, raising awareness, sharing learning, encouraging change and auditing progress.
Working with HSIB and Patient Safety Learning is a real milestone for us – they will have influence where we do not.
Good management of staff fatigue will improve safety and wellbeing for staff and, ultimately, will make patient safer.
Our next blog
In our second blog, we will discuss managing fatigue as part of a safety culture
- McClelland L, Holland J, Lomas J-P, et al. A national survey of the effects of fatigue on trainees in anaesthesia in the UK. Anaesthesia 2017;72 (9): 1069-77. https://doi.org/10.1111/anae.13965.
- McClelland L, Plunkett E, McCrossan R. A national survey of out-of-hours working and fatigue in consultants in anaesthesia and paediatric intensive care in the UK and Ireland. Anaesthesia 2017; 74 (12): 1509-23. https://doi.org/10.1111/anae.14819.
- British Medical Association. BMA Fatigue and Facilities charter. July 2018.
Further resources on fatigue
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.
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