Search the hub

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 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. 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. 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. 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. 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. 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. 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. 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.

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.[1] 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.[2] 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. #FightFatigue campaign 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.[3] 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. Organisational culture 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 References 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 Association of Anaesthetists fatigue resources. Fatigue resources on the hub.