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This Health Services Safety Investigations Body (HSSIB) report follows on from HSSIB's launch report, ‘Fatigue risk in healthcare and its impact on patient safety’, which introduced the concept of fatigue and outlined the risk posed to patient safety from staff fatigue. The International Civil Aviation Organization’s definition of fatigue was adopted by this investigation, where fatigue is defined as: “A physiological state of reduced mental or physical performance capability resulting from sleep loss, extended wakefulness, circadian phase [the natural daily internal body clock], and/or workload (mental and/or physical activity) that can impair a person’s alertness and ability to perform safety related operational duties.” The investigation engaged with a wide range of healthcare staff to learn what impact fatigue had on patient safety in acute NHS hospitals. The investigation explored the NHS systems and processes in place to capture and learn from the risk posed by fatigue on patient safety and staff safety. It also considered the main factors that contribute to healthcare staff being fatigued. The investigation shares findings from staff interviews, discussions and observational visits to several acute hospital trusts, combined with evidence from national bodies, forums and networks with insight on this topic. The report also refers to supporting surveys and literature. While the investigation focused on staff working in acute hospitals, the findings will be relevant to providers and staff in other health and care settings. Findings Staff fatigue contributes directly and indirectly to patient harm. However, there is little evidence available to help understand the size and scale of the risk, how it impacts on patient safety, and those staff groups who may be most at risk of fatigue. There was variation in how the concept of fatigue was understood and the impact it could have on patient safety and staff safety across the healthcare system. This inconsistent understanding prevented fatigue risks being addressed. The risks posed by staff fatigue are not always clear to trusts. The systems and processes needed to provide the information to assess staff fatigue risk are not always well developed or well used. However, some trusts were starting to explore these risks. A positive safety culture was a key enabler to support healthcare organisations to recognise and manage fatigue risk. Staff fatigue is not routinely captured as part of patient safety event reporting or routinely considered as part of patient safety event learning, or other governance processes. Fatigue was perceived by organisations and staff as an individual staff risk, with limited organisational accountability. This sometimes led to a blame culture and punitive actions when staff were fatigued, and limited actions to drive improvement. Fatigue arises from a number of personal and organisational factors, which can overlap. Organisational factors that contributed to staff fatigue included workload, long shifts, insufficient rest facilities and inadequate rest breaks during and between shifts. Personal factors that contributed to an increased risk of fatigue included caring responsibilities, menopause, pregnancy, religious practices and socioeconomic factors. Fatigue was found to have a negative impact on staff safety. A key risk related to this was staff driving home after a long shift and being involved in fatal car accidents or near misses. There are barriers to acknowledging the risk posed by staff fatigue. These include historical beliefs and norms around working long and additional hours, pride and ‘heroism’ of NHS staff. The demands on healthcare services, and workforce and financial constraints, limited the ability of some organisations to address fatigue risks. There is limited regulatory and national oversight of the risks posed to patient safety by staff fatigue in healthcare. There was limited consideration of the risk of staff fatigue in national initiatives addressing workforce challenges and care delays. The systems-based approach and supporting materials provided to trusts implementing the NHS England Patient Safety Incident Response Framework (PSIRF) helped to prompt consideration of staff fatigue in safety event learning, but this was not routine in all organisations. Safety recommendations HSSIB recommends that NHS England/Department of Health and Social Care identifies and reviews any current processes that may capture staff fatigue related data. The output of the review should identify how information about factors impacting on staff fatigue can be collated and further enhanced to aid the understanding of fatigue risk in healthcare. This data will help inform the development of any future strategy and action to address staff fatigue risk and its impact on patient safety. HSSIB recommends that the NHS Staff Council, via the Health, Safety and Wellbeing subgroup, convenes fatigue science experts and other key stakeholders to develop and test a consensus statement defining fatigue for all healthcare staff. The group should work with existing networks to promote the definition and a shared understanding of the causes and impacts of fatigue. This will help to support a consistent understanding of fatigue among healthcare providers and improve the understanding of factors that may impact on staff fatigue and patient safety. Safety observations Research funding and commissioning bodies can improve patient safety by prioritising future research to measure and assess the impact of staff fatigue on staff and patient safety. This should include patient experience and the health economics of staff fatigue due to reduced performance and productivity. Healthcare organisations and professional bodies can improve patient safety by including aspects of fatigue when conducting staff surveys in order to help build an understanding of the level of fatigue and any impact on staff performance and patient safety. This will help organisations assess and understand the risks associated with staff fatigue, and to monitor and manage the risk of staff fatigue. Healthcare regulators and professional bodies can improve patient safety by: considering how they can contribute to driving improvement in the understanding and awareness of staff fatigue; considering how they can support and share best practice on mitigations for the risk of staff fatigue; considering organisational and individual factors that may have contributed to staff fatigue when making decisions about regulatory assessment and action. Government and national organisations can improve patient safety by accounting for the impact of staff fatigue on patient safety when developing national priorities for NHS services. Healthcare organisations can improve patient safety by considering the principles and activities for a systems approach to fatigue risk management and the roadmap to implement this as described in the Chartered Institute of Ergonomics and Human Factors white paper ‘Fatigue risk management for health and social care’. Related reading on the hub: Managing fatigue as part of a safety culture – a blog from Nancy Redfern, Emma Plunkett and Roopa McCrossan Why we need to manage fatigue in the NHS – a blog from Nancy Redfern and Emma Plunkett CIEHF: Fatigue risk management for health and social care

One of the most transformative changes to the US health care system in the last few decades has been the widespread adoption of electronic health record (EHR) systems and online patient portals. The patient portal has improved patient access to medical records and facilitated direct communication between patients and their health care teams, improving patient satisfaction, enhancing health care use and increasing treatment adherence. The implementation of online patient portals has altered clinical practice workflows considerably, allowing the streamlining of interappointment communication. However, direct messaging between patients and their health care team is also having a negative impact on healthcare professionals. Increasing reliance on portal messaging as a primary form of communication and more patients using portals increased the volume of messages being sent. Work associated with portal messaging has fallen primarily on doctors, and many of them end up using time outside of clinical work hours to respond. Limited access to appointments has led to more complex and time-consuming messages. This trend is causing higher levels of staff burnout and female doctors are disproportionately affected. This article looks at the issues and potential solutions.

On 27 February, NIHR held a SafetyNet webinar on the Impact of shift work on safety outcomes for patients with Dr Chiara Dall’Ora, Associate Professor of Health Workforce at the University of Southampton. The recording of the webinar is now available. During this webinar, you will learn about the impact of a variety of staffing and shift work configurations on safety outcomes for patients. The body of research relies mostly on objective nurse roster data, as well as patient outcomes extracted from hospital systems. Using robust longitudinal methods, we have uncovered how working long shifts and high proportions of night shifts jeopardises patient safety. You will also learn what are the ongoing research projects that the team are leading on.

The NHS Staff survey is one of the largest workforce surveys in the world and is carried out every year to improve staff experiences across the NHS. It asks staff in England about their experiences of working for their respective NHS organisations. Of the 1.5 million NHS employees in England, 731,893 staff responded to the survey in 2024. Responses to key patient safety questions in this year’s survey included: Reporting of errors, near misses and incidents 33.60% of staff have seen errors, near misses, or incidents that could have hurt staff and/or patients/service users in the last month (2023: 33.47%, 2022: 33.69%). 59.71% of staff said their organisation treats staff who are involved in an error, near miss or incident fairly (2023: 59.51%, 2022: 58.21%). 86.43% of staff said their organisation encourages staff to report errors, near misses or incidents (2023: 86.40%, 2022: 86.14%). 68.21% of staff said that when errors, near misses or incidents are reported, their organisation takes action to ensure that they do not happen again (2023: 68.22%, 2022: 67.42%). 61.29% of staff said that they are given feedback about changes made in response to reported errors, near misses and incidents (2023: 61.05%, 2022: 59.91%). Concerns about clinical safety 71.53% of staff said they would feel secure raising concerns about unsafe clinical practice (2023: 71.45%, 2022: 72.05%, 2021: 75.13%, 2020: 72.82%). 56.83% of staff said they were confident that their organisation would address their concern (2023: 56.87%, 2022: 56.76%, 2021: 59.51%, 2020: 60.57%). Speaking up about concerns 61.82% of staff said they feel safe to speak up about anything that concerns them in their organisation (2023: 62.34%, 2022: 61.53%, 2021: 62.07%, 2020: 65.70%). 49.52% of staff said they were confident that their organisation would address their concern (2023: 50.08%, 2022: 48.67%, 2021: 49.77%). Care for patients and service users 74.38% of staff said that care of patients or service users is their organisation's top priority (2023: 75.16%, 2022: 74.07%, 2021: 75.65%, 2020: 79.54%). 70.92% of staff agree that their organisation acts on concerns raised by patients or services users (2023: 70.64%, 2022: 69.17%, 2021: 72.12%, 2020: 75.03%). Workload and resources 47.26% of staff said they are able to meet all the conflicting demands on their time at work (2023: 46.59%, 2022: 42.85%, 2021: 42.91%, 2020: 47.53%). 58.08% of staff said they have adequate materials, supplies and equipment to do their work (2023: 58.40%, 2022: 55.51%, 2021: 57.20%, 2020: 60.24%). 34.01% of staff said there are enough staff at their organisation for them to do their job properly (2023: 32.28%, 2022: 26.24%, 2021: 26.93%, 2020: 38.16%).

A new global survey of care workers reveals a deepening staffing crisis in the health and care sectors, with nearly 70% of workers frequently understaffed and over a third (36.4%) saying they are always working short-handed. Released on the fifth anniversary of the WHO’s Covid-19 pandemic declaration, the UNI Global Union report—based on responses from 11,233 workers across 63 countries—exposes a care system still in freefall. Despite being hailed as heroes, care workers face chronic understaffing, poverty wages, and surging workplace violence, driving many out of the profession and leaving patients at risk. Workers without union protections are affected by this trend even more intensely. The same failures that cost tens of thousands of lives during the pandemic remain dangerously ignored. UNI warns that these conditions are driving workers away from the sector, exacerbating a crisis that governments and employers have failed to address. The survey shows that union membership and collective bargaining significantly improve worker retention and satisfaction. Safe staffing levels are essential for high-quality care and safer work environments, but chronic shortages in hospitals and care homes undermine patient health – even causing preventable deaths. For care workers, understaffing leads to poor morale, increased workplace violence and injury rates, and high turnover. “Five years after the pandemic, care workers are still being overworked, underpaid and exposed to dangerous conditions,” said Christy Hoffman, General Secretary of UNI Global Union. “This report is a wake-up call. Without immediate action to raise wages, improve staffing levels, and combat workplace violence, care systems will collapse.”

The UK's leading medical defence organisation, the Medical Defence Union (MDU), has carried out the survey of 481 doctor members. The proportion saying tiredness has impacted their ability to treat patients safely has increased from a quarter (26%) in 2022 to a third (35%) of doctors responding to the latest survey. MDU survey findings 89% of doctors felt sleep deprived at work some of the time, 22% said this happened daily and 19% weekly. 35% said tiredness had impaired their ability to treat patients and 34% said tiredness may have played a part. There were 69 near misses and 17 cases in which a patient sustained harm. 38% were rarely or never able to take breaks during the working day, including lunch breaks with 27% not having a staff room to take a break in. 62% said winter pressures had increased this year and added to tiredness levels. 90% want government to continue funding specialist practitioner support programmes. The most common reasons for tiredness were high patient demand (67%), being unable to take a break because of work pressures (65%), being unable to switch off outside work (50%) and no opportunity to eat/drink during a shift/session (29%). The most reported impacts of tiredness included poor concentration (72%) not looking after yourself (70%), difficulty switching off from work (62%), decision making difficulties (53%) and poor mental health (42%). The MDU has called on the government and NHS employers to do more to ensure there are adequate resources in place to allow exhausted doctors to take regular breaks. This is part of a package of measures needed to support the health and wellbeing of the NHS workforce including the need to continue funding support services like Practitioner Health for those experiencing burnout. Further reading on the hub: Managing fatigue as part of a safety culture – a blog from Nancy Redfern, Emma Plunkett and Roopa McCrossan Why we need to manage fatigue in the NHS – a blog from Nancy Redfern and Emma Plunkett Fatigue | Association of Anaesthetists

This report explores the workforce challenges facing general practice in England, and highlights the pressing need to address the reasons why GPs are leaving the profession or reducing their contracted hours.

Shift work can introduce additional health, safety and wellbeing challenges. This article explore some of these challenges, including the increased risk of injury or illness, sleep and fatigue problems, psychological health, and suggest ways you can ensure safe and healthy shift work.

Statistics and key facts about the impact of hydration, nutrition, sleep, and regular breaks on workforce wellbeing.

This resource from the Royal College of Nursing encourages health and social care managers to ensure that nursing staff are taking their at-work breaks, are well hydrated and have access to nutritional food. It outlines the case for making improvements and the legal responsibilities of employing organisations, and provides tips and case studies to support the implementation of improvements. The document is supported by a short guide for nursing staff and posters to encourage nursing staff to self-care and take steps to rest, rehydrate and refuel.

US healthcare organisations continue to grapple with the impacts of the nursing shortage—scaling back of health services, increasing staff burnout and mental-health challenges, and rising labour costs. While several health systems have had some success in rebuilding their nursing workforces in recent months, estimates still suggest a potential shortage of 200,000 to 450,000 nurses in the United States, with acute-care settings likely to be most affected.1 Identifying opportunities to close this gap remains a priority in the healthcare industry. This article highlights research conducted by McKinsey in collaboration with the ANA Enterprise on how nurses are actually spending their time during their shifts and how they would ideally distribute their time if given the chance. The research findings underpin insights that can help organizations identify new approaches to address the nursing shortage and create more sustainable and meaningful careers for nurses.

This study from Allan et al. investigates whether nurses working for a national medical telephone helpline show evidence of “decision fatigue,” as measured by a shift from effortful to easier and more conservative decisions as the time since their last rest break increases. The study found that for every consecutive call taken since last rest break, the odds of nurses making a conservative management decision (i.e., arranging for callers to see another health professional the same day) increased by 5.5% from immediately after 1 break to immediately before the next. Decision-making was not significantly related to general or cumulative workload (calls or time elapsed since start of shift). The authors concluded that every consecutive decision that nurses make since their last break produces a predictable shift toward more conservative, and less resource-efficient, decisions. Theoretical models of cognitive fatigue can elucidate how and why this shift occurs, helping to identify potentially modifiable determinants of patient care.

The Community Hospitals Association (CHA) has designed a suite of resource packs as a way of sharing some of the learning in an accessible way. This resource pack focuses on the topic of safer staffing in community hospitals. This resource pack has been compiled because of requests from members of the CHA and the Special Interest Group in Q The resource pack covers the following: Methods. The context for safer staffing in terms of legislation and regulation requirements. The differences across devolved countries such as Scotland and Wales. The principles of safer staffing. Evidence and tools. What is different about Community Hospitals? Case Studies from CHA Community Hospitals COVID-19 Study. What next? References.

In a world where most people wake up with the sun and head to their ‘9 to 5’, night shift work can be a challenge – but can it also be bad for your health? What do those health effects mean for your risk of cancer? Can working night shifts cause cancer? Worldwide Cancer Research presents the evidence. In 2007, the International Agency for Research on Cancer (IARC) classified shift work that follows an irregular time pattern as a probable cause of cancer. This was based on some animal and human studies that found that people who worked shifts or during the night were more likely to develop some types of cancer, such as breast and prostate cancer. It also came from the idea that not following the natural day/night cycle and disrupting that natural rhythm in your body, called your ‘circadian rhythm’, could have a negative impact on health. This is somewhat true, as there are biological processes that are triggered by exposure to daylight, or by hormones that fluctuate over the course of the day. However, more recent studies on night shift work and cancer risk factor in information like this, such as BMI and waist size, and have not found that shift work itself makes someone more likely to cause cancer. In 2016, a meta-analysis (which combines the data of many different studies together) found no link between night shift work and breast cancer. In 2020, another meta-analysis that included data from 57 different studies and at least nine different types of cancer found no increased risk with night shift work. So no, night shift work does not itself increase your risk of developing cancer. Instead, this type of working pattern may lead to other health behaviours or factors that increase your risk, such as being overweight or obese, or not doing enough physical activity.