Responding to pressure

The uncertainty caused by unsafe staffing and systems can cause stress for staff of all grades, particularly when there are gaps on rotas.

This can include ‘moral distress’ where institutional and resource constraints create unease among doctors from being conflicted about the quality of care they can give. For more information, see the BMA’s work on moral distress which also signposts resources for doctors.

It is sadly not uncommon for doctors to feel pressured into working inappropriate and unsafe levels of overtime, or to cancel annual leave or work when unwell, to fill these gaps.

If you are feeling pressured into unsafe working, help is available. You can call a BMA adviser, raise concerns as set out in this guidance, or read the UK Government guidance on whistleblowing.

The BMA’s Peer support service provides a one-to-one confidential space to talk with another doctor 24 hours a day, 7 days per week. No membership is required.

Getting meaningful rest

Meaningful rest is a rest break that provides benefit in terms of cognitive offload and subjective reenergisation. This could mean using your break to have a relaxing chat with colleagues, read a book, listen to a podcast or music, watch television, eat, or engage in a mindfulness exercise. Studies indicate that a meaningful rest can improve cognitive function, reduce error risk, improve judgement and improve productivity.

You may also want to use your break to have a nap. There is now a substantial body of evidence that a 20-minute nap can be beneficial for cognitive function, performance and reducing error rates. In order to take a good quality 20-minute nap, your body needs to be ‘told’ it is time to rest, a process which is impaired by the presence of blue light. Therefore, rest facilities should be dark, quiet and of a comfortable ambient temperature.

You are entitled to privacy and dignity and should have sole use of a piece of furniture for the length of your rest in a context conducive to rest. If you wish to take a nap, you can follow the below guidance:

• Ensure nursing staff are aware of your break, where you will be, and to save any non-essential bleep jobs/questions for the period of your break. If there is a hospital at night system, it may be possible to inform the coordinator so they can filter your bleeps during the break.
• Ensure your bleep is close by and that the batteries have not run out in case an emergency bleep is sent out.
• Whilst at work and on shift you have a duty to patients to respond to any emergency or urgent calls regarding patients. However, it is reasonable that your break should be undisturbed by bleeps or calls to complete non-urgent/non-emergency tasks that can wait 30 minutes without impacting patient safety.

Anticipating and managing fatigue

You can mitigate the risk of fatigue by taking steps to understand what factors optimise your ability to manage and anticipate fatigue – such as ways to improve your sleep routine, how to prepare for shift work and being on call, and how to manage fatigue when making decisions about patient care.

Getting your sleep environment right and ensuring you have a good sleep routine are important, as is seeking help and support from an accredited occupational medicine specialist about any concerns you have about fatigue and sleep problems. Your employer must be made aware if you feel unfit to work or continue to work because of fatigue.

It is now a requirement within the 2016 contract in England for employers to provide junior doctors with either a place to rest or alternative arrangements when you declare you are too tired to drive home.

For more information see the BMA's guidance on anticipating and managing fatigue and the Fatigue and facilities charter.

Managing the night shift

There is growing evidence highlighting the physiological impact of night shift working, which is leading organisations to consider night shift work as different to day shift work. This is important for junior doctors who regularly undertake night shifts and have to maintain vigilance and make prompt, patient safety-critical decisions throughout their shifts.

If you are working the night shift, there are ways you can best prepare yourself, protect yourself during the shift, and maximise recovery. Please see the BMA’s guidance for more detail.

Healthcare bodies have a duty to their patients by incorporating strategies to partially mitigate the impact of night shift working on their staff. This could include a 20-minute nap during a contractual 30-minute natural break during a night shift. If you are working in England, remember to exception report if you are not getting to take these breaks.

Supporting good quality decision making

The need to frequently make decisions about patient care, often whilst under severe pressure, can increase the risk of poor-quality decisions over time while on duty.

Where possible:

• plan your day to break up times when you are making key decisions, and factor in when you are most alert (usually first thing in the morning)
• do an activity that is not too taxing (eg a short walk or listening to music) during your breaks
• keep hydrated and eat healthily to help stay alert
• if you feel your decision making is impaired, take time to double check what you recommend and consider putting off the decision if you can

For more information, see the BMA’s Fatigue and Sleep Deprivation Guidance.