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Working in the NHS, especially in the face of ever increasing pressures, is demanding, challenging, and often stressful.
When we don’t get enough rest and sleep, our brains and bodies don’t function at their best – meaning we find it even more difficult to cope.
Doctors, nurses and other clinical staff are pulling together to meet increasing demands in an overstretched service to ensure patients are safely treated. There are ever more patients to be seen, and the complexity of the care they need is rising to match.
We work longer, more intense hours - yet the provision of regular breaks and proper rest facilities for healthcare staff is patchy at best. Many find it feels harder and harder to interrupt patient care even to take a break. Time to sleep, to recuperate and regenerate, becomes less and less – and the effect of work stresses means the quality of what sleep we do get plummets. Each new shift often begins with us just that little bit more sleep deprived than the shift before.
When our patients need us to be functioning at our absolute best, our working conditions are increasingly leaving us progressively more sleep deprived and exhausted. These pressures can only be endured for so long – and when people succumb, the systems that depend on them will fail.
When healthcare professionals work without breaks, fatigue progressively impacts ability: decisions become harder, slower … and are more likely to be riskier or wrong. The longer we work without a break, the more likely we are to make a clinical error: tired doctors make mistakes.
We’ve forgotten that breaks are there first and foremost to help ensure safe, effective and efficient clinical care.
It’s not just the care we provide that’s at risk. Tiredness, especially in intense environments, creates major risks to our own health as well. Working 24/7 around the clock to provide care, those risks are magnified further by the effects of shiftwork and sleep deprivation.
When we are tired, personal risks, such as needlestick injuries and more accidents in the workplace, rise. Far too often, exhausted medical staff fall briefly asleep at the wheel driving home after finishing a night shift, significantly increasing their chances of dying in a road traffic accident.
While many other safety-critical industries, such as airlines, oil rigs and railway companies, recognise the impact of long working hours and shift work, the NHS has always been less good at doing so. Airlines ground a plane rather than see its crew go over their safe working hours limits - the same option isn’t available in healthcare. In the NHS, the pressure is to keep the plane in the air at all times … meaning that rules designed to protect those keeping it there can end up being ignored, or forgotten.
European Working Time Directive rules, including the limit of an average 48 hour working week, and rules regarding rest and statutory leave, do apply to those working in the NHS but service pressures and workforce shortages mean they are often not robustly and consistently enforced. Many doctors commonly work well beyond the end of their shifts, or even on days off. They skip breaks – and if they do take them, they often carry on doing administrative tasks as they hastily gulp down a stale sandwich.
Our focus is almost always on the patient’s needs, on keeping the plane in the air, no matter the cost … forgetting that if we don’t look after the plane’s crew, it’s impossible to fly the plane at all.
What is our profession doing to address this?
The BMA placed safe working at the heart of negotiation of the 2016 junior doctors’ contract.
As a result, the new contract makes it absolutely clear that “limits on working hours and protected rest periods … are necessary to ensure both patient safety and the safety of the doctor.”
When junior doctors “feel unable to travel home … due to tiredness”, the new contract makes it a legal requirement for Trusts to either provide an appropriate place for them to sleep, or” to make alternative arrangements for their safe travel home.”
When junior doctors miss breaks or work late, the new contract puts in place the exception reporting process to rapidly escalate this to a response, either with overtime pay (creating a disincentive for their employer) or time off in lieu to rest. If a swift response doesn’t appear, the new contract puts in place the role of Guardian of Safe Working, a statutory appointment who “shall provide assurance that doctors’ working hours are safe.”
While these provisions legally apply only to junior doctors working the 2016 contract, we expect Trusts to consider this best practice for all doctors and healthcare professionals, and to put measures in place accordingly.
BMA work on fatigue and sleep deprivation emphasises the evidence behind the significant impact of fatigue, and why Trusts, and the NHS as a whole, cannot afford to ignore it any more.
It offers practical support, with tips on when tiredness is most likely, the risks of fatigue at work, and how to maximise rest and recovery. As well as a written document, there’s also a short video with tips on how best to manage fatigue.
These steps are just a start.
A comprehensive, co-ordinated strategy is urgently needed to highlight and manage the impact of fatigue across the NHS.
As pressure grows, fatigue takes on ever-increasing importance, not less. As more and more NHS staff give unstintingly from their own personal reserves to meet demand, rates of sickness and burnout rise, and leaving the NHS altogether becomes more and more tempting for many.
We need leadership by governments and national bodies, complemented by a range of actions by employers and staff.
It will take time and effort , and must be done in parallel with equally vital work around safe staffing and provision of appropriate resources.
While there are strategies that individuals can adopt which help to minimise the impact of fatigue on their personal wellbeing and professional function, this is a problem that lies at the very heart of modern NHS care, and can only be addressed by a systemic approach to both causes and solutions.
Employers must take full responsibility for the care that they provide – and that means remembering that to look after our patients, we must also look after ourselves. Simple steps can begin now, by:
Fatigue awareness and management must become central to planning and training our future workforce, to address factors such as excessive workload and long working hours.
We must work together across the healthcare workforce to develop service models which allow us to safely, effectively and efficiently safely treat our patients, remembering that looking after ourselves is an essential part of ensuring the system is sustainable.
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