World National Sleep Day is an opportunity to remind ourselves of how essential sleep is and, perhaps more importantly, to remind ourselves of the risks of not getting enough of it. The last few years have seen lots of positive work on the topic of sleep deprivation, starting with the Fatigue and Facilities Charter released by the BMA in 2018.
However, there remains many barriers in a junior doctor’s work life to a healthy relationship with sleep.
Early in the first wave of the COVID-19 pandemic, I was involved in an accident cycling to an on-call shift at work. I ended up in the back of an ambulance, carted to hospital to rule out a skull fracture. I had worked 12 out of the previous 14 days, including four weekend shifts. Sleep had been in short supply.
The hospital was being over-run, stress was at an all-time high as the uncertainty of COVID hit home. I had picked up extra shifts the previous weekend to cover for staff shortages, wanting to help my colleagues out. Mere days later I would find myself in hospital, a patient myself, and with facial injuries suggesting the next age of Mordor had dawned.
It was only after the physical scars had healed, the workload had dropped and the NHS had time to catch its breath that I looked back on and recognised how sleep deprived I had been the day of the crash. Not only had I put myself and others at risk on my commute, what sort of clinician would I have been while working with that level of fatigue and sleep deprivation?
Let’s take a look at the evidence we have available with regards to the effects of sleep deprivation. An individual who experiences a moderate level of sleep deprivation (the equivalent to being awake 17 to 19 hours in a row) can have the same reaction time to someone who has a blood alcohol level of 50mg/100ml (the legal safe limit for Scotland).
On a similar note, working longer shifts (typically >10 hours) is associated with a 25-30% higher risk of injuries than working an eight-hour shift. It is no surprise then that there is emerging data that the rate of self-reported errors is higher during night shifts and extended shifts. Then there is the possible long-term effect on our health: shift work and long hours are associated with higher rates of cardiovascular disease as well as higher rates of mood disorders such as depression and anxiety. In essence, sleep deprivation can harm our patients as well as us as individuals.
We know the typical junior doctor work schedule contains rapidly changing shift patterns often with long shifts (70% of us will work extended hours in a normal month). We know this is a risk factor for sleep deprivation. New safety limits introduced in the 2016 contract mean there is a contractual limit to protect doctors, but this doesn’t stop rotas affecting our levels of fatigue.
It often means rota coordinators get more savvy at pushing rotas to the limit. Add in a global pandemic, winter pressures and the rigorous demands of the job, it becomes a mission to tackle fatigue and maintain good sleep.
So, what can we do to promote good sleep despite the obvious barriers in our way? How can we protect ourselves as clinicians and individuals?
As a profession we are getting better at acknowledging the effect of sleep deprivation. In 2018 the BMA released the Fatigue and Facilities Charter which was introduced to improve rest facilities and reduce fatigue among doctors. In 2019, the BMA junior doctors committee secured £10m investment across all trusts in England, leading to revamped doctors rest facilities and more on-call rooms.
In addition, it provides employers guidance on how to reduce fatigue, for example using forward-rotating shift patterns leading up to night shifts (day, evening, nights). While the majority of the funding has been allocated, there remains significant amounts unspent, for which the BMA has secured a rollover into the next financial year.
Outside of the Fatigue and Facilities Charter, the BMA has produced guidance on managing fatigue associated with doctors’ work patterns. It is a useful tool for clinicians and employers. The resource can be accessed here and contains useful advice with topics such as having good sleep hygiene, tackling night shifts and ways in which your employer can help.
Remember, your employer has a duty to ensure contractual limits are adhered to. For example, if you are unsure your rota is compliant, you can use the free rota checker tool here. For junior doctors in England, you can also exception report work that varies from your agreed work schedule. If you have any concerns regarding your contract, you can contact the BMA here
It is clear that sleep deprivation affects us all as clinicians. It can have significant implications for our own safety as well as those we treat.
If you are sleep deprived, reflect on what are the barriers to good quality of sleep for you. Is there a rota issue that can be addressed? Is it a simple matter of good sleep hygiene? Or for some of us, even if the above are done well, we might just need the extra help offered by a professional in sleep medicine.
And remember, if you don’t feel safe, you probably aren’t. Look after yourself and get a good night’s sleep!
Dervla Ireland is a foundation year 2 in London.