‘As a foundation year 1, I had a very, very busy set of shifts and [due to tiredness] almost fainted while trying to cannulate a patient, I remember my vision just went black. It was very scary and it was then that I realised that I needed to stop [and take a rest].’
The vivid recollection of one junior doctor’s experience of working while battling intense fatigue, is probably one that will be sadly all too familiar for many professionals working in the health service.
The concept of the overworked, exhausted doctor is a long established one. From the infamous 100-hour working weeks experienced and still remembered by many doctors, to today’s workforce operating in an understaffed and over-burdened NHS.
Yet while the idea of practising medicine and dispensing care to patients while short on sleep has historically been seen as part and parcel of the job, recent mounting bodies of research indicate that sleep deprivation and fatigue pose considerable risks.
In January, the BMA published a briefing on fatigue and sleep deprivation, with specific focus on the aspects posed by the impact of different working patterns.
With doctors routinely working in high-intensity, demanding conditions over long hours at night or early morning and often with short recovery times between shifts and rapidly rotating schedules, doctors are acutely vulnerable to sleep deprivation-induced fatigue.
Guidance for trusts
With the importance of adequate rest in mind, the BMA junior doctors committee has now produced a Fatigue and Facilities Charter.
The charter is a strategy and framework employers are encourage to follow, which seeks to address the whole spectrum of factors contributing to sleep deprivation and fatigue.
It advocates that trusts employ forward-rotating shift patterns (day-evening-night) to minimise the body clock disruptions caused by transitions between irregular hours, as well as a minimum 46-hour recovery period following completion of a final night shift, which is a contractual requirement for most junior doctors working in England. For new staff, the charter calls on trusts to basic education on induction regarding working at night and to screen staff working shifts for sleep disorders.
The effects of fatigue are not simply a case of being tired, with the briefing noting that a lack of sleep diminishes cognitive and psychomotor skills, in turn increasing the likelihood of occupational accidents and clinical errors.
The findings are backed by an academic paper, Effects of Sleep Deprivation on Cognition, which states that among the most consistent effects of being sleep deprived were ‘reduced attention and psychomotor vigilance and increased variability in behavioural responses’.
The paper further concludes that sleep deprivation could impact a sufferers’ mood and emotional functioning ‘which may affect the assessment of risk and the types of judgements and decisions people ultimately make’.
Speaking to number of junior doctors about their experiences of working while battling fatigue, BMA News gained some frank insights into the realities of being a sleep-deprived doctor working in the NHS.
Towards the end of a night shift last year, having had only 30 minutes of sleepless rest, one foundation doctor 2 recalls how she felt too tired and unwell to continue.
‘I remember being so ill that I said that I needed to stop and the night coordinator chased after me and tried to make me see another patient,’ she explained.
‘I had to say no, as I could barely walk downstairs I was so wobbly [on my feet] and when I later tried to eat I couldn’t even hold the spoon and just fell asleep.
‘As a doctor you become selfless and you put your patients forward because our aim is patient safety, but we sometimes forget that in order to give patient safety we have to be safe ourselves.’
Another trainee doctor, a core trainee 1 in anaesthetics, said that for the last few years, sleep deprivation had been a near constant condition while in training.
‘As you start to work in clinical practice after being a medical student, sleep deprivation seems quite unusual to start with. After a few months you begin to feel fatigued and sleep-deprived pretty much all the time and it becomes your de facto physiological state if you’re not careful.
‘I know that at the end of one particular night shift … I had been asked to do an arterial bloods gas stab, while I had double vision [from tiredness]. Another time when I haven’t felt particularly safe is when my crash bleep has gone off around a quarter of an hour before the end of my night shift, I know I’m not working at the same kind of level of effectiveness.’
A systematic review into shift and night work published in 2011, found that long hours and shift and night work increased the risk of occupational accidents.
‘I’ve had a lot of experiences where I don’t remember driving home after a night shift,’ one GP trainee told us.
‘I remember leaving the unit in the morning and just literally getting in my car and the next thing I remember is being in my own flat and I don’t remember that time in between.’
The charter also sets standards on the facilities that employers should provide, including doctors’ mess areas available 24/7 and sleeping facilities available free of charge to all compulsory or voluntarily resident staff working on call at night.
Dan Bunce is a GP specialty trainee 1 based at Somerset Partnership NHS Foundation Trust, who recently took to social media, tweeting a photo of the room he used while on call, to highlight the importance of good sleeping facilities for staff.
Des res for doctors
Known as the doctor’s bungalow, the building includes a bedroom for with an en-suite bathroom made exclusively available to whoever is on call, as well as a communal kitchen and living room for all doctors.
The room has power sockets, lamps, desk and cupboard space, and those using it even have access to a washing machine and tumble dryer.
The rooms are regularly cleaned and well maintained, including fresh sheets, meaning that there is no onus on staff to provide their own bedding.
Dr Bunce said that he had already experienced the gamut of rest facilities that existed across different trusts, but insisted that the facilities at his current trust should be the standard.
‘I’ve experienced quite a wide variety of facilities in the years that I’ve been training. When I worked an ITU job there was an on-call room but it was shared with the consultants. If the consultant on call lived quite a distance away they’d be using it so that you were relegated to sleeping on some chairs in the doctors’ office.
‘The trust that I worked at last year had just got in some bunk beds which were starting to be used, although with four beds in one room it could feel a bit awkward if you were on a night shift if you were getting bleeped and waking up other people who were in the same room. It was good to have somewhere but it didn’t really fit having the private place to go and sleep.’
‘A sofa in the doctor’s mess is, a lot of times, the best you can hope for. Whilst that can be fine for catching just 30 minutes on a night shift, the big problem is if you’re coming to the end of a night shift and you think “I might be able to get three hours’ sleep”, people are starting to come in for the day shift, so you don’t really get that period of rest.’
He added that the value of having a private and exclusive place to catch up on sleep was illustrated recently when he had to respond to an urgent clinical request in the early hours of the morning.
‘On my last set of nights, I was called in the middle of the night to have to section someone and being awake for several hours and starting to feel drained while sorting all that out, having somewhere I could go, privately with a proper bed, after having gone through all that, to go and sleep for a few hours so that you feel refreshed enough to drive home, was a lot better than being asleep on a sofa.
‘It should be the standard that there are rooms available, it’s demoralising to know there isn’t somewhere to stay and it makes you feel a little bit less valued by your employer if they haven’t got somewhere for you to rest.’
One doctor, a core trainee 2 in anaesthetics based in the north of England, said that at his trust, the type of rest facility available to staff varied by department, and that he hoped that the sleep charter would be able to address this sort of inconsistency.
‘In the anaesthetic department it depends on what grade you are. The consultant has a bed, the registrar has a bed but the junior doctor has a plastic, reclining chair which tips back about 150 degrees. I’ve never had a wink of rest on it.’
He added that while not a common occurrence, he had heard of colleagues who had opted to sleep in their cars due to a lack of suitable facilities within the hospital itself.
In addition to the often-patchy provision of rest area facilities, one doctor said that she had worked in trusts where the management sometimes adopted a hostile attitude to the very idea of staff being able to sleep while on call.
She said she knew of colleagues who were concerned about admitting to being fatigued, as this would be noted and potentially used against them if they were to make a mistake at a later date.
‘In some trusts, employers don’t look on [doctors] resting overnight, on shift kindly. A trust I used to work at there was an email sent round by a senior programme director saying that they had heard that someone had moved a mattress into one of the surgical on-call rooms.
‘The email stated that as doctors “we should not be sleeping on shift” and added that anyone caught doing so would face disciplinary action.’
BMA junior doctors committee chair Jeeves Wijesuriya said that the launch of the charter represented a much-needed response to the growing issue of sleep deprivation among doctors.
He said: ‘We know that fatigue can have a devastating effect on junior doctors and their patients. Tired doctors are at much greater risk of making mistakes that put themselves or their patients at risk. By signing up to this fatigue and facilities charter we want employers to recognise their duty of care to doctors to minimise these risks.’
JDC deputy chair for terms and condition of service and negotiations Peter Campbell added: ‘Systems that do not protect breaks for healthcare workers are fundamentally unsafe and must be challenged at a local and national level.
‘The BMA is giving its local negotiating committees the tools to effectively make the case for high quality facilities, and a culture that respects breaks and recognises fatigue. We want to ensure that we are all working towards a system that keeps doctors and patients safe.’
Read the charter
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