I have recently undertaken several return-to-work interviews with team members following short periods of sickness absence and the common thread running through all was fatigue and tiredness. I am not suggesting that this is something new, but a review of literature considering fatigue in NHS staff turned up several recent publications.
NHS Employers (2023) pointed out that 207 000 working days are lost in the UK annually due to insufficient sleep resulting in the annual cost for lost sleep in the UK running at £50 billion.
The Royal College of Nursing (2017) undertook a national survey of nurses and midwives. It asked about colleagues’ last shift or day worked in health or social care. More than 30 000 responses were received in 2 weeks. The findings described the impact that poor staffing has on both patient care and colleagues’ own wellbeing with 59% of respondents saying that they were not able to take sufficient breaks on their last shift. One colleague described how chronic staffing shortages result in a situation where ‘a lot of shifts are covered by the goodwill of staff who agree to stay on for a few more hours despite being tired and run down’. Inevitably, the colleague noted, ‘this leads to burnout’.
The Healthcare Safety Investigation Branch (HSIB) was set up in 2017. Its core function is to provide independent investigations of healthcare incidents. Pickup (2023), a senior educator at HSIB, discussed how staff fatigue has been highlighted in several HSIB reports, reflecting that although ‘fatigue’ is an everyday term, there is a well-developed evidence base that describes its effects on human performance, including:
- A lack of time to recover and sleep reduces physical coordination and reaction times, leading to a detrimental impact on decision making and an increase in risk-taking behaviours
- After 17 hours awake, a person’s reaction times are the equivalent of being at the limit of alcohol level for driving
- There is a 27% increase in the risk of an incident or injury during a 12-hour shift compared with an 8-hour one
- One hour of sleep is worth approximately 2 hours of high-performance work.
In other industries, for example longdistance lorry driving, the management of rest is closely monitored. The health sector approach to fatigue appears to be at odds with those adopted in other sectors where safety is a priority.
Part of the challenge is that, although we know the impact of fatigue, one could reasonably say that it is impossible to pinpoint exactly where and how fatigue may have played a part in a safety event. Equally, staffing levels, and the flexibility to work long days, pose barriers to seeking alternatives to mitigate the risks.
‘In other industries the management of rest is closely monitored. The health sector, which should be setting safety standards for others, appears to be at odds with that approach’
This conundrum has led HSIB to develop a set of questions with a team who reviewed human factors expertise and available evidence (Pickup et al, 2022). The aim was to consider the body of knowledge concerned with the impact of fatigue on performance and the necessity for fatigue-management systems in safety-critical industries. The result is designed to function as a fatigue trigger tool to provide information to the investigator on the presence of a higher level of risk associated with fatigue
The questions included fields relevant to:
- Sleep:wake time
- Consecutive shifts
- Shift duration/pattern
- Quality of rest.
A pilot of the ‘fatigue trigger tool’ suggested it could be useful but raised risks in the form of staff anxieties associated with investigating and reporting fatigue as this could be seen as a fitness to practise issue. Pickup (2023) reflected that fatigue is often seen as a property of the individual rather than the organisational environment. As a result, there is a risk, for example, that shift patterns and workloads are not regarded as an organisational issue therefore they are not acted upon. The question, she suggests, would appear not to be whether healthcare institutions should start to manage fatigue as a risk, but how. What strategic action should they take to develop pragmatic systems to manage fatigue for the many different types of work and workforce?