Starting the conversation around NHS staff fatigue and patient safety

Scientific basis of fatigue

Fatigue is an everyday term, but it is underpinned by well-developed academic science that explains the effects on human performance. That is, how it can impact the physical and mental capabilities of people.

A few key facts about fatigue include:

1. A lack of time to recover and sleep will reduce physical coordination and reaction times and detrimentally impact decision making and increase risk-taking behaviours.
2. After 17 hours awake, our reaction times are equivalent to being at the limit of the drug/alcohol level for driving.
3. There is a 27% increase in risk of an incident or injury during a 12-hour shift compared to an 8-hour shift.
4. One hour of sleep is worth approximately 2 hours of high-performance work.

No safety warning

Unlike other factors that will influence our performance (e.g., alcohol, drugs), fatigue does not carry a safety warning. Yet it has a detrimental impact to individual health, a person’s ability to perform reliably and impacts the safety provided by an organisation.

The management of risk is integral to any organisation. The management of staff fatigue as a risk to organisational safety is less acknowledged in healthcare compared to other safety critical industries.

Let’s be clear, other safety critical industries have not always managed fatigue well and this reflects the ‘tricky’ nature of fatigue management. The challenge materialises in the difficulty in pinpointing where and how fatigue plays a part in any safety event or on organisational and individual performance. This is despite very clear scientific evidence on the impact of fatigue.

Incident analysis or metrics that monitor safety and performance are multifactorial, hence isolating fatigue as a cause is impossible. There is further tension created within organisations as discussions around fatigue link heavily to staff capacity, acceptable workloads or work patterns, which have direct implications for organisational performance measures relating to efficiency, cost and productivity.

The example of the railway industry

Let’s look at the example of another safety critical industry and consider how the railway industry has come to recognise and embed fatigue management into their safety strategy.

The catalyst came from the Clapham Junction incident in 1988, when Lord Hidden’s recommendations led to the Hidden Limits for working duration and rest periods across the railway industry. At the time these limits did not reflect the science behind fatigue but rather acted as a stepping stone for the industry to introduce some boundaries that were operationally achievable in the context of the workforce at the time.

The original Hidden limits have since been superseded by the Office of Rail and Road ‘Fatigue Factors’. The European Working Time Regulations have supported the management of the risk of fatigue; some healthcare staff can and often do opt out of these.

The unique challenge faced by healthcare

Healthcare is different in many ways from many industries. However, comparable reliance is placed on the physical and cognitive capabilities of staff to ensure safety when operating a train, plane or nuclear power plant compared to delivering clinical care and performing a safety critical healthcare procedure.

Within any safety critical industry, the performance of staff is fundamental to the safety of the organisations they work within. Like the railways back in the 1980’s healthcare may consider it challenging to change working patterns and provision of recommended levels of rest – arguably it’s more difficult to take breaks when this may make a difference between life and death than whether a train is delayed. However, to not consider the need to manage the risk of fatigue amongst healthcare staff would appear at odds with the standards set for other safety critical industries. The European Working Time Directive has gone some way to introduce a standard that could influence work duration and breaks. However, in healthcare we see the norm in organisations or professional groups opting out of these and little real enforcement.

Understanding staff fatigue in the NHS

HSIB has started to consider this challenge and the role it has as an independent investigation body. This has led to work to develop a set of questions that seek to understand system and organisational factors influential to the work and rest patterns of NHS staff.

A pilot of this Fatigue Trigger Tool suggests usefulness of the tool, however, raises a real risk in the form of staff anxieties associated with investigating and reporting fatigue. In healthcare, individual accountability is cited most frequently as a barrier.

Healthcare typically considers fatigue as the property and within the control of the individual, rather than influenced by organisational factors. Healthcare staff and investigators have expressed real concerns about reporting on fatigue recognising this may lead to questions around their fitness to practice. However, if the shift patterns and workload are imposed by the system, this is surely not an individual issue, but a healthcare one?

The question would appear not whether healthcare should start to manage fatigue as a risk but how strategically to develop pragmatic operational fatigue management systems for the many different types of work and workforce?