Dr Nancy Redfern and Dr Emma Plunkett give the latest on crucial work to get healthcare to recognise the threat to safety posed by tired staff.
Last year we set out to HCSA members why sleep is so important to our clinical performance, and some of the challenges of working long hours and night shifts.
Staff well-being, or the lack of it, was a talking point during the Covid pandemic, but nowadays the need for “efficiency” and the lack of money for the NHS have taken centre stage. There is still a long way to go.
That said, more organisations are recognising the issue of healthcare staff fatigue. They may not all be NHS organisations, but they do appreciate the challenges the health service faces.
Three excellent publications by some of these organisations have contributed to an improving landscape and describe practical approaches to managing fatigue and its risks.
The 2024 white paper by the Chartered Institute for Ergonomics and Human Factors, probably the experts in the field, sets out the case for Fatigue Risk Management for Health and Social Care. It explains why it is needed and outlines pragmatic ways to develop, implement and sustain an effective approach for healthcare.
The Society of Occupational Medicine produced a well-researched consensus document on Fatigue Risk Management (FRM) in February, intended for occupational physicians but with wise advice for anyone interested in safe service delivery and staff wellbeing. They tell us to manage fatigue like any other human factor hazard, register fatigue as a risk on the Risk Management Framework, and develop a FRM Strategy – a systems approach based on principles of risk and safety management.
Perhaps the most wide-reaching and potentially influential report is the Health Service Safety Investigation Body’s (HSSIB) investigation, The Impact of Staff Fatigue on Patient Safety, published in April. It points out that staff fatigue contributes directly and indirectly to patient harm, but warns the risks posed by staff fatigue are not always clear to NHS employers. They tend to regard it as an individual risk and not something for which the organisation has any responsibility.
The observations and recommendations include improving the capturing of fatigue-related data and encouraging healthcare-specific research in this area. There are also a series of local-level prompts which organisations and staff can use to address concerns in this area.
If you have read these and are wondering what is next, look out for publications from the CATNAPS team. This aptly titled research project into the management of fatigue in the ambulance service in England is making good progress. The full project title is Co-producing an Ambulance Trust National Fatigue Risk Management System for Improved Staff and Patient Safety and the website has lots of information and links to useful resources.
Some NHS organisations are making improvements. Bristol and Newcastle have fatigue on the risk register and Worcester have done an excellent survey of all night staff showing the steps individuals take to mitigate fatigue [Night staff fatigue. Sarah-Louise Troth. British Journal of Healthcare Assistants, May 2024, DOI: 10.12968/bjha.2024.18.5.166].
Others are less keen. The HSSIB points out that many of us, and many of our managers and leaders, don’t understand how we can recognise and mitigate staff fatigue. This is particularly the case in busy, overstretched units.
Small things do make a difference to everyone’s productivity and mood, such as making sure everyone has a break, providing places for power naps, and making sure food offered at night is healthy and protein-based without lashings of high calorie options.
There is good evidence that we’re safer and quicker if we do these things. But until people know what impacts staff fatigue is having, until we report fatigue-related errors, we we will continue to see lots of people making the excuse that they’re too busy to make changes.
When one hospital discovered that 20 percent of nurses described having a micro-sleep driving home after a busy night shift, they gave this a “red” rating on the risk register and started staff education on ways of managing circadian misalignment at night.
Other sectors are far ahead of health when it comes to recognising and acting on the dangers of fatigue. Nowhere is this clearer at the annual Healthcare Fatigue Forum, where we get together with other front-line staff and academics focused on the issue. When experts attend from other “high hazard” operations such as air and rail, they often look askance at descriptions of the way NHS organisations – where they are patients – fail to acknowledge and manage staff fatigue. But while their sectors may have mature fatigue risk management systems, closer conversation reveals that they don’t have everything sorted.
In the world of fatigue safety more reports are a sign of working systems. Fewer reports are a sign things may be being brushed under the carpet.
A fellow attendee who works in the air sector shared a recent conversation where it was reported that Kazakhstan airline had recorded two fatigue-related incidents and near misses per year, whereas one leading UK budget carrier had about 1,000 per month. As he said, “Who would you rather fly with?”.
It was hard not to feel a sense of embarrassment that, after five years of working on the issue, there are still lots of hospitals where not even two fatigue-related incidents are reported per year.
Achieving system change is a slow process, but we’re determined that in the end healthcare will be as safe for staff and patients as other safety-critical industries. The publications released in the last year are significant steps in the right direction. If the NHS engages with putting this advice into practice we will make some worthwhile progress. There is reason for hope.
- Dr Nancy Redfern and Dr Emma Plunkett are consultant anaesthetists and founder members of The Fatigue Group, a Community Interest Company founded in order to continue the work of the #Fightfatigue campaign. It is happy to provide workshops, talks or support to anyone wanting to take the first steps in effective fatigue risk management.