- Rachel S Oeppen, consultant radiologist1,
- Colin R Melville, honorary professor in medical education2,
- Peter A Brennan, consultant maxillofacial surgeon3
All doctors will be familiar with the feeling of being tired after a long shift or a series of nights on call. To some extent, this is unavoidable. But does the NHS’s working environment and culture normalise the inevitability of tired and fatigued staff, rather than finding ways to proactively minimise it?
The terms “tiredness” and “fatigue” are sometimes used interchangeably in healthcare, but they’re distinct, even if the two can be conflated. Tiredness is a physiological state that can be corrected only by sleep. Acute tiredness can lead to impaired cognitive function and decision making.12 During or after an arduous work period, which might include a busy on-call commitment or night shifts, catching up on sleep will help healthcare staff recover—but only if they have adequate time away from work to do so.3
Acute and chronic fatigue can occur because of sleep deprivation over time, but they can also result from severe physical or mental exertion, stress, illness, or a combination of these and other factors. Symptoms include chronic tiredness; sleepiness; changes in mood, including irritability; impaired judgment and decision making; regular headaches; dizziness; loss of energy; and muscle weakness.4 Acute and chronic fatigue can affect task performance, patient care, mental health, wellbeing, and resilience.5 Many healthcare workers will have experienced fatigue to some degree.67
NHS working conditions over the past four years, including during the pandemic and the more recent industrial action, have added to the pressures on healthcare staff. Doctors are regularly working beyond their normal limits, putting them at greater risk of the physical and psychological effects of fatigue. This can lead to mental health issues and low morale; sickness leave; and poorer work performance, time management, and efficiency589—potentially harming individuals, healthcare teams, and the wider healthcare service. It’s important that staff can recognise the signs of fatigue in themselves and colleagues and that employers put measures in place to reduce the likelihood of it developing.
Helping the NHS workforce beyond covid
During the covid pandemic, many NHS trusts began paying greater attention to the physical and emotional needs of staff and recognised their importance in maintaining a strong workforce. Employers supported various wellbeing initiatives, including opening lounges and spaces for staff to rest and recuperate while at work. In some of these spaces staff could relax and have free hot drinks and snacks during rest breaks.10 These had a positive effect on wellbeing at a time when many healthcare staff were working far more than their contracted hours and with the uncertainty and fear of a new virus.
As we emerged from the pandemic, most of these wellbeing areas closed and the spaces were reallocated for other activities. NHS trusts and other employers might have assumed that the risk of fatigue in staff had receded along with the threat of covid and that, as a result, they needed less in the way of support and resources. However, the cumulative effects of the pandemic and the backlogs that ensued, as well as new challenges (including strikes), have meant that supporting staff wellbeing is more important than ever.
Making self-care part of the system
The professional culture of doctors has historically been built on resilience, stoicism, and the ethos of putting patients first, but all healthcare staff need time to recuperate to maintain the highest standard of patient care. Adequate time to rest between shifts is vital: at least 11 hours is considered essential.3 This important message should be regularly emphasised and promoted by regulators, royal colleges, and employers.
Normalising self-care is an important starting point in mitigating the risk of fatigue and its long term consequences. Employers should ensure the provision of adequate rest breaks in job plans, shift work with appropriate time off to recharge, and hot food out of hours. They could also do more, through their internal communications and the culture they promote, to raise awareness of the signs and symptoms of fatigue and the importance of wellbeing. Regular short breaks should be facilitated to allow staff to drink fluids and eat regularly.11 Senior staff should model work-life balance by having their own quality time away from work and emails, and annual leave allowances should be fully used.
Organisational resources that may also be useful include providing a psychological “safe space” for staff, where self-care strategies can be taught and doctors can share their difficulties in a supportive, non-discriminatory environment. Professional help is also available and shouldn’t be seen as a sign of failure. Staff should regularly be made aware of the possible networks and psychological “first aid” support available in primary and secondary care if needed.
While healthcare shouldn’t be directly compared with other professions, we can certainly learn lessons from some of them. High performance athletes are not unlike doctors, in being under constant pressure to deliver results in a stressful environment. Athletes are encouraged to rest regularly to ensure that they get adequate and good quality sleep and that their nutrition and hydration are optimised.12 As the pressures on NHS workers are greater than ever, it’s imperative that staff are supported in looking after their own physical and mental health and wellbeing so that they can provide the best care for patients.
Competing interests: RSO and PAB declare no competing interests. CRM is medical director and director of education and standards at the General Medical Council. Views expressed in this article are personal opinions and do not necessarily reflect those of the General Medical Council.
Provenance and peer review: not commissioned; not externally peer reviewed.