Fatigue management in healthcare: it is a risky business

In this issue, McClelland et al. provide data on self-reported fatigue in a large cohort (n = 3847) of anaesthetic consultants and paediatric intensivists in the UK and Republic of Ireland 1. Although much has been written on fatigue in junior doctors and trainees, this is one of the first studies to report systematically on working time arrangements and self-reported fatigue and well-being in senior medical staff. The study asked respondents to describe their working time arrangements for ‘out-of-hours’ and ‘on-call’ work, to speculate on the causes and consequences of fatigue and suggest approaches to mitigating fatigue (risk). As with other hospital-based cohorts, the respondents reported widespread fatigue with significant negative consequences reported for the personal health and well-being of consultants. Interestingly, the cohort was not asked questions about the implications of fatigue on clinical performance, error or patient safety although this link is well established from other studies 2, 3. According to the survey results, long working hours (often in violation of pre-Brexit regulatory requirements), out-of-hours work and/or on-call activities predictably reduced sleep opportunity and sleep, and lead to elevated levels of sleepiness/fatigue. Of particular interest was the finding that around one-third of respondents were expected and/or required to work the next day irrespective of the amount of call-out activity over the preceding night. They reported this as the most significant cause of sleep loss and fatigue and recommended such practices be stopped given the subsequent risks while commuting or working the next day. That is, where a doctor was required to be on-call, next day work should be restricted or re-tasked to provide an adequate recovery period or alternative low-risk activities (e.g. professional development rather than clinical care). Critically, fatigue was not an isolated event. Respondents with frequent significant sleep loss may well be cognitively impaired with rather obvious implications for physician or patient safety/well-being. In the event of a commuting accident or adverse medical event, these practices undoubtedly create significant legal liability for organisations, administrators and senior clinicians responsible for ensuring a safe-system-of-work or defending against legal claims attributable to fatigue-related error. However, there remain significant cultural impediments to acknowledging the direct relationship between fatigue and organizational risk, which need to form a focus of corrective action. With respect to reduced quality of life, nearly three-quarters of the respondents reported a moderate to significant negative impact on family and social life and a small proportion (1–3%) believed that the fatigue attributable to the working time arrangement played a significant role in mediating their personal experience of depression, anxiety or burnout. Although this association is less direct than the link with error, work-related fatigue has also been linked with increased risk of mental illness and has frequently been identified as a potential cause of suicide in junior doctors 4, 5. If this is the case, fatigue may also carry additional liability for employers where it can be demonstrated that the working time arrangement contributed to the health problems experienced by an employee 6, 7. The paper also explored the perceived level of support provided by employers to manage their health and well-being vis-à-vis the working time arrangement. This particular work is new and, in our view, makes a valuable contribution to the literature. Nearly two thirds of the respondents reported lack of employer support for managing their health and well-being at work. These respondents reported work environments that could be broadly characterised as unmanageable due to being ‘too busy’, ‘understaffed’, ‘no opportunity to take designated breaks’, ‘coping with overbooked lists’ etc. Interestingly, the third of respondents who did feel supported identified breaks after being on-call along with a supportive and collegial work environment as the key reason. For those responsible for managing workplace health and safety obligations, the implications of this study should be concerning. Consistent failure to address issues that contribute significantly to fatigue such as understaffing, failure to provide legally mandated breaks and overscheduling work-loads indicate a potentially dysfunctional (patient) safety culture within the organisation and expose hospitals and administrators to significant legal liability in the event of a fatigue-related error/adverse event 6, 7. When asked how best to address these issues, respondents suggested the obvious solutions: more staff on the rota; better rotas with more breaks; compulsory rest periods before or after on-call activities and enforced breaks while on shift. These are tried and tested solutions for which the likelihood of implementation is close to zero in the current healthcare environment in the UK. And here lies the intractable problem. A healthcare system that is demonstrably stretched but within which, any additional resources will more likely be used to address latent or un-met demand with little if any likely improvement in the working time arrangements for the staff working within it. This is truly what Rittel and Webber 8 meant when they coined the phrase a ‘wicked problem’. So where do we go from here based on the results given the unlikely provision of significant additional resources to employ more doctors on better rosters? If we are to move past this impasse, it will require us to look at how we manage the issue of working time arrangements, fatigue and patient/physician safety in a new way. It will require us to understand that solutions based on more money or even those developed for other industries (e.g. tighter regulation) are ill-suited to the area of healthcare. So, given the challenges facing the discipline, how should we think about the issue? How might we move forward? First, it is important to understand that the ‘culture’ in healthcare around extended working time arrangements is, on one level, completely sensible. Unlike transport, manufacturing or mining, strict adherence to working time regulations carries a very obvious and negative consequence. There will be too few medical practitioners to meet the community expectations around healthcare delivery and taxation. If we enforce traditional working time arrangements considered acceptable in other industries, we will be required to withdraw services from the community. Even if the requested financial resources were made available (which is unlikely), there is not an unlimited supply of doctors waiting to be employed in order to help reduce the hours of those currently employed. At an intuitive level, most clinicians righty believe that a rigid enforcement of ‘fatigue friendly’ working time arrangements could actually produce a sub-optimum clinical outcome. By attempting to solve the ‘fatigue problem’ by reducing working hours, a number of unanticipated negative outcomes can be accidentally created. Such unanticipated outcomes include: difficulties for junior staff in gaining critical clinical competencies; work-load issues that arise from the requirement for individuals to maintain a higher concurrent patient load; failures in continuity of patient care due to an increased number of patient handovers; and a lack of clinical ‘currency’ due to less time actively undertaking clinical practice. Although it is true that tired doctors make more mistakes and are more likely to experience reduced well-being, the overall negative health outcomes associated with the withdrawal of services required to reduce fatigue will likely be worse at a population level. Arguably, and in the vast majority of cases, a tired doctor is better than no doctor at all – unless of course you are the unfortunate patient who is a victim of a medical error or the unfortunate doctor that falls asleep at the wheel driving home! In reality, the link between the working time arrangements and patient and practitioner well-being can be very complex. Arguably, long working hours enable medical practitioners to gain experience more quickly, maintain continuity of care, maintain currency in a broader range of procedures, to treat more patients and to reduce aggregate health burdens more cost effectively. On the other hand, there is a price to pay in terms of the increased risk to patient and physician well-being associated with working the long hours. In our view, the complexity of dealing with fatigue by changing working time arrangements alone can lead to feelings of impotence and paradox and an understandable preference to ignore or overlook the problem rather than deal with it. Hospital administrators and senior clinicians often understand the paradoxical nature of the complex fatigue risk calculus – but at an informal or intuitive level. This knowledge is often acquired through experience and a sophisticated understanding of all the competing priorities that need to be managed on a day-to-day basis. On the one hand, this lived experience can be very valuable and can potentially optimise overall health outcomes in very complex decision making environments – despite high levels of fatigue. On the other hand, it can also reflect instinctual ad hoc decision making and an unquestioning attitude to traditional culture, custom and practice with actually little regard for patient or doctor well-being. The challenge for 21st century managers will be to ensure issues surrounding fatigue are tackled with a mature and considered approach to the management of risk as part of a formally documented safety management system. Our argument is that effective fatigue risk management is much more than simply reducing working hours of individual clinicians. Rather, in order to ensure best-practice outcomes for doctors and their patients, decisions need to be made that identify the actual hazards associated with fatigue, quantify them from the perspective of risk to both staff and patients, and put in place appropriate strategies to mitigate this risk. Take, for example, what we know to be one of the most hazardous activities medical staff undertake from a fatigue-related perspective, which is driving home after nightwork. Simply reducing working hours will not directly mitigate the risk of driving home after nightwork. However, strategies such as suitable napping facilities, simple tools for an individual to assess their fitness for driving home, allowances for other forms of transport and education around driving risks are much more effective strategies. Not only will these strategies actually reduce fatigue-related risk but putting in place such forms of risk mitigation will also protect hospital managers from forms of legal exposure that results from failing to provide staff with a safe workplace. “where the net risks associated with continuing to work are less than the net risks associated with an employee ceasing to work, it may be reasonable for an employee to continue to work provided sufficient additional controls are put in place”. This statement formally acknowledges the very difficult choice that healthcare providers are often forced into and provides a potentially defensible legal position to justify the decision to continue to work. More importantly, this statement identifies that the provision of care within our current health systems is always a matter of risk management and risk mitigation. The corollary of this legal defence is that in requiring an employee to work extended hours, the employer must accept that while the risk of not providing a service is substantially greater than continuing to work, the risk of continuing to work is also greater than ceasing work (albeit less than withdrawing service). As such, an employer should take all reasonable steps to ensure that fatigue-related risks are adequately ‘controlled’ if and when working time is extended. That is, acknowledging that extending working hours does increase risk and requires the employer to implement additional risk controls to ensure an employee can work as safely as possible ‘whilst fatigued’. In our view, the most important step for organisations, administrators and senior clinicians can make is to formally acknowledge that fatigue is often unavoidable in 24/7 healthcare delivery and, therefore, so is fatigue-related risk. It can, however, be managed 9. As a manager, one's primary responsibility is to identify, quantify and mitigate the risks associated with fatigue. However, this is not merely to assure compliance with the rules of rostering within an industrial agreement. Rather than pretend that fatigue does not exist based on compliance with rules of rostering, this change in perspective will help managers to ensure that staff can ‘work safely whilst fatigued’. This is a critical shift in cultural perspective. Once fatigue can be openly acknowledged as a hazard – with safety implications for staff and patients – it can be monitored and managed using pre-existing approaches 10. Systematic approaches to identifying, managing and mitigating fatigue-related risk have been widely adopted in many industries over recent years, and have been embodied in formal regulatory frameworks by the International Civil Aviation Organisation, the US Federal Railroad Administration and the Australian National Heavy Vehicle Regulator. In healthcare specifically, fatigue risk management systems (FRMS) have recently been adopted in several jurisdictions including Australia 11 and Canada 12. Using these guidance materials, organisations are provided with scientifically and legally defensible methodologies for measuring and managing fatigue risk based on general principles of safety management 13, 14. Most FRMS focus on the six points outlined above in order to identify and manage fatigue-related risk more effectively. The advantage of these approaches is that they enable organisations to acknowledge, measure and mitigate fatigue-related risk without compromising doctor or patient health and safety. Most importantly, they provide a clear pathway on how to manage a risk generally allocated to the ‘too hard’ basket. Although it may not always result in less fatigue, it will significantly reduce the risks associated with fatigue and ensure we minimise the modifiable risks to doctors and their patients. This may well help significantly reduce the likelihood of adverse medical events and help reduce some of the negative effects of fatigue on doctors and their families. And the best thing, we can start implementing a fatigue risk management system tomorrow; changing the roster will take much, much longer! The authors thank the healthcare institutions who have contributed to the innovative approaches to fatigue risk management described in this paper. No external funding or competing interest declared.

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