Fatigue is something we all experience on a regular basis, however it isn’t something we talk about as much as we should. Sitting here writing this piece, day two post a busy 24-hour Saturday call, I am still feeling the effects: exhaustion, lethargy, and a frustrating inability to concentrate on the task at hand.

Long working hours, night shifts and sleep deprivation are common features of working as a healthcare professional. These things are often simply seen as part of the job. There exists a prevalent and perverse culture of fatigue in Irish hospitals, with those who vocalise their exhaustion often being branded as lazy or not-up-to-the-job, while those who fail to take breaks or to rest seen as hard working and heroic. This culture is a damaging one. There is an abundance of evidence demonstrating the harmful effects of work-related fatigue for both physician and patient. For the fatigued doctor, there are personal safety risks, with an increased likelihood of occupational accidents, such as needle stick injuries, and an increased risk of road traffic accidents driving to/from work. In the long term, shift work and chronic sleep deprivation have been associated with an increased risk of cardiovascular disease, type 2 diabetes and certain cancers. Fatigue can also adversely affect our mental health and wellbeing. From a patient safety perspective, fatigue can impair our performance, leading to an increased risk to the patient through a higher incidence of medical errors and adverse events (see Maeve McAllister’s article in this issue). There has been a growing recognition and appreciation of the risk posed by fatigue in recent years. The “24 NO MORE” campaign and NCHD strike in 2013 was evidence of this. In the UK, following the tragic death of an anaesthetic trainee after falling asleep at the wheel of their car in 2015, the AAGBI launched their Fight Fatigue Campaign in an effort to improve our understanding of fatigue and to help promote a change in culture. While some improvements have been made, there remains a long way to go. Sleep deprivation of approximately 18 hours leads to a level of cognitive impairment that has been shown to be comparable to individuals with a blood alcohol concentration of 0.05%, which is the drink-driving limit in Ireland. This assumes you have had an adequate amount of sleep in the preceding days. If not, you reach this level a lot quicker. The fatigue-impaired anaesthetist is more prone to make attention-related errors and to take riskier decisions that may compromise patient care and lead to patient harm. Landrigan et al. (2004) found that interns committed more serious medical errors while working extended shifts (24 hours or more) compared to the intervention schedule that involved working shorter shifts. Lenzer (2015) claimed a 3-fold increase in patient deaths from preventable events when sleep-deprived first year residents were on call. Worryingly, our insight into our own level of impairment is significantly impaired when fatigued, leading to poor judgment, for example, when deciding if we are safe to drive home after call, or when called to a critically ill patient in resus a half hour before the end of a long shift. Even in the absence of evidence, this is surely all common sense? When I tell my friends or family that I have to work a 24 hour shift I am always met with looks of bewilderment and something along the lines of “I wouldn’t want a sleep deprived doctor looking after me!” Fatigue is bad. Yet, somehow this common knowledge has not yet fully permeated the healthcare system. As part of Masters in Healthcare Management, I conducted a national fatigue-related survey of anaesthetic NCHDs in Ireland. A total of 134 anaesthetic NCHDs took part. As part of this, I asked respondents to complete the Fatigue Assessment Scale. Based on their scores, the prevalence of clinically significant fatigue among respondents was 59%. The survey also attempted to assess the subjective effects of work-related fatigue on NCHDs, with 81% reporting that it had negatively impacted their physical health, 84% their psychological wellbeing, 74% their personal relationships, 69% their performance at work, and 93% their ability to manage things like exam revision, audit etc. Worryingly over half of respondents reported that work-related fatigue had negatively impacted all 5 of these areas. Using the recommendations outlined in the 2014 AAGBI Fatigue Guideline as the standard, I asked trainees to provide a subjective assessment of the adequacy of hospital management of fatigue in the workplace. While some of these recommendations appear to be commonplace, such as access to rest facilities and refreshments, others do not, such as having a departmental plan in place to manage staff who are unfit to continue to work as a result of an onerous duty, and education on fatigue and its impact. For the sake of patient safety, steps need to be taken to manage work place fatigue. Of course, staff education and training to help them better cope with working in such a demanding environment are important. However, resilience cannot be the only answer. This must be matched with changes at an organisational level. Mechanisms must be put in place to mitigate fatigue risk and to support staff to provide safe and effective patient care. Finally, a cultural shift is required, to help change attitudes across the workforce to ensure that people understand the importance of guarding against fatigue in maintaining patient safety, to promote positive attitudes towards rest, and to help reduce the stigma attached to talking about fatigue We spend all day managing derangements in our patients’ physiology. We need to learn to respect the derangements in our own physiology as a consequence of fatigue and sleep deprivation, not only for our own health and wellbeing, but ultimately for the health and safety of the patients in our care.

Image taken from: Kecklund Göran, Axelsson John. Health consequences of shift work and insufficient sleep. BMJ2016;355 :i5210.