Guest blog by Dr Mary Bernadette Dalton, Independent Consultant Occupational Physician
Fatigue is a work-related hazard. Linked to sleep loss and circadian dysregulation, it disproportionately affects shift workers. From 1967 at Manchester Medical School, Prof Mills, a chronobiology pioneer, embedded biological underpinnings of human energy management. Our bodies need energy to work and “We are rhythmic creatures, living in a rhythmic world."
Seeds of my interest in fatigue were sown during childhood, observing my father, grandfather and uncles working nightshifts in Middlesbrough’s heavy industries. Fatigue has also interlaced my 53 years doctor-life. As a junior doctor, my energy levels flagged, working brutal rotas of seven days, 1:1 or two nights, often 48 hours without sleep. Richard Feynman’s quote in the ‘Challenger Report’: “Nature cannot be fooled” resonates, conjecturing that trauma of overwork was a likely contributory factor to not only my dimmed academic passion and wellbeing, but ‘Power off’ for some colleagues. There was no respite from sleep disturbance, as I counterbalanced work as mother of four children (including twins) with hybrid daytime work in general practice, women, and children’s health.
Despite fatigue following me, energy efficiency challenged by juggling family responsibilities, chronic illness (MS), and menopause, with duties as Occupational Physician from 1990 (Consultant 2011), I neglected fatigue studies, lulled into a false sense of security by NHS’ health and safety (H&S) systems controlling most workplace hazards.
Then a lightbulb moment. My daughter, a GP, gave me Matthew Walker’s book “Why we Sleep,” which patients and colleagues raved changed their lives, prompting my revision of the human energy system, now forefront of scientific agenda. This new learning affirmed:
- sleep (and its timing), plays a crucial role in health, restoring energy;
- time spent working by day is not biologically equivalent to working time at night;
- work resulting in sleep loss and circadian dysregulation increased risk of fatigue, ill-health, mortality, cognitive impairment, and accident;
- fatigue undermines patient safety, workforce productivity, retention, and sustainability.
What struck me was that we are facing a “human energy crisis,” and the NHS holds a unique chance to address the pressing challenge of energy impairment in workers. Fatigue risk management systems, optimal sleep and circadian health, could help stabilise the NHS.
Fatigue has substantial financial and operational impact. I realised that fatigue had slipped under the radar. The NHS appeared blind to the problem’s scale (prevalence, or cost) and had done little over the last 45 years to ‘grasp the nettle’. Risks to night workers’ health remained underappreciated, much as risks to asbestos workers were underappreciated some generations ago. With poor legislative emphasis, widespread lack of knowledge, training and health surveillance, NHS systems were inadequate for managing fatigue, not consistently recognised as a workplace hazard in NHS risk registers.
The Fight Fatigue campaign highlighted sleep-deprived clinicians being part of a health care system in trouble, and doctors still dying because of working practices.
The pandemic and Long COVID then exacerbated unmanaged fatigue. Failure to meet physiological needs (food, water, sleep, rest), became critical issues, for both staff wellbeing (sickness absence, long term ill health, burnout), and patient safety (errors, near misses).
We Northwest Consultant Occupational Physicians raised awareness that fatigue is a predictable, preventable, and currently uncontrolled hazard, and consequence of certain working arrangements. NHS fatigue non-management risks normalising avoidable harm. Our thinking echoed that of the Chartered Institute of Ergonomics and Human Factors and The HSSIB.
The goal is for fatigue be managed as fundamentally a workforce and patient safety risk, a systems issue, with clear leadership accountability, mandatory workforce standards, education, data collection, and health surveillance. To reform systems, culture and reduce inequalities, and end the merry-go-round of ‘fighting fatigue with no framework,’ the existing H&S apparatus needs updating.
Aware change unlikely without a push from government, the SOM/University of Warwick orchestrated cross-disciplinary, reputational power, in the context of the Government’s 10 Year Health Plan’s emphasis on prevention.
The chapter on delivery of system reform has started but is not finished. E.g. see the ‘Fighting Fatigue: Addressing shift work, sleep and the public health burden,’ SOM/University of Warwick document.