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.
Seeds of my interest in fatigue were sown during my childhood, observing my father, grandfather and uncles working nightshifts in Middlesbrough’s heavy industries.
In the 1960s, Prof Mills, a chronobiology pioneer at Manchester Medical School, embedded biological underpinnings of human energy management, stating that our bodies need energy to work and “We are rhythmic creatures, living in a rhythmic world."
Fatigue has also interlaced my 53 years as a doctor. As a junior doctor, my energy levels flagged, working brutal rotas, often going 48 hours without sleep. I conjectured that trauma of overwork was a likely contributory factor to my dimmed academic passion and wellbeing.
There was no respite from sleep disturbance, as I counterbalanced being a mother of four children (including twins) with daytime work in general practice, women's, and children’s health. I next juggled chronic illness (MS) and menopause with duties as an Occupational Physician.
Then I had a lightbulb moment. My daughter, a GP, gave me Matthew Walker’s book ‘Why we Sleep’, which patients and colleagues said changed their lives. This prompted me to revisit the “human energy system”, now at the forefront of the scientific agenda. This new learning affirmed that:
- 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, and
- fatigue undermines patient safety, workforce productivity, retention, and sustainability.
What struck me was that we are facing a ‘human energy crisis’. The NHS has 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, and I realised that it 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, which was 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 a 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 to 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 health and safety apparatus needs updating.
Change is unlikely without a push from government. I welcome the SOM/University of Warwick cross-disciplinary document and links to the Government’s 10 Year Health Plan with its emphasis on prevention.
System reform has started but is not finished. Do take a look at ‘Fighting Fatigue: Addressing shift work, sleep and the public health burden,’ SOM/University of Warwick document.