Aviation
What is the difference between Fatigue and Tiredness?
Is there a difference between fatigue and tiredness or are they different terms used to describe the same thing?
Lack of sleep and tiredness leads to slower thinking and reaction times, reduced patience and empathy, and makes people less able to cope with high-pressure, high-consequence situations. Crucially, data show it can negatively impact employee and patient safety, and contribute to serious, preventable incidents, or “never events”. 1
Yet unlike in other safety-critical sectors, there is currently no industry-specific legislation on the management of staff fatigue in the UK. Aviation, for example, has long understood the importance of monitoring and managing employee tiredness, and has implemented an approach which extends above and beyond the European Working Time Directive. This has yielded impressive results in terms of improved safety and aircrew wellbeing.
With so many parallels between the two sectors, from the pressures they place on their staff to the wide range of specialised knowledge and equipment needed to “do a safe job”, there is much healthcare can learn from aviation.
It is no secret that healthcare professionals (HCPs) are at high risk of sleepiness and fatigue. They tend to work long, consecutive shifts with few breaks, and follow shift patterns that include nights or early mornings. It all adds up to sleep loss, the need to stay awake for extended periods, and circadian rhythm disruptions.2
Being a healthcare professional has always been tiring, but the current landscape of workforce shortages, ongoing strikes, and post-COVID-19 waiting lists is compounding the problem – a problem that is bad for the health of HCPs and patients alike.
A 2016 review of 38 meta-analyses and 24 systematic reviews found a link between shift work and accidents, Type 2 diabetes, weight gain, coronary heart disease, stroke, and cancer, as well as between insufficient sleep and cardiometabolic diseases and accidents. The paper also highlighted laboratory studies that indicated both shift work and sleep loss increased cardiometabolic stress and cognitive impairment.2 In addition, with tiredness and lack of sleep resulting in lower patience and empathy, slower thinking times and higher irritability,3 they can reduce a person’s ability to deliver safe, effective care.
A Health Services Safety Investigations Body review highlighted staff fatigue and its impact on safe working as a contributor to “never events” in the NHS. A case of retained swabs after childbirth, for example, occurred at a time of “greater fatigue risk”, and 12-hour night shifts “may have been a factor”.1
The risks are not confined to the frontline of care delivery. In August 2015, a specialty trainee in Norfolk and Norwich University Hospital’s Anaesthetic Department, died after the car he was driving collided with a lorry on his way home from work.4 He had just completed a weekend of nights on call in the Critical Care Unit. An inquest was told he had probably fallen asleep at the wheel, after singing to his wife on the phone in an effort to stay awake.5 Anecdotal reports from colleagues suggest that he was aware that he was fatigued and was offered a rest facility in the hospital but declined it due to personal circumstances and that the rest facility was noisy, and colleagues found it difficult to sleep there. It is possible that a combination of high adrenaline levels on shift completion, an overwhelming urge to leave the work environment and a lack of understanding of the physiology of sleep resulted in him not fully appreciating the extent of his fatigue levels.
This fatal accident prompted a survey of trainee anaesthetists in the UK and Ireland, which found 57% had experienced an accident or near miss while driving home from a night shift.6 A similar study of consultants in anaesthesia and paediatric intensive care departments found 43% had fallen asleep while driving. In 39% of the cases, this had happened after a working a long or overnight shift or being on call.7
The potential impact of workplace tiredness and fatigue on HCPs and patients is obvious. What is less obvious is knowing what to do about it. Many of the contributing factors, such as long and night shifts, are ubiquitous across the sector.
Aviation is a fitting parallel. Like healthcare, it is a safety-critical sector, and, like HCPs, pilots and crew work long shifts, often overnight, under high cognitive pressure.
In aviation, just as in healthcare, this can lead to sleepiness, fatigue, and all the associated dangers. Over the last 20 years, investigations have identified it as the probable cause in between 21 and 23% of major aviation accidents.8
Unlike healthcare, however, the aviation industry has enhanced rules and regulations designed to mitigate the risks. In particular training on the causes and consequences of fatigue are mandatory. While they have evolved over the years, they were first introduced back in the 1950s, after a string of fatal accidents were attributed to fatigue.9
International Civil Aviation Organization (ICAO) requires all countries to have fatigue management regulations.10
The European Union Aviation Safety Agency (EASA), for example, mandates “flight duty periods” be limited to 13 hours, or 10 to 11 hours if the employee came on shift at an “unfavourable start time”, i.e. very early or very late and depending on the number of sectors. This is because fatigue is most likely, and most severe, between the hours of 2am and 6am, the so-called “window of circadian low”.11 Airlines must also provide adequate time for eight hours rest, considering commute time, between shifts, as well as “extended recovery rest periods” of 36 hours after seven days of work, and of two days twice a month.11
The ICAO also recommends the use of fatigue risk management systems (FRMS),12 which it defines as a data-driven means of continuously monitoring and managing fatigue-related safety risks. Based on scientific principles and knowledge of sleep and operational experience, such systems aim to ensure “personnel are performing at adequate levels of alertness”.12
In essence, it is a comprehensive approach that comprises ongoing fatigue risk assessment, mitigation strategies, and incident reporting, as well as a commitment to continual improvement. And it’s an approach that works. In a recent poll of FRMS Forum members, 65% of respondents said FRMS had reduced crew fatigue in the previous 10 years.13
Despite multiple studies demonstrating the dangers of fatigue in healthcare, however, equivalent rules in the sector are limited.
Managing fatigue in healthcare is not an easy or a quick fix. Fortunately, we are not starting from scratch.
The Working Time Regulations 1998 and Working Time Regulations (NI) 2016 limit the number of hours an employee can work to 48 a week. They also mandate a minimum 20-minute break when working more than six hours, and an 11-hour rest period between shifts.14
While opt out is possible, the British Medical Association advises against it,15and the Royal College of Nursing is among the professional organisations that recommend against shifts of longer than 12 hours.The Working Time Regulations 1998 and Working Time Regulations (NI) 2016 limit the number of hours an employee can work to 48 a week. They also mandate a minimum 20-minute break when working more than six hours, and an 11-hour rest period between shifts. 14 The realities of working on the frontline of healthcare, however, mean such rules are often bent or broken.
Some trusts have added staff fatigue to their risk registers in recent years. While this is an important first step, if leaders are to effectively manage the problem, they need to take a leaf from aviation’s book.
They could, for example, introduce fatigue reporting, which asks staff to report fatigue-related near misses or mistakes. They could even implement a “call in fatigued” policy, though this will, of course, require protocols to address workforce gaps as and when they arise.
As has been shown in aviation, recording such incidents helps build evidence based on the scale of the problem and the need to manage it. It can also help guide the development of mitigation strategies, and provide the baseline needed to enable continual improvement.
There are many simple mitigation strategies that have proved effective in aviation that could have a similar impact in healthcare.
One is avoiding harmful shift patterns. This involves not mixing day and night shifts, allowing sufficient time in between individual and blocks of shifts for staff to recover, and not viewing the day after a night shift as a “day off”. Refraining from setting shifts of more than 12 hours, which have been linked to an increased risk of safety incidents,16 and ensuring staff take reasonable breaks, are others.
Healthcare leaders can also consider implementing “controlled rest”, as used in aircraft cockpits, by providing or improving facilities for fatigued HCPs to nap during breaks or sleep after a night shift on call before driving home.
A recent paper has recommended that all doctors and nurses should be allowed and encouraged to take a 20-minute power nap during night shifts. It is claimed to help to keep patients and HCPs safe.17
This echoes the NHS Staff Council, which supports the ‘power nap’ as a way of coping with fatigue during a night or long shift,18 and the Royal College of Physicians, which almost twenty years ago described a nap as “a powerful means of staying refreshed, both before and while on duty”.19 What’s more, in terms of mitigating the impact of shiftwork on the health of individuals, napping has also been shown to break the link between working nights and increased body mass index – a risk factor for numerous conditions including cardiovascular disease and Type 2 diabetes.20
Underlying any effective change, however, is the need to raise awareness of the dangers of fatigue among staff. This is particularly important in acute medical disciplines such as anaesthesia, obstetrics, critical care, and emergency medicine.21
Initiatives such as the Joint Fatigue Working Group’s #FightFatigue and the European Patient Safety Foundation Fight Fatigue Together campaigns, as well as the FRMSc’s Healthcare Fatigue Forum are already leading the charge, but there is much more work to be done.
We need to replace the “hero” culture of working long hours with one that accepts that managing fatigue is a staple of quality patient care, and in which people feel safe to report their own and their colleagues’ tiredness.
Change will take time. It will involve education on the causes and consequences of fatigue, and the establishment of processes that embed the principles and objectives of fatigue management into healthcare systems. Yet with one in four UK doctors telling a 2022 survey that their tiredness had affected their ability to safely care for patients,22 there is no time to lose.
Fatigue is a huge problem in healthcare, and, as demand and staff shortages continue to increase, it will only get worse. Tackling it may feel like an insurmountable task, but we have no choice but to take action.
Fortunately, there is much we can learn from sectors that have already completed their journey to effective fatigue management, like aviation. The Chartered Institute of Ergonomics and Human Factors recently published a roadmap for improving fatigue risk management in health and social care that presented the benefits of a collaborative cross-industry approach23.
What is clear is that if we work together and find ways to share best practice and support each other, we can emulate the airline industry’s success, and protect staff and patient safety for years to come.
FRMSc has co-founded the Healthcare Fatigue Forum with Dr Nancy Redfern and Dr Emma Plunkett. The Forum brings together experts and interested parties in the field of healthcare fatigue to learn, develop and implement fatigue risk management in health and social care professions.
To find out more about the Forum and to register to attend the annual Forum meeting in November 2024 then visit https://www.frmsc.com/healthcare
References
Is there a difference between fatigue and tiredness or are they different terms used to describe the same thing?
The recent Batik Air flight that veered off course due to both pilots falling asleep provides a reminder as to the role that personal lives have on fatigue.
The closure of Niger’s airspace earlier this month has further narrowed the corridors available to airline operations. On 7th August 2023, the military junta in Niger announced the closure, citing the possibility of military intervention from neighbouring states.
