A hard-won battle to ‘Fight Fatigue’

In recent years there has been significant attention on the effects of fatigue from night shift working. There is increased recognition that sleep deprivation can affect physical, psychological and emotional well-being. Fatigue can impair decision making, logical reasoning and result in increased risk-taking behaviour [1]. There have also been devastating stories of trainee doctors involved in accidents when driving home after night shifts. This was demonstrated in a study of 2231 trainees that found that more than half had experienced an accident or near-miss in this situation [2].

The Association of Anaesthetists, in collaboration with RCoA and FICM, have produced a wealth of ‘Fight Fatigue’ resources to highlight both individual and organisational responsibilities for safe night shift working [3]. However, there still remain significant systemic barriers to achieving suitable in-shift and post-shift rest facilities. Misgivings remain among some managers about trainee doctors sleeping on their breaks during night shifts. There are increasing financial constraints on Health Boards and Trusts with rest facilities being seen as a luxury, and concerns regarding the equity of such facilities amongst different healthcare professionals.

Fatigue can impair decision making, logical reasoning and result in increased risk-taking behaviour. 

Our campaign started almost 24 months ago when the construction of the £350 million Grange University Hospital in South Wales was nearing completion. This was the first major hospital to be built in Wales for more than two decades. The University Health Board serves a population of approximately 600,000, and employs more than 300 trainee and SAS doctors. In early 2019, we became aware that this new hospital would not have suitable night shift rest facilities for trainee doctors. Early discussions revealed that there was neither funding nor space for these facilities. The absence of suitable rest facilities would have fallen in the Association’s unacceptable ‘Red’ category (Figure 1) [4].

We subsequently wrote a letter to the Executive Board and set up an electronic link for doctors across the Health Board to add their names as co-signatories in support of our campaign. Within days we had gathered over 350 trainee and consultant signatures. During the many months of meetings that subsequently followed, we faced the barrier that construction had started in 2017 and was nearing completion, with most of the site having already been designated in the planning stage that took place years before this. Further difficulties arose when the COVID-19 pandemic hit, as the Health Board decided to open the new hospital six months early.

We sent further formal letters to the Health Board, again gathering signatures from hundreds of trainees and consultants across all specialties. We took this opportunity to re-emphasise guidance and legislation surrounding the need for appropriate rest facilities, as well as communicating the benefits these would have on well-being, safety, retention and recruitment [5]. This collaborative, representative approach was key to our final success. Our campaign was also strengthened by involving a number of other key stakeholders including the Welsh School of Anaesthesia, BMA representatives, local MPs, and the Welsh Government. These stakeholders wrote letters, attended meetings with us, and used their own resources to help support our campaign.

Our successful campaign has managed to achieve the following: 

1. The Health Board commissioned the redevelopment of open plan office space into 22 private rooms, each containing dual function equipment (a bed which converts into a desk for use as office space when not in use as a rest facility; Figure 2). This fulfils the 'Green' rest facility standard [4], but also addresses the issue of optimal agile working space utilisation. 
2. We felt that it was important for rest facilities to be available from the opening of the hospital, especially with the demands of working in the COVID-19 pandemic. After further negotiation, the Health Board agreed to hire 28 sleep pods until the individual rooms were available.

We, along with all the Health Board representatives who were involved, are delighted to have been able to bring this sizeable project to fruition. We are proud to have contributed to the wellbeing and safety of doctors and patients, both present and future, and hope that this will serve as an example for other organisations so that we can continue collectively to support, protect and promote the best asset of the NHS - its workforce.

Amrit Dhadda
ST3 Anaesthetics
Royal Glamorgan Hospital, Llantrisant 

Laura McClelland
Consultant in Anaesthesia & Critical Care
Princess of Wales Hospital, Bridgend 

Tei Sheraton
Consultant in Anaesthesia
Royal Gwent Hospital, Newport 

Twitter: @liberian_girl01

References 

1. Alhola P, Polo-Kantola P. Sleep deprivation: impact on cognitive performance. Neuropsychiatric Disease and Treatment 2007; 3: 553-67. 
2. McClelland L, Holland J, Lomas J-P, Redfern N, Plunkett E. A national survey of the effects of fatigue on trainees in anaesthesia in the UK. Anaesthesia 2017; 72: 1069-77. 
3. Association of Anaesthetists. Fatigue and anaesthetists, 2019. http://dx.doi.org/10.21466/g.FAA.2014 (accessed 31/3/2021). 
4. Association of Anaesthetists. Fatigue resources, 2019. https://anaesthetists.org/Portals/0/PDFs/Wellbeing/Fatigue%20Pack_Scotland. pdf?ver=2020-10-15-133930-043 (accessed 31/3/2021). 
5. British Medical Association. Fatigue and sleep deprivation, 2020. https://www.bma.org.uk/advice/employment/working-hours/fatigue-and-facilities-charter (accessed 31/3/2021).