A national survey of the effects of fatigue on trainees in anaesthesia in the UK

Authors


  • Presented in part at the AAGBI Linkmen Conference, Birmingham, UK, September 2016, and the Group of Anaesthetists in Training, Cardiff, UK, July 2017.
  • This article is accompanied by an editorial by Farquhar, Anaesthesia 2017; 72: 1055–8.
  • You can respond to this article at http://www.anaesthesiacorrespondence.com

Summary

Long daytime and overnight shifts remain a major feature of working life for trainees in anaesthesia. Over the past 10 years, there has been an increase in awareness and understanding of the potential effects of fatigue on both the doctor and the patient. The Working Time Regulations (1998) implemented the European Working Time Directive into UK law, and in August 2009 it was applied to junior doctors, reducing the maximum hours worked from an average of 56 per week to 48. Despite this, there is evidence that problems with inadequate rest and fatigue persist. There is no official guidance regarding provision of a minimum standard of rest facilities for doctors in the National Health Service, and the way in which rest is achieved by trainee anaesthetists during their on-call shift depends on rota staffing and workload. We conducted a national survey to assess the incidence and effects of fatigue among the 3772 anaesthetists in training within the UK. We achieved a response rate of 59% (2231/3772 responses), with data from 100% of NHS trusts. Fatigue remains prevalent among junior anaesthetists, with reports that it has effects on physical health (73.6% [95%CI 71.8–75.5]), psychological wellbeing (71.2% [69.2–73.1]) and personal relationships (67.9% [65.9–70.0]). The most problematic factor remains night shift work, with many respondents commenting on the absence of breaks, inadequate rest facilities and 57.0% (55.0–59.1) stating they had experienced an accident or near-miss when travelling home from night shifts. We discuss potential explanations for the results, and present a plan to address the issues raised by this survey, aiming to change the culture around fatigue for the better.

Introduction

The working patterns of doctors have changed significantly since the European Working Time Directive was introduced in 2009 [1]. Although recognition and understanding of fatigue in the workplace has evolved in recent years, the potentially devastating effects of inadequate rest are still seen, suggesting that doctors continue to experience considerable work-related tiredness [2]. Much of our understanding of fatigue derives from studies in aviation. A detailed definition refers not only to airline crews, but can also be applied to anaesthetists: “Fatigue is defined as a physiological state of reduced mental or physical performance capability resulting from sleep loss or extended wakefulness, circadian phase, or workload (mental and/or physical activity) that can impair a crew member's alertness and ability to safely operate an aircraft or perform safety-related duties” [3].

Work outside normal office hours forms a significant portion of any trainee anaesthetist's contracted duties [4]. Weekday work in office hours may be just as intense, but there are usually more doctors in the hospital with whom to share tasks, and thus ensure that rest breaks can be taken. The guidance relating to doctors’ rest entitlements during a period of work are laid out by the New Deal agreement for junior doctors, and state that ‘natural breaks of thirty uninterrupted minutes after every four hours worked should be taken’ [5]. For those undertaking partial shifts and out-of-hours work, actual rest breaks of the same duration are required in addition to natural breaks. These should also be uninterrupted, but can be taken at any time and the New Deal guidance expects that there will be appropriate cover at all times to support this [5]. The 2016 Junior Doctor Contract stipulates that breaks should be reduced to 30 minutes for every 5 hours worked, and another 30 minutes for a shift lasting for more than 9 hours. A total of four long day or night shifts of a maximum of 13 hours’ duration is permitted within 1 week [6]. Failure to achieve these breaks in their intended form may result in fatigue [7]. Fatigue and sleep deprivation result in deterioration of cognitive and psychomotor skills [8]. Impairment of cognitive function after approximately 18 hours without sleep has been shown to be comparable to individuals with a blood alcohol concentration of 0.05% [9], which is the drink driving limit in Scotland [10]. This level of fatigue may result in poor performance and may contribute to errors [11]. Indeed, in New Zealand, 80% of respondents to a survey of anaesthetists reported making a fatigue-related error [12]. According to a survey of shift workers in America conducted by the National Sleep Foundation, shift workers are more likely to drive when fatigued, and twice as likely to fall asleep at the wheel compared with non-shift workers [13].

A recent finding of the National Sleep Foundation Drowsy Driving Consensus Working Group confirms that people who have slept for less than two hours within the past 24 are unfit to drive a motor vehicle [14]. Doctors may soon be faced with the need to seek alternatives to driving after night shifts, as awareness of the dangers of fatigued driving increases [15]. For doctors in many areas, there are no public transport options that coincide with shift patterns, and the cost of using taxi services may be prohibitive. It is worth considering the specifications of the new UK junior doctor contract which states that; “where a doctor advises an employer that the doctor feels…. unable to travel home due to tiredness, the employer must, where possible, provide an appropriate rest facility where the doctor can sleep… Where the provision of an appropriate rest facility is not possible the employer must make sure that alternative arrangements are in place for the doctor's safe travel home” [16].

We conducted a national survey to assess the impact of fatigue reported by trainees in anaesthesia in the UK, and to enhance our understanding of factors that may exacerbate the problem.

Methods

We designed an anonymous survey with 22 closed (drop-down menus) and open (free-text entry) questions. These explored the degree to which respondents were affected by fatigue, how frequently this occurred, the adequacy of rest breaks, whether rest facilities were available in their hospital, and any factors that influenced decision-making around the self-management of fatigue. We also sought information about clinical experience when fatigued, and asked about road traffic accidents and near misses. Although the survey was anonymous, respondents were invited to provide their contact details in the free-text section to allow for clarification of free-text comments.

In February 2016, the survey was sent to anaesthesia trainees in Wales. The response rate was high, and early trends indicated concerning levels of fatigue in the trainee population, prompting us to extend data collection to Scotland, Northern Ireland and England from May 2016. Data collection ceased at the end of December 2016. Paper copies of the survey were used for the initial phase of data collection in Wales, but we converted this to an online survey for ease of dissemination. We emailed individual anaesthetic departments and Schools of Anaesthesia with a link to the questions. Frequent postings on social media led to a steady increase in response rate. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) and the Royal College of Anaesthetists (RCoA) assisted in publicising the survey, with web links in their member communications and by discussing the survey at relevant events.

Several sources were considered for determination of the denominator (the total number of trainees working in anaesthetic training posts in the UK in 2016). These included the RCoA census, RCoA e-portfolio and the GMC National Training Survey (NTS), of which the latter was decided to be the most accurate data source available [17]. The denominator number was obtained via correspondence with the RCoA and verified using the GMC National Training Survey (NTS) reporting tool.

Results

A total of 2231 responses were received. Of these, 38 respondents described themselves as ‘other’ or ‘consultant’, nine gave no answer to this question, and 14 stated that they were on maternity leave or working overseas. These were discounted, which left 2170 trainee responses.

The number of anaesthetic trainees who received the GMC NTS was 3772 (information from the RCoA), giving an estimated return rate of 57.5%. If ACCS trainees, trainees on maternity or sick leave and those out of programme are included, the denominator increases to 4323. It is likely that many of these groups would not have completed the survey, and we therefore interrogated the GMC NTS reporting system to determine the number of trainees that were actually working in UK training posts in 2016. From this, the number of trainees with anaesthesia as a parent specialty was 3810; those working in an anaesthesia post was 3656, and if this were extended to include Intensive Care Medicine it rises to 4051. We believe that the initially quoted number is a reasonable estimate and have used this for the calculated response rate, but it is possible that this ranges from 3656 to 4323. The true response rate therefore lies between 50% and 60%.

There were replies from all 28 Schools of Anaesthesia (Table 1). However, due to the difficulties described above, it has not been possible to obtain data for the total number of trainees in each School of Anaesthesia. There were replies from 225 (88.6%) of the hospitals listed as having College Tutors on the RCoA website. There was a balanced response from all training grades (Table 2).

Table 1. Number of responses from individual Schools of Anaesthesia
 No. responses
Wales189
Kent Surrey Sussex155
West of Scotland142
North-west117
South-west106
Yorkshire Humber W94
Barts and the London93
Birmingham87
North86
Central London83
East of England82
Yorkshire Humber S82
Stoke on Trent75
Wessex73
Mersey69
Northern Ireland68
Not clearly stated60
Nottingham East Midlands58
South-east Scotland56
Bristol54
South-east London54
Warwickshire52
Imperial51
Yorkshire Humber NE44
South41
Oxford35
St Georges26
Tayside22
North of Scotland16
Table 2. Responses according to training grade. Values are number (proportion)
Current training level 
CT1–2712 (32.8%)
ST3–4616 (28.3%)
ST5–7842 (38.8%)
Total2170

Table 3 and Fig. 1a–c show data regarding work commutes. The average distance commuted one-way was 17.8 miles (95%CI 17.1–18.5). This varied between Schools of Anaesthesia, ranging from 3.6 (1.6–5.6) in the north of Scotland, to 33.5 (26.8–40.2) in Yorkshire and Humber and the north-east of England. More than three quarters of trainees use a car or motorcycle to get to work, with nearly half using the motorway as part of their commute; for those who use the motorway, the average commute is 26.9 miles (25.8–28.0). Trainees from the London Schools of Anaesthesia are the only group who used public transport more frequently than their own vehicle, although their travel times are generally in excess of 30 minutes. Of all trainees, 59.7% (57.6–61.7) travelled for longer than 30 minutes on their journey home after a night shift.

Table 3. Travel questions. Values are number (proportion [95% CI])
  
Do you use the motorway during your commute? 
Yes983 (45.5 [43.4–47.6%])
No1178 (54.5 [52.4–56.6%])
How long does your commute usually take after a night shift?
< 15 minutes260 (12.1 [10.6–13.4%])
15–30 minutes609 (28.2 [26.3–30.1%])
30–60 minutes898 (41.4 [39.5–43.6%])
> 60 minutes394 (18.3 [16.6–19.9%])
Figure 1.

(a) How do you travel? Blue – all responses, red – London schools only. (b) Do you ever feel too tired to drive home after a night shift (% response)? Blue – yes, red – no. (c) Have you ever had an accident/near miss when driving home after a night shift? Percentage response, blue = yes, red = no. green = prefer not to say.

Of all respondents, 84.2% (82.7–85.7%) of respondents stated that they had felt too tired to drive home after a night shift, and 57% (55.0–59.1%) had experienced an accident or near miss when driving home after a night shift. In the free-text option, many talked about falling asleep at the wheel and ‘microsleeps’. Being woken by rumble strips was a recurrently cited event. Individuals also described accidents from minor bumps and scrapes, to significant incidents resulting in their car being written off by insurers. Adverse events were not only reported by motor vehicle users. There were also multiple reports of such events amongst walkers and cyclists.

We examined the availability of rest facilities for trainees (Table 4). Only 31.9% (30.0–33.9%) of trainees were aware of the existence of rest facilities where they could sleep after a night shift. Only 16.8% (15.1–18.5%) of respondents had ever used such a room to sleep after a shift. Reasons given included ‘just wanting to get home’, or the unsuitability and lack of accessibility of facilities. Trainees in some areas are required to pay for these rooms (10.7% [9.2–12.2%]). Ninety-seven trainees gave specific costs, with a range between £5 and £65 per shift. Some reported having to pay a rate for two nights because they required the room from the morning into the evening.

Table 4. Responses relating specifically to rest facilities. Values are number (proportion [95%CI])
 Response
Do post-shift rest facilities exist within your hospital (‘sleep off room’)?
Yes693 (31.9% [30.0–33.9%])
No932 (43.0% [40.1–45.1%])
Don't know544 (25.1% [23.3–27.0%])
If they exist, how easily accessible are these facilities (‘sleep off room’)?
Very easy160 (9.9% [8.4–11.3%])
Easy231 (14.3% [12.6–16.0%])
Some effort171 (10.5% [9.1–12.0%])
Difficult108 (6.7% [5.5–7.9%])
Very difficult77 (4.8% [3.7–5.8%])
Don't know874 (53.9% [51.5–56.3%])
Have you ever used such facilities (sleep off room)?
Yes320 (16.8% [15.1–18.5%])
No1585 (83.2% [81.5–84.9%])
If not, why not? (Select all that apply)
I prefer just to get home927 (65.1% [62.6–67.6%])
The facilities are unsuitable197 (13.8% [12.0–15.6%])
I have never felt the need146 (10.3% [8.7–11.9%])
Other478 (33.6% [31.1–36.0%])
Do you have to pay for post-night shift rest facilities?
Yes187 (10.7% [9.2–12.2%])
No574 (33.0% [30.7–35.2%])
Don't know981 (56.3% [54.0–58.6%])
Do you have accessible and adequate rest facilities available during your shift (i.e. private area with bedding/comfortable chair)?
Yes1387 (64.4% [62.3–66.4%])
No739 (34.3% [32.3–36.3%])
Don't know29 (1.3% [0.8–1.8%])

Overnight facilities appear to be better, but there were still 739 respondents (34.3% [32.3–36.3%]) who stated that they did not have access to adequate rest facilities (bedroom/private area with bed or comfortable chair) during a shift.

Sleep around the time of, and during night shifts is explored in Table 5. Most trainees are not getting regular periods of uninterrupted sleep at work overnight, and less than a quarter stated that they could then sleep ‘well’ or ‘very well’ in between shifts. Of all respondents, 87.9% (86.3–89.4%) use caffeine as a stimulant to mitigate the effects of fatigue (Fig. 2). Additional substances are used by some to attenuate the impact of sleep disruption.

Table 5. Rest quality both on and off shift. Values are number (proportion [95%CI])
 Response
How often do you sleep for at least 30 minutes uninterrupted during a night shift?
Most shifts396 (18.3% [16.7–20.0%])
About half611 (28.3% [26.4–30.2%])
Less than half787 (36.5% [34.4–38.5%])
Never365 (16.9% [15.3–18.5%])
Whilst on a set of nights, how well are you able to sleep in between shifts?
Very well105 (4.9% [4.0–5.8%])
Well380 (17.6% [16.0–19.2%])
I get by945 (43.9% [41.7–45.9%])
Poorly643 (29.8% [27.9–31.8%])
Barely at all83 (3.8% [3.0–4.7%])
Figure 2.

Do you use other substances in order to sleep/remain awake around the time of night shifts? Error bars are 95%CI.

Finally, the survey looked at the subjective effects of work-related fatigue. Most respondents described a negative impact across a broad range of areas (Fig. 3).

Figure 3.

Perceived effects of fatigue on the individual. Do you believe that work-related fatigue has negatively impacted any of the following areas? Error bars are 95%CI.

Discussion

Our survey presents a worrying picture of both the frequency and effects of fatigue among UK anaesthesia trainees. High numbers of trainees cite fatigue as a cause of suboptimal physical health, deterioration in psychological wellbeing, impairment of ability to carry out essential elements of training, including examinations, audit and quality improvement projects. Additionally, over two-thirds of respondents stated that personal relationships were adversely affected by fatigue, yet only just over half recognised that ability to do their job was affected. This gives an important insight into how UK trainees perceive a factor that affects their ability to carry out a role. It could be suggested that good physical and emotional health, good quality interpersonal relationships and the capacity to undertake academic work are the main foundations that enable a trainee to thrive. High numbers of trainees report using caffeine-based stimulants in order to preserve mental alertness when fatigued, and some resort to the use of either alcohol, or sedatives (over-the-counter or prescribed) to induce sleep.

The opportunity to rest for adequate periods in a suitable environment whilst on a night shift is lacking for many of those surveyed. This is likely to result in fatigue, deterioration in cognitive function and poor performance [11, 16]. We arbitrarily described adequacy of such facilities as ‘a quiet room with a bed or comfy chair’, but no formal minimum standard exists, and thus, the answer to this question relies on individual interpretation of an undefined standard. A disturbing number of respondents reported involvement in some kind of accident or near miss when travelling home after a night shift. The indisputable threat that this poses to the safety of trainees and also the public is huge. There are likely to be more stringent repercussions for those who are caught driving when fatigued in the future [18]. The time taken for anaesthetic trainees to commute to and from work is likely to be higher than for permanent employees, due to the need to rotate to different hospitals as part of training. Whilst there were no significant variations in length of commute between Schools of Anaesthesia, there may be a need to pay attention to the organisation of rotations in the future to minimise frequent lengthy commutes. Hospitals and trainees should also be encouraged to recognise that commute times will impact negatively on the total rest time between shifts.

Surprisingly, the survey revealed that a significant proportion of trainees either did not know if post-shift rest facilities were available to them or consciously chose not to use them. Many said that this was due to facilities only being available for a short period, feeling that short rests compounded overall fatigue and sleep disturbance. This does not explain the widespread reluctance to use the post-shift facilities, and while the survey did not fully investigate the reasons for this, a frequent free-text response stated a desire to ‘just get home’. This highlights a need to both ensure proper rest opportunities whilst on shift, and education about individual personal responsibility to optimise rest before, during and after a night shift, so-called ‘good sleep hygiene’.

The free-text comments included insightful information regarding specific situations. They reflect how important hospital size and the number of rota tiers are to the workloads and rest opportunities of trainees and on-call consultants alike. Multiple examples were provided of nursing staff objecting to doctors resting on shift, and in some instances intentionally disturbing them. This may indicate a cultural issue in some hospitals, potentially caused by difficult regulations surrounding on-shift rest breaks for nursing staff with deferral to ‘the employer’ regarding the possibility of leaving the clinical area during a break [19-21]. It is unclear why this cultural attitude which discourages overnight rest whilst on shift has evolved, but it is likely that the introduction of the European Working Time Directive and Hospital at Night initiative have influenced this significantly over the past 10 years. Since the abolition of 24-h resident on calls, rest facilities have been slowly removed from hospitals.

We have identified some limitations of the survey. The response rate for a national survey was encouraging, but there were a large number of trainees who did not respond, and so conclusions must be interpreted with due caution. However, even if all non-responders answered the same way as the minority of respondents, the scale of the problem lessens but remains significant. For example, if all non-responders had never felt too tired to drive home, the proportion who had felt too tired to drive would reduce to 48.0% (1811/3772). Similarly, the proportion who have had a road traffic accident or near miss would be 32.6% (1229/3772). These remain substantial proportions. Other elements of the survey asked questions regarding the accessibility of rest facilities and ability to take rest breaks. Given the spread of responses from all Schools of Anaesthesia and almost every hospital, it is likely that the sample of responses captures the majority of on-call rotas worked by trainee anaesthetists.

Regarding limitations of the survey questions, a drop-down menu of trusts should have been made available, rather than requiring these details to be entered as free text. It would have been useful to obtain data regarding the nature of overnight work and to investigate the possibility of partial bleep-filtering systems in certain settings. The survey did not include questions about trainees conducting anaesthesia whilst fatigued because it was felt that respondents may fear medico-legal repercussions, both individually and for their organisation. The survey should have encouraged respondents to add free-text comments regarding their reluctance to use post-shift rest facilities. The numbers reveal a low uptake of these services where facilities exist, although the reasons for this are still not clear.

A number of respondents have objected to the fact that non-training grade doctors were excluded from the survey. We accept that similar problems affect this group, but due to the difficulty in obtaining an accurate number of individuals in non-training posts, it was not deemed possible to achieve a denominator, and hence to provide reliable statistics. We believe that the changes generated by the ongoing fatigue work will also directly benefit non-training grade anaesthetists on resident shift rotas.

The consequences of fatigue on the safety of doctors, patients and the general public can no longer be ignored. A multi-pronged approach to detection, education and prevention is required, to drive forward cultural and organisational changes necessary to promote good sleep hygiene in the National Health Service.

In part as a result of this survey, a ‘Fatigue Group’ has been established in association with the AAGBI, its trainee arm (the Group of Anaesthetists in Training, GAT) and the RCoA. The group's projects include establishing a traffic-light grading system for rest facilities and cultural attitudes toward fatigue in hospitals, with a view to highlighting the best, and empowering those working in trusts where there is little progress to advocate changes. Similarly, responsibilities for individual doctors will be defined. A comprehensive induction ‘Fatigue Education Package’ will be piloted in Wales in the near future. This contains short videos, infographics, local rest facility information, fatigue monitoring tools and a downloadable relaxation audio specifically designed for doctors. Specific tools are being created to help guide hospitals improve rest facilities and make workers aware of the risks of fatigue. Proforma documents have been designed, outlining the specific information that Trusts are required to give to trainees about how to access both on-shift and post-shift rest facilities. It is hoped that by adopting this approach, individual hospitals will be strongly encouraged to address the issues of fatigue and provide rest facilities as this becomes the norm. Those slower to adapt should make the same cultural and organisational changes to catch up.

A large amount of the work of anaesthetists is unpredictable and delivered out of hours. Shifts can be very busy, and the sheer volume of work combined with caring for very sick patients may make it impossible for an individual to take essential rest breaks during a night shift. The structure of rotas varies widely between hospitals depending on size, services offered, number of allocated trainees and rota gaps. The free-text responses highlighted the fact that incessant bleeps and lack of cross cover can sometimes make it impossible to take proper breaks.

To ensure that each doctor on shift takes recommended breaks, other specialties have introduced bleep-filtering services in some hospitals, and these are reported to prevent interruptions during rest periods. The nature of anaesthetists’ work would restrict the implementation of a full bleep screening strategy, but adaptations of this policy may have potential benefits. It is important that the team covering each night shift work ensures that each team member takes breaks. This is the subject of a trust-wide campaign recently launched at Guy's and St Thomas’ NHS Trust [22].

Action is needed on three levels if we are to address the impact of fatigue on individual doctors and on the quality and safety of the care they deliver. We can draw on the extensive experience of the aviation, rail and petrochemical industries to guide strategies within healthcare [3]. Organisations should have a strategy to minimise the likelihood of its employees becoming excessively tired at work, with good rota planning, appropriate staffing levels, and rest facilities where staff can lie flat in a dark environment, both during a break and following a shift [23]. Individual doctors should understand the impact of fatigue, practice good sleep hygiene and take appropriate action if they are becoming excessively fatigued [24]. The teams in which we work must identify any team member who is critically tired and having microsleeps, remove them from the working environment, support them in getting appropriate rest and ensure they do not drive until they have rested.

Making good sleep hygiene the norm amongst trainees in anaesthesia will be challenging for individual trusts and practitioners alike. We hope that by highlighting the nature of the problem of fatigue, and firmly supporting doctors and managers to shape progress, a solid platform for innovation and a shift in attitude will be created.

Acknowledgements

Dr Roopa McCrossan has contributed to the qualitative analysis of survey data. Dr Paul Clyburn provided guidance and support during the conduct of the survey. Dr Mike Farquhar provided education tools and advice regarding rest optimisation. The following people assisted in the data collection process: Dr Sally El-Ghazali, Dr Louise Burton, Dr Brigitte Baxter, Dr Laura Dyal, Dr Elizabeth Killick, Dr Stewart Prestwich, Dr Maxene Murdoch, Dr James Knock, Dr Karen Pearson. No external funding or competing interests declared.