Author: Amar Mashru / Editor: Charlotte Davies / Codes: CC24, CC4 / Published: 11/06/2019
In 2017 69% (368) of UK Emergency Medicine Trainees surveyed by EMTA felt too tired to safely drive home after a night shift. 57% had an accident or near miss when driving home after nights, with 40% of those surveyed driving on the motorway as part of their commute. 89% believe that work-related fatigue had negatively affected their performance during Emergency Medicine practice or training.
This blog is to convince you why the conversation about our breaks, our sleep and our rest is one to start having, keep having and not stop having. Keep reading. And keep talking.
Staff die driving home from night shifts. We know that fatigue and being awake through the night impacts on concentration, decision making and, perhaps worse still, blunts our insight into the risks those decisions entail – we may not believe we’re taking the risks we are. With that, shift work and poor sleep have short and long term consequences on our own mental and physical health that would be remiss to ignore. Individuals and organisations that fail to respect the innate cycles, powers and limitations of human physiology will always risk failing to mitigate against the impact on staff and patient health of constantly fighting against them.
But this can change. This can change by informing yourself, choosing to watch, maybe modify, your habits and routines, and talking. Talking with each other, your bosses and your wider professional circles, by whatever means you feel most comfortable, and allowing the conversation to trickle up and change the culture around staff care to make extinct unhealthy and unsafe practices so that there is a time we are able to look back on them as perverse historical quirks of a bygone age.
Our individual commitment does not need to be an onerous one or a time consuming one. Moreover you can quickly start enjoying the rewards the empowerment brings. Reflecting on these changes and sharing your messages with colleagues can start to shift the paradigms of normality and expectation around rest and sleep. It does work. We have seen it first hand. But it will not be a passive process.
The story for us starts at the EMTA Conference 2017. Dr Mike Farquhar, who has become synonymous with sleep for all the right reasons(!), presented his now ubiquitous talk on the importance of understanding our sleep physiology and the impact of shift and night work on our health. Mike had the attention of the whole room, followed soon after by their captive engagement during the (urgently extended) Q&A. For the observer, second only to the moment when every person in the room stood in answer to the question whether they knew of a colleague who had committed suicide, it was a notably profound session that struck a chord with all of the trainees and consultants present that day.
This was our lesson number 1: The facts about sleep and rest, when presented, resonate with a truth in us all we find inescapably captivating. It is our physiology. It is how we have evolved and to recognise this is a lightbulb moment we feel almost embarrassed to have failed to acknowledge sooner.
So why wasn’t this being recognised on a system wide scale? Had the conversation already been shut down by the wider powers at play? No. And the College quickly proved that for us. We recognised the profundity and the simplicity of Mike’s message and realising how true it felt to the fears and lives of EM trainees, took the message, in the form of a campaign idea, to the Royal College of Emergency Medicine. And they completely agreed. The clinicians and senior staff who work at the College understood this message wholeheartedly. Perhaps the universality of the campaign, and of Mike’s work, is to confront you with your own health and, ultimately, your own mortality. Perhaps still, it’s because the tagline, “your patients need you rested” feels so irrefutably and emotively valid.
Lesson 2: As individuals we want this situation to be better, for us. As clinicians we want this situation to be better for patients.
In April 2018 the Emergency Medicine Trainees’ Association launched their #RestEM Campaign with the full support of the Royal College of Emergency Medicine. And thanks to the College, printed versions of the posters were sent to every Emergency Department in the country and with it the conversation around staff fatigue, sleep and rest and its inseparable connection to patient care has continued to gain traction and interest; building on the significant work that came before it and helping to place structure around that which has come since.
The premise of the campaign is first and foremost to highlight the importance of the relationship between staff care and patient care. Secondly, to start to give a sense of the sort of changes individuals and organisations can make.
The individual changes need not be drastic, but they must be conscious. If you have not read Mike Farquhar’s advice please stop reading this and check out his resources here. It is for all intents and purposes a list of tips and ideas. Read each one and think about your relationship with it, whether you want to change it and then a plan to work out how. Screens in the form of our smartphones and laptops are a struggle for all of us but, together with a few adjustments to the sleeping environment and routine, may be a big step in improving the quality of our sleep. Within this we start to reflect on how and when we use caffeine, exercise and light and the incoherent messages these send our brain about when it is meant to be alert and when it is allowed to rest. Working shifts, particularly nights, can feel defeating to the concept of routine but it makes it even more important that consideration is given to our sleep, our breaks and our rest and we must allow ourselves that respect for our health.
The system changes, in some regards, are bringing to light contractual and basic obligations and requirements Trusts and Departments already have but are either poorly understood or under-recognised. This includes how frequently and how long breaks should be taken for and the expectations of rest and sleep facilities at work. Ultimately, however, the biggest cultural change required is that which embraces the understanding that our patients need us rested and high functioning staff can deliver high quality patient care.
Perhaps the most interesting push back against the campaign concerned the issue around breaks. In amongst a significant amount of support there were those who were almost annoyed at the advice to take their breaks when there simply aren’t enough staff or isn’t enough time for that to be possible; that a power nap or a rest area whilst on shift were fanciful to the point of frustrating to be considered advice.
Lesson 3: Healthcare is not waiting for the resources to make changes it doesn’t recognise the importance of changing.
CEOs, Clinical Directors, HR do not, in the main unfortunately, have elaborate, drawn-up plans for building staff rest areas, providing hot meals and free healthy snacks, ensuring that clean bedrooms are available post nights and the staff are mentally and physically looked after to best care for themselves and patients. This has not yet become part of the innate expectation of the priority or the standards that need to be met. I hope that very soon this idea reads as outdated but as we stand the conversation hasn’t been allowed to present itself as the staff-centered solution to better patient care. This is why it is absolutely vital that we talk and keep talking about this subject, emphasising its importance until it is allowed to creep into cultural norms and realities about staffing and shift work. Flip the concept of staffing levels on its head. Rather than claim we cannot have breaks until there are more staff, recognise still that until breaks and ergonomic rotas and shifts that truly reflect the intensity of the work and unique challenges of Emergency Medicine are understood, they cannot in themselves be a driver for safe staffing. But without that explicit understanding of the patient safety benefits of staff health, that argument will fail to find itself at the fore.
Rock climbers do not wear their safety gear to help them climb. They wear it in case they fall. Inherent in participation in the activity is the very explicit recognition of risk and of safety. There is a clear appreciation that risks are being taken and to excel and achieve wonderful things within that activity, as ED Doctors do every single day, those risks must be recognised, understood and minimised. Visible risks naturally appear more obvious, hidden risks are easier to keep hidden, ignore and take particular diligence to uncover and address.
Lesson 4: This is the perfect time to cement these concepts into the culture of what it means to be part of the specialty of Emergency Medicine.
Our speciality, in the grand scheme of things, is young. Who we are, what defines us and how we work continue to be evolved, adapted and debated year on year. We are still very much in our infancy and in a prime position to set some key characteristics at the heart of what we stand for. Recognising that providing staff care is a patient safety consideration can be what we do well. It can be the quality other specialities look to us to role model for them. The knife edge of acuity, pressure and stress can be met by an absolute prioritisation of the wellbeing of the staff exposed to those environments and a pride in the way that we choose to protect our patients by protecting ourselves.
There are some fantastic examples around the country of progress and positive change that we will continue to highlight in admiration and optimism. The College continue to work hard to change our standards and expectations of our individual working practices and those of our organisations. A huge thanks to those around the country working so hard to improve this locally and nationally. When you see good examples please share them so that we can all enjoy the inspiration that does surround many of us. But start with yourself, your own behaviours and knowledge, and tell people what has worked for you and let it build slowly from there. The change is palpable. The language must be driven into the everyday, and understanding and innovatively repeating the message is a fantastic first step we can all take and will deliver the difference we want to see.
If you’d like to know more, read all of the links below, or “Why we Sleep“.
Dr Amar Mashru
On behalf of the Emergency Medicine Trainees’ Association