Sleep, fatigue and the workplace

Our sleep cycles are regulated by our internal body clock. Factors such as natural light and darkness influence our sleep cycles, with our body releasing specific hormones to tell us when we should be awake or asleep.

The NHS is there for those who need it night and day. While shift work is therefore necessary, it can negatively affect the sleep patterns of our staff. This can feel very similar to jet lag, which can leave a person feeling lethargic, exhausted and physically uncomfortable. The impact that fatigue has on the health of staff and their ability to care for patients is significant and must be acknowledged.

A good sleep routine and habits are much more difficult to achieve with shift work. Regular breaks during shifts, especially night shifts, and days off work are essential for keeping staff mentally and physically well. This should not be seen as a luxury, but an essential part of delivering safe and efficient patient care. 

“Rest and breaks are essential to combat fatigue. Airports close runways rather than allow air traffic controllers to work without breaks, because anything less is simply not safe. The NHS’ runways must always stay open - but that means we must think even more about how we support our staff to do so safely.” Dr Michael Farquhar, consultant in children’s sleep medicine at Evelina London Children's Hospital 

Power naps can be a useful skill for staff to develop. Research undertaken by NASA looking at how to reduce the impact of fatigue, demonstrated improvements in performance of about 34 per cent and alertness by 54 per cent following an in-shift power nap. Spaces that allow for undisturbed rest or power naps can therefore be an effective way to reduce fatigue.

These power nap tips are suggested by Dr Michael Farquhar:

• For a good nap, there needs to be a quiet, dark, comfortable space where sleep is possible.
• A comfy reclining chair or a camping mat can work, though it does need to be a space away from the noise and activity of the ward/work area.
• The discipline of simply lying back, shutting your eyes and relaxing in the quiet for 15 to 20 minutes has its own benefit. The trick is not to worry about whether you fall asleep or not - if it happens, it happens.
• Practicing techniques like mindfulness or breathing exercises can help, both to encourage sleep, but also to help to relax. Don’t forget to set an alarm, or ask a colleague, to wake you though!
• If you drink caffeinated drinks through the night, another useful trick is to take a shot of caffeine just as you put your head down to nap. Caffeine takes about 15 to 20 minutes to kick in - which means as you wake at the end of your nap, you get a double boost from both the sleep and the caffeine.

The levels of fatigue experienced after a night shift can produce similar effects to driving at the legal alcohol limit, increasing the risk of road traffic accidents. Offering staff, a place to rest if they need to before driving or cycling home is therefore critical to ensure their safety after a shift. The NHS Staff Council’s Health, Safety and Wellbeing Group (HSWG) have developed an infographic containing key facts and statistics that highlight the importance of supporting shift workers in your organisation.  

The NHS is the biggest employer in Europe, collectively employing over 1.3 million staff across a diverse number of job roles and professions.

NHS staff are employed on a variety of working practices and patterns, which can be demanding and tiring. Factors such as workforce issues and rota gaps can add further challenges, with badly designed shift patterns also having a negative impact in staff health. This can increase sickness absence rates, presenteeism, increased errors at work and patient safety incidents.

It is generally acknowledged that staff are the NHS greatest and most valuable assets, and evidence links healthy, valued staff to better patient outcomes. The NHS is committed to promoting staff health, safety and wellbeing, with the NHS People Plan calling for organisations to have safe spaces for staff to rest and recuperate.

However, lack of access to basic wellbeing needs such as hydration and sleep have been identified as a major concern for NHS staff wellbeing and patient safety. In a magazine article by the Royal College of Paediatrics and Child Health, they say we must emphasise the basics, such as regular rest and breaks within shifts, and meaningful time away from work to recharge. Looking after our staff is a key professional responsibility, and individuals should not be made to feel guilty for taking time to look after themselves. If we don’t look after our staff now, many more will become ill and leave the profession.

Our back to basics for a healthy working environment infographic includes statistics and key facts about the impact of hydration, nutrition, sleep, and regular breaks on workforce wellbeing.

Our supporting the wellbeing needs of NHS staff guidance supports NHS health and wellbeing leads and managers to prioritise and fulfil staff wellbeing needs.

The NHS Staff Council’s Health, Safety and Wellbeing Group (HSWG) has developed guidance to support NHS organisations to improve their provision of staff welfare facilities.

Working on getting a good night’s sleep is an important part of individual responsibility. Achieving this requires good sleep routines, environments and habits that we can all put in place, such as exercising, a good diet, and limiting exposure to electronics, social media or the news before bed.

Incorporating time to relax and unwind into daily routines can also help reduce the effects of stress. Finding helpful strategies and techniques is essential, with apps such as Headspace and Unmind being fantastic tools to help manage our own health and wellbeing. Headspace is currently free to access for NHS staff until 31st March 2024, and free access to Unmind has been extended until 31st December 2024.

General tips on improving sleep

Acknowledging and managing the causes and developing healthy habits at bedtime is much more helpful to get a good night’s sleep. Here are a few tips to share with staff in order to help them improve their sleep:

• develop a consistent routine for bedtime and wake time
• use your preferred relaxation techniques, particularly in the last hour before bed
• before bedtime, write a to-do list for tomorrow to get things out of your head
• reduce your use of electronic screen devices in the hour before bedtime and remove screens from your bedroom
• make your bedroom as quiet, dark and comfortable as possible
• get as much natural light exposure as possible, especially first thing in the morning, to keep your body clock ‘in sync’
• stick to a regular exercise routine as much as possible
• eat regular, healthy meals, and stay hydrated
• limit the use of caffeine and alcohol, especially closer to bedtime.

There are many other factors that can impact on our quality and quantity of sleep. Mental health can play a big part in our ability to switch off at night. Societal factors such as the after-effects of COVID-19 pandemic or increased worries caused by current the cost-of-living crisis, can impact negatively on our mental health and wellbeing.  

Health factors can also cause us not to sleep well, such as the effects of long COVID or symptoms of the menopause. Our web page on supporting recovery after long COVID includes information on how we can best support affected staff. Our menopause and the workplace page offers information on how menopause can affect staff and practical guidance for employers on how to improve the workplace.

Walsall Healthcare NHS Trust

For National Sleep Day on 18 March 2022, the trust undertook a Take a Break campaign to combine their events with European Working Time Directives for night workers, whereby staff were offered an annual health assessment.

For the campaign, the trust's health and wellbeing team visited every department in the hospital and the community during the night shift, over the course of a week, with drinks and treats to chat to staff about:

• the importance of taking a break, and to promote the rest areas in the trust, including the sleep pods
• how staff could access free health assessments with occupational health
• top tips to improve sleep
• advice on driving home from work after a night shift
• links to webinars and information on how to get better sleep and sleep hygiene
• promotion of the whole health and wellbeing offer available to staff
• recruitment of health and wellbeing champions.

The trust also offers a free beverage area run by volunteers, called the manor lounge. During the event, this area was opened for the first time at night so that staff could access free hot drinks during the night shift.

Herefordshire and Worcestershire Health and Care NHS Trust

The trust ran ’The Great Sleep Challenge’ for their staff. The challenge consisted of a one-hour workshop, where staff were asked to share some of the issues they were having with sleep. It also included an education piece on tips and techniques to try and help promote better sleep, and staff then completed a template with information such as how many hours of sleep they normally get on average.

Attendees of the workshop were also given a guided relaxation that they could listen to, called The Gated Meadow, designed by Clare Knighton, a training and development officer at the trust.

Over the course of the week, the staff was then asked to try some of the tips and techniques shared during the workshop, record them on a diary sheet, and meet up virtually at the end of the week to discuss the results.

Whilst the challenge was initially set out with the aim of working out the extra hours of sleep people were able to achieve, the real value was seen in all the different ways staff were able to implement the sleeping techniques, and the effects it had on their wellbeing.

• Our back to basics for a healthy working environment infographic includes statistics and key facts about the impact of hydration, nutrition, sleep, and regular breaks on workforce wellbeing.
• Sleep and Recovery Toolkit - Business in the community.
• Fifteen-minute consultation: problems in the healthy paediatrician - managing the effects of shift work on your health - Dr M. Farquhar.
• For nature cannot be fooled. Why we need to talk about fatigue - Dr M. Farquhar.
• Managing the effects of shift work on health - guidance published by the Institution of Occupational Safety and Health (IOSH).
• Sleep, breaks and wellbeing for health professionals - Dr M. Farquhar.
• Sleep In The Time of COVID-19: Advice for NHS Staff - Dr M. Farquhar.
• Supporting the wellbeing needs of NHS staff - guidance to support NHS health and wellbeing leads and managers to prioritise and fulfil staff wellbeing needs.
• Supporting the wellbeing of shift workers in healthcare - guidance produced by the NHS Staff Council's Health, Safety and Wellbeing Group.
• What might best practice look like for managing good sleep practice for night workers at work? - guidance from The Society of Occupational Medicine.
• Why do we need sleep? - article from the Sleep Foundation covering the science behind sleep, how much sleep we need and the importance of getting enough sleep.
• The effect of resistance exercise on sleep - study looking at the acute and chronic effects of resistance exercise on sleep quantity and quality.
• Fatigue risk management for health and social care - research paper on improving fatigue risk management in health and social care to improve patient safety and health workers' health and wellbeing.