Hours, sleep, teamwork, and stress

For every complex problem there is a simple solution ... and it’s wrong H L Mencken   

Many studies show that the quality of patient care can be severely affected by the stress levels of clinical staff, particularly doctors.¹ We know too that doctors suffer high levels of stress and depression,² more so than other workers.³ Strategies aimed at resolving the working difficulties of British doctors in training have been concerned primarily with the long, often excessive, hours worked. Following tough central directives and hard work by local task forces, many doctors now work fewer hours than five years ago. Has this reduced stress levels—or is there more to be done?

Hours of work are easy to measure and as a strategy of stress reduction reducing them has an attractive logic. However, very little evidence confirms a relation between the number of hours worked and the level of stress or depression experienced.¹ Moreover, other factors cause junior doctors greater stress than hours alone—for example, difficult relationships with senior doctors.⁴ Not surprisingly therefore recent studies show stress levels to be still high,³ training adversely affected, and satisfaction with new shift systems far from positive.⁵

The causes of stress are clearly more complex than this focus on hours implies. Research in other workers suggests that loss of sleep rather than long hours of work is the problem, causing decrements in mood and performance,¹ and this has also been confirmed in doctors.^6–7 The quality of sleep is also important, and evidence shows that this is inferior in those on call, expecting to be woken, who show greater sleepiness the following day.⁸ Thus traditional approaches to the demands of patient care, relying on long periods of on call—and broken sleep—are no longer sustainable.

But the experience of stress is not only a reaction to harmful external influences: stressors are counteracted by positive aspects of work, such as support from colleagues and seniors. Senior doctors often underestimate the impact they have on the working lives of their juniors. For example, the more time consultants dedicate to supervision and training, including feedback and appraisal, the more satisfied junior doctors are with their posts.⁹

We also know that membership of a well functioning team—one with clear team and individual goals, that meets together often, and that values the diverse skills of its members—reduces stress levels and increases performance.¹⁰ The ability to create such a team may not always come naturally, and the white papers’ identification of team leadership skills as part of clinical governance is encouraging.

Thus coherent teamwork is crucial for the delivery of good quality patient care both directly in terms of efficient and effective services, and indirectly via its effects on reducing stress. Apart from their opportunities for support and supervision, teams are micro-organisations that are capable of innovative approaches to making on call commitments both practicable and bearable—perhaps even fulfilling.

Established patterns of working that did well enough when demands were less intense are not appropriate for current health care: new working practices need to respond to changes such as shorter patient stays, increased ambulatory care, and heightened patient expectations. Individual solutions will depend on local circumstances, but there are innovative examples of teamwork patterns that minimise sleep deprivation by looking at the whole context of patient care.¹¹ Most solutions require collaboration between managers, doctors, nurses, and other professions. For example, many of the tasks and questions about patient care at night can and should be done by staff other than doctors.¹² Rotas and on call commitments need to be organised in the context of the daily activity of the team. Outpatient clinics, endoscopy lists, and routine surgery need not be scheduled to coincide with a team’s responsibilities for emergency care. And on call commitments for emergencies should be understood as a 48 hour commitment—the day of and the day after “take.” Moreover, work patterns may need to respond to the experience—or inexperience—of team members: Do consultants, for example, reduce their or their registrars’ clinic lists in order to support the new preregistration house officers in that first week in August?

These solutions are all a matter of good organisational practice. Hospitals have a duty to provide a culture and structure in which good teams can flourish, perhaps using protocols for their management and development in much the same way as they would apply protocols for the management of patient care. Consultants are crucial in this process; they need to appreciate their potential influence— both positive and negative—on stress experienced by doctors in training. But they also need the authority, the skills, and the time to work with other healthcare professionals, including senior nurses, to develop and nurture coherent and functioning multiprofessional clinical teams. Such teams need to be aware of all the responsibilities of a unit and, with knowledge of each other’s work, develop ways of working together and supporting each other. The best ways will vary between hospitals and specialties, and the organisational changes will be more taxing than simply changing rotas to meet new limits on doctors’ hours. But unless the work of doctors is understood in the context of supportive teams, future generations of doctors will be as stressed as their predecessors. The focus on hours has been an important first step, but now it is time to develop more innovative ways to improve the quality of work for doctors and other health professionals—and with it the quality of patient care.