Working overtime

In May, the findings of the Whitehall II study suggested that working 3-4 hours overtime per day can adversely affect coronary health, leading to an increased risk of coronary heart disease. This is just one of the many claims that have been made about the effects of fatigue on people who work long hours.
   
It’s long been understood that working long hours and taking too few breaks can impair judgement, increase stress and lead to physical and mental illness. But for some people – such as those who work in the healthcare industry, where it’s essential to provide round-the-clock care – it might seem as if long hours and overtime are unavoidable.
   
It might not seem much, now and again, to take on extra overtime – especially when healthcare facilities are short of staff, patients need caring for and a little extra money would be handy for staff. But without proper rest, healthcare workers run the risk of lapses in attention, impaired decision-making, and delayed reaction times. Indeed, the Healthcare Workforce portal points to research by the University of Warwick in conjunction with Coventry and Warwick Hospitals NHS Foundation Trust, which found that “less tired doctors make fewer errors in the care they give to patients and that their pattern of working, along with the number of hours which they work each week, make a significant contribution to improved health and safety for both patients and doctors”.
  
It is, however, possible to manage working hours and shift patterns to make sure staff, as well as patients, go home healthy and well. Regulations are now in place to safeguard employees in all sectors, and the healthcare industry is continuing its efforts to improve the working patterns of shift workers and help to safeguard their health.

REGULATIONS
The European Working Time Directive (EWTD) has been part of UK law since October 1998, implemented with an opt-out clause under the Working Time Regulations 1998. The regulations set minimum requirements for working hours, rest periods and annual leave. The goal of the directive is to safeguard workers’ health and safety by ensuring that every employee gets adequate rest and breaks.

Generally, the Working Time Regulations entitle employees to:
• 11 hours continuous rest in every 24 hours
• 24 hours continuous rest in a seven day period, or 48 hours in 14 days
• an average working week of no more than 48 hours
• a 20-minute break in every six-hour work period
• four weeks annual leave.

If employees work night shifts, they shouldn’t work more than an average of eight hours in a 24-hour period, averaged over seven weeks. They must also be offered a free health assessment before they start working at nights, and on a regular basis after that.
   
If a rest break has to be interrupted or delayed to ensure continuity of care, then the employee must compensate for that by taking a break immediately after the end of the working period.
   
The Health and Safety Executive (HSE) is responsible for enforcing the maximum weekly working time limit, the night working limits, and health assessments for night work, but not for enforcing time off, rest break entitlements or paid annual leave entitlements.
   
The NHS implemented the regulations in a phased programme that was completed in 2009. Junior doctors in training were the last group to have their working week reduced to 48 hours. This happened in incremental stages that saw their weekly hours reduced to 58 hours in 2004, then gradually to 48 hours by August 2009.

CREATING EFFICIENCIES
The directive hasn’t gone unchallenged in the healthcare sector. Junior doctors, for example, have raised concerns that an enforced 48-hour week might compromise their training. This has led to a range of projects within the NHS, including one at the Avon and Wiltshire Mental Health Partnership NHS Trust, which features in a case study on the Healthcare Workforce portal.
   
Seeking to ensure that junior doctors would be able to meet the requirements of the Working Time Regulations, the trust analysed and changed its way of working, improving the efficiency of patient services along the way.
   
“We carried out an audit of all the calls that junior doctors were expected to answer,” said consultant psychiatrist and director of new ways of working Christine Vize in the case study. “We looked at our protocols and our triage systems to make sure that doctors would not be called out spuriously, and we audited their activity both during the day and at night.”
   
The trust found that junior doctors were being called out unnecessarily, and realised that new ways of working – such as allowing nurses to administer some medications – would improve the quality and timeliness of interventions.
   
“Ultimately, one of the main things we learnt from the project was that junior doctors’ time could be used more efficiently,” said Vise. “We have taken steps to address that and made changes to optimise their efficiency for the benefits of service users.”

EDUCATION STAFF
Whatever the challenges and business benefits that arise from implementing the Working Time Regulations, it’s important not to lose sight of the fact that the health and wellbeing of employees was the driving force behind the directive. For some employees, it may be tempting to grit their teeth and carry on, but educating them about the effects of fatigue on themselves and their patients can go a long way towards ensuring safe and more efficient working practices.

IOSH has developed a range of resources to promote health and wellbeing among employees, including our free-to-download publication Working well – guidance on promoting health and wellbeing at work, and our resource database, the Occupational health toolkit.
   
The healthcare industry encompasses a huge variety of professions and institutions, from large hospitals to small GP practices and all the medical, nursing and support staff that work in them. There is no one size fits all solution to balancing patients’ needs with the legal requirements of the Working Time Regulations, but that balance must be achieved.
   
When it comes to the emergency situations and patient care commitments of healthcare workers, it’s not always possible to down tools the moment your shift ends. If there’s a staff shortage, for example due to sickness, some staff might occasionally have to continue working after their shift has finished.
   
Because they work on averages, the regulations should be flexible enough to allow for this type of situation while aiming to ensure that employees get enough breaks overall. Implementing the Working Time Regulations and ensuring that they’re adhered to isn’t without its challenges – but it can also be an opportunity to review workloads and implement best practice, while ensuring the health and wellbeing of employees and service users alike.

IOSH is the Chartered body for health and safety professionals.

FOR MORE INFORMATION:

IOSH resources: www.iosh.co.uk/information_and_resources/guidance_and_tools.aspx

Working Time Regulations: www.hse.gov.uk/contact/faqs/workingtimedirective.htm

Healthcare Workforce Portal: www.healthcareworkforce.nhs.uk/working_time_directive.html

HSL/HSE research on health and safety and working long hours: http://www.hse.gov.uk/research/hsl_pdf/2003/hsl03-02.pdf