Breaks at breaking point—doctors need to take time out in a pandemic

Work during the covid-19 pandemic—whether it is frontline care, administration, management or pastoral support—has two hallmarks which makes it problematic for fatigue and performance: it is relentless and it is unpredictable.

The demands on healthcare workers are high, shifts are long, and urgent work is carried out in the shadow of a rapidly accumulating backlog of “normal” work. Commentaries have pointed out an increasing “covid fatigue” among healthcare workers, a state compounded by the disappearance of normal periods of respite—fewer chances to grab a coffee, no time to catch up with colleagues, less informal chat in the corridors.

Spending time continuously “on task” has clear negative consequences for performance and wellbeing. More than a century ago, Japanese student Tsuro Arai set herself the masochistic task of solving complex multiplication problems continuously over four 12-hour days. By forcing herself to work continuously without rest and meticulously documenting the results, Arai provided the first firm evidence that (predictably) humans cannot maintain cognitive performance over 12 hours without a break. Instead, performance becomes slower and less accurate as “time on task” increases, only returning to normal after periods of respite. Fast forward more than a century, and healthcare workers are regularly working lengthy periods without a break, trying to deal with a pandemic that has been ongoing for many months, in an already over-stretched health service. 

Even in times of normal service, health-relevant decisions and behaviours change as time on task increases. GPs are more likely to prescribe unnecessary antibiotics towards the end of clinics, gastroenterologists are less likely to detect polyps in afternoon than morning colonoscopies, compliance with hand hygiene protocols declines from the start to the end of shifts, surgeons are less likely to decide patients require surgery towards the end of shifts, and telephone helpline nurses become progressively more likely to refer callers to other healthcare professionals as time since last break increases. The latter example raises a key point—changes in nurses’ decision making were related specifically to the time elapsed since last break and not to workload or time on shift in general. In other words, it is the timing and presence (or absence) of breaks within the work period, rather than overall workload which is critical.

In addition to being demanding, work in a pandemic is novel and unpredictable. Workers must adapt rapidly to an evolving situation, thinking flexibly, solving problems, staying focused and remaining vigilant to change. This requires a type of cognitive functioning that is effortful and draining. Under normal circumstances, this kind of high level, intensive thought is less common—most situations are at least somewhat familiar and can be navigated with little conscious deliberation. In the pandemic, this balance has been reversed and human cognition is simply not designed to operate in its most effortful mode for protracted periods. Extended periods of high level thought quickly lead to fatigue and associated changes in decision making and behaviour.

From a worker’s point of view, fatigue can be thought of as an adaptive signala tell-tale sign that we have spent too long “on task” and should change task or take a break before performance suffers and mistakes or accidents occur. Recent campaigns and initiatives highlight the importance of healthcare staff responding to fatigue and taking adequate breaks. Breaks are important in any line of work, under any circumstances, but should be considered essential in the present situation where work is particularly mentally draining.

Enabling staff to take adequate breaks in a busy, over-stretched health service is easier said than done. One possible solution is the adoption (in addition to standard breaks) of regular “microbreaks” throughout busy or demanding work periods. Microbreaks, as the name implies, are short breaks, typically of a few minutes’ duration which provide enough respite to mitigate some of the declines that would otherwise occur in wellbeing and performance over time. Studies in surgery for example, show that surgeons who take regular, brief microbreaks (of 90 seconds to 5 minutes) during operations, report; improvements in physical and mental performance, reductions in pain and discomfort, reduced stress, and fewer intraoperative events. Importantly, operations with microbreaks take no longer than standard operations, suggesting that the breaks “pay for themselves” by counteracting normal reductions in efficiency over time.

As we move into the next phase of the pandemic with winter and a potential second wave on its way, it’s more important than ever to prioritise breaks. Work demands remain high, and mass disruption to services ensures that change and unpredictability will continue for the foreseeable future. Healthcare staff have been operating beyond capacity for an extended period and are already fatigued. Enabling adequate breaks during this period, and applying lessons from fatigue research to practice, will be essential if performance, wellbeing, and safety are to be protected going forward.

Julia Allan is a Health Psychologist and Senior Lecturer at the University of Aberdeen, UK.

Daniel Powell is a Lecturer in Health Psychology at the University of Aberdeen, UK.

Kathleen Ferguson is President of the Association of Anaesthetists and consultant anaesthetist at Aberdeen Royal Infirmary, UK. 

Emma Plunkett is a Consultant Anaesthetist in Birmingham, UK, and chair of the Joint Association of Anaesthetists, Royal College of Anaesthetists and Faculty of Intensive Care Medicine Fatigue Working Group. @emmaplunkett

Competing interests: KF is employed by NHS Grampian as a Consultant Anaesthetist, President of the Association of Anaesthetists, Specialty member of Devices Expert Advisory Group for the MHRA. EP is chair of the Joint Fatigue Working Group.