We are all human. We get tired, stressed, and distracted. This module looks at these very human limitations - like fatigue, workload, and cognitive load - and how they affect our ability to work safely.

Most importantly, we'll look at practical strategies to manage these risks for ourselves and our teams.

Learning Outcomes

  • Identify how fatigue, stress, and workload affect clinical and non-clinical performance.
  • Define 'cognitive load' and the myth of multitasking.
  • List three strategies to manage and mitigate performance limits.
  • Explain the importance of psychological safety in managing limitations.

The 'Dirty Dozen' in Practice: Fatigue, Stress, and Pressure

In Module 1, we introduced the 'Dirty Dozen' - the 12 most common precursors to error. In this module, we focus on the ones that have the biggest impact on our performance: fatigue, stress, workload, and distraction.

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It is not a personal failure to be affected by these. It is a predictable human limitation.
  • Fatigue: This is not just 'feeling tired'. It is an "overwhelming sense of tiredness that is prolonged." In the NHS, this is often driven by "historical beliefs... around working long and additional hours."
    • The Effects: Fatigue has real, measurable consequences, including "difficulty concentrating, difficulty making decisions... poor memory, coordination... and slower reactions."
  • Stress: Negative stress, whether from work or home, has similar effects. It can cause "low motivation, energy and focus" and "mood swings."
  • Workload and Pressure: When the demands of the job exceed our ability to cope, our performance suffers. This is a constant reality in many parts of the NHS.

These factors don't just add up; they multiply. A stressed team member who is also fatigued and working under pressure is at a much higher risk of making an error, no matter how skilled or dedicated they are.

Cognitive Load and the Multitasking Myth

Every task we do takes up mental energy. 'Cognitive Load' is the term for "the amount of mental effort expended in working memory."

Think of your working memory as your brain's 'RAM' or 'mental bandwidth'. It is powerful, but it is finite.

In a busy healthcare setting, many things compete for this limited bandwidth:

  • Interruptions: A ringing phone, an alarm, a colleague asking a question.
  • Distractions: Noise, visual clutter, or even your own thoughts.
  • Multitasking: This is the most important one. We believe we can 'multitask', but the science is clear: we can't.

What our brain actually does is switch very quickly between tasks. This switching "divides cognitive resources," "increases cognitive load," and "can overload working memory."

When we are cognitively overloaded, our performance is "impaired." We are more likely to make mistakes, and our communication skills are often the first thing to suffer.

Strategies to Manage and Mitigate Our Limits

A Human Factors approach means we accept these limitations and build strategies to mitigate them. The Health and Safety Executive (HSE) is clear: fatigue is a hazard that employers have a legal duty to manage.

Here are some evidence-based strategies:

Take Your Breaks
This is the most basic and most important mitigation. The Working Time Regulations require a 20-minute break for a 6+ hour shift, but "more breaks are encouraged" on long or demanding shifts.

The Power Nap
For staff on long shifts or night shifts, this is a powerful strategy. Research shows a short period of sleep or a 'power nap' of around 20 minutes during an authorised break can significantly help cope with fatigue.

Manage Your Cognitive Load

    • Reduce Clutter by keeping your desk, trolley, or workspace as clean and organised as possible. "Excessive visual stimuli increases mental load."
    • Reduce Notifications by turning off non-essential notifications on phones and computers.
    • Protect Your Time by trying to 'single-task' for critical jobs. For example, use a 'Do Not Disturb' vest when administering drugs.

Team Strategies
Talk about these factors. In a briefing, ask: "Who is on a long shift? Who is on their third night? Let's make sure we support them and double-check their critical tasks."

The Importance of Psychological Safety

How do all these ideas link together? You can only use these strategies if you work in an environment with Psychological Safety.

Psychological Safety is "the shared belief... that it's okay to express ideas and concerns, to speak up with questions, and to admit mistakes, all without fear of negative, unjust consequences."

Why is this so important for managing human limitations?

You need psychological safety to:

  • Say: "I am too tired to do this safely. I need to take my break."
  • Say: "I am feeling overloaded. Can you please double-check this for me?"
  • Say: "I don't know the answer. Can you help me?"
  • Admit: "I think I've made a mistake."

In a blame culture, staff are afraid to admit these things. They "push through," leading to burnout and, ultimately, patient safety incidents. Psychological safety is the foundation that allows us to be open about our human limitations and manage them as a team.

Key Takeaways

  • Human limitations like Fatigue, Stress, and Pressure are not personal failings; they are predictable risks.
  • Cognitive Load is the amount of 'mental bandwidth' we have. It is finite.
  • Multitasking is a myth. It is really 'rapid task-switching', which increases cognitive load and leads to errors.
  • We can mitigate these risks with strategies like taking breaks and, on night shifts, taking a 20-minute 'power nap'.
  • Psychological Safety is essential. It gives us permission to admit our limitations and ask for help without fear.

Knowledge Check


1. Which of the following statements about multitasking is true?
2. Which strategy is recommended for managing fatigue on long shifts?
3. Why is "Psychological Safety" essential for managing human limitations?
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