RECOVERY BETWEEN WORK SHIFTS AMONG EMERGENCY MEDICAL SERVICES CLINICIANS P. Daniel Patterson, PhD, NRP, Daniel J. Buysse, MD, Matthew D. Weaver, PhD, EMT-P, Clifton W. Callaway, MD, PhD, Donald M. Yealy, MD is associated with poor sleep quality, daytime sleepiness, occupational fatigue, and poor safety outcomes in the workplace.2,3 Shift workers regularly report problems with sleep, fatigue, and poor recovery between shifts.4−8 These problems may result from working too many shifts in a row or not having enough time between shifts to rest and recover.6−10 In this context, fatigue is an “unpleasant symptom incorporating feelings of tiredness to exhaustion creating conditions that interfere with the ability to function in a normal capacity”11 ; recovery refers to improvement in workrelated mental and/or physical fatigue after recuperative rest, either after a day of work or during time between work periods/shifts.8−10 Emergency medical services (EMS) systems often deploy schedules that create shift workers; in addition, EMS workers often accrue large amounts of overtime or work at multiple organizations, creating on-the-job fatigue.2,4,12,13 In some locations, more than 80% of EMS workers hold multiple jobs,14 which may limit opportunities for rest and recovery between shifts. Most EMS workers in the United States adhere to a 12-hour or 24-hour shift pattern, with some working 48 consecutive hours or more.2,4 Fatigued EMS workers have higher rates of injury,2 contributing to a growing concern for EMS worker fatigue among federal oversight organizations, including the National Institute for Occupational Safety and Health (NIOSH).15−18 Despite this concern, there is little research on EMS worker sleep, fatigue, shift work, and intershift recovery.12 Recovery from shift work, fatigue, and sleep are well studied in other professions, and there is a growing body of research linking shift work to health indicators, such as body mass index (BMI).19−21 There is limited research on fatigue and recovery between shift work involving EMS workers.12 In this study, we describe EMS worker recovery between shifts and examine associations between key variables linked to recovery, including age, BMI, years of experience, and shift length.2,6,8−10,22−24
Prehosp Emerg Care Downloaded from informahealthcare.com by University of Otago on 07/14/15 For personal use only.
ABSTRACT Objective. Shift workers regularly report sleep problems, fatigue, and the need for recuperative rest between shifts (intershift recovery). We sought to characterize intershift recovery among emergency medical services (EMS) workers and the role of worker demographics and work-related factors. Methods. We combined cross-sectional survey data from two studies of EMS shift workers who completed standardized instruments, including the Occupational Fatigue Exhaustion Recovery (OFER) scale. A multivariable regression identified demographic and work factors most strongly associated with intershift recovery. Results. Mean intershift recovery among 450 EMS workers varied by clinical setting, general health status, length of work shift, sleep quality score, fatigue score, and daytime sleepiness. Recovery was better for EMS workers who report greater satisfaction with their schedule, higher for shift schedules >12 hours, and lowest for individuals who usually work 12-hour shifts. Conclusion. In this sample of EMS workers, greater recovery between shifts is associated with satisfaction with scheduling and longer shift length. There were weaker associations of recovery with health status, sleep quality, and workplace fatigue. Future studies should address the relationship of intershift recovery with time off between shifts, workload, and workplace safety and performance. Key words: sleep; fatigue; shift work; recovery; EMS PREHOSPITAL EMERGENCY CARE 2015;19:365–375
INTRODUCTION Shift work is defined as “any arrangement of work hours other than standard daylight hours.”1 Shift work
Received August 12, 2014 from the Department of Emergency Medicine, Carolinas HealthCare System Medical Center, Charlotte, North Carolina (PDP), Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (MDW, CWC, DMY), and Department of Psychiatry and Clinical Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (DJB). Revision received November 6, 2014; accepted for publication November 11, 2014. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
METHODS Overview of Study Design and Study Sample
Address correspondence to P. Daniel Patterson, Department of Emergency Medicine, Carolinas HealthCare System Medical Center, 1000 Blythe Blvd., 304J MEB, Charlotte, NC 28203, USA. E-mail: [email protected]
We used cross-sectional survey data from two separate studies of EMS workers in the United States.
doi: 10.3109/10903127.2014.995847
365
Prehosp Emerg Care Downloaded from informahealthcare.com by University of Otago on 07/14/15 For personal use only.
366 We pooled data to improve the representativeness of our EMS worker target population. EMS workers are employed as an emergency medical technician (EMT)-basic, -intermediate, or -paramedic. Another EMS worker group includes licensed prehospital nurses or EMS physicians who work as medical directors of EMS organizations. We surveyed EMS workers attending two regional conferences in the northeastern United States between February and March 2014 using an experimental questionnaire, the Sleep, Fatigue, and Alertness Behavior (SFAB) survey.25 The goal of the SFAB study was to develop a reliable and valid survey tool for measuring EMS worker alertness behaviors, which include, but are not limited to, behaviors such as 1) taking naps or taking rest breaks at work,26−31 2) consuming caffeinated beverages on duty to stay alert,32 3) doing physical exercise while on the job,33,34 or 4) use of talking/conversation with colleagues as a form of mental exercise to stay alert. A convenience sample of 355 workers completed the SFAB survey, representing approximately 45% of potentially eligible survey participants attending the conferences.25 The second set of survey data comes from the baseline assessment of 100 EMS workers who voluntarily participated in the SleepTrackTXT pilot randomized clinical trial (clinicaltrials.gov NCT02063737).35 Aims of the SleepTrackTXT trial included 1) determining feasibility of using text messages to assess fatigue and sleepiness in real time, and 2) assessing impact of sending textmessage strategies for fatigue reduction on end of shift fatigue.35
Study Protocol The SFAB study collected data using a paper-based tool. EMS workers attending the conferences completed a survey if meeting the following eligibility criteria: 1) active EMS clinician in the western Pennsylvania region; 2) certified or licensed as an emergency medical technician at the basic, paramedic, or flight paramedic level, a prehospital/emergency nurse, or an EMS physician who provides both online and off-line medical oversight of EMS clinicians; and 3) 18 years of age or older. For the second sample, we collected SleepTrackTXT study data at baseline using a secure electronic survey tool after each EMS worker gave informed consent.
Measurements EMS workers in both studies answered the following established survey scales: the Pittsburgh Sleep Quality Index (PSQI, 18 items),36 the Epworth Sleepiness Scale (ESS, 8 items),37 the Chalder Fatigue Questionnaire (CFQ, 11 items),2,4,38 items from the general affect subscale and social/family subscale of the Schedule Attitudes Survey (SAS, 5 items),39 and the Occupational Fatigue, Exhaustion, Recovery Scale (OFER, 15
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items).40 The OFER includes three subscales each with five items: the Chronic Fatigue subscale (OFER-CF), the Acute Fatigue subscale (OFER-AF), and the Intershift Recovery subscale (OFER-IR). We collected response options for each of the established surveys using previously validated methods for each scale and calculated summary composite scores.36,38,40 Sleep quality scores ≥6 indicate poor sleep quality, CFQ scores >4 indicate severe mental and/or physical fatigue, higher scores on the ESS indicate worsening daytime sleepiness, and higher scores on the OFER-IR indicate greater ability to recover between shifts.36−38,40 The PSQI, ESS, and CFQ have been used previously in EMS worker study samples and have shown positive psychometric properties of reliability and construct validity.2,4,41 We calculated an SAS composite score by rescaling Likert responses (strongly agree, disagree, neither agree or disagree, agree, and strongly agree) on a 0–100 scale and dividing the sum by five (one item with opposing valence was reverse coded). We used 0–100 scaling to facilitate comparison and interpretation with other key outcomes, such as the OFER, which also uses a 0–100 scale. In this study, higher SAS composite scores are interpreted as greater dissatisfaction with one’s work schedule. The developer gave permission to use the OFER. Demographic variables captured in both studies include age, sex, license/certification, type of work setting, number of clinical jobs, years of experience, full-time employment status, number of shifts worked in previous month, length of shift most commonly worked, self-perceived health status, and height/weight. We collected age as a continuous variable and then stratified into five categories based on previous research by Winwood and colleagues.6 Categories of license/certification include EMT-basic, paramedic, nurse, physician, and other. Type of work setting was stratified as ground-based EMS, airmedical EMS, emergency department, intensive care unit, and other. Number of clinical jobs was dichotomized into 1 or ≥2. We collected “years of experience” as continuous and reported as a categorical variable to align with previous research of EMS workers: 0–10 years, 11–20 years, and ≥21 years.2 Similarly, we stratified employment status into full-time, part-time, and volunteer after collecting the “number of shifts worked in previous month” as continuous data. The post hoc categorization of shifts was >12-hour shift, 12-hour shift, and 12 hours, were overweight or obese, and reported poor sleep quality and high levels of fatigue on most measures of sleep/fatigue (Table 1). Scores on the PSQI and other measures of sleep or fatigue are comparable to scores reported in previous studies of EMS workers.2,4 The demographics of our study sample are similar to EMS worker samples taken in other studies using convenience and random sampling techniques (Table 2).44−49 Figure 1 highlights the proportion of EMS workers responding (slightly agree, agree, or strongly agree) to the five items that comprise the OFER-IR. The mean
368
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TABLE 1. Demographic characteristics of EMS workers
Mean age (±SD) Sex,% Male Female Certification/license,% EMT-basic Paramedic Nurse Physician Other Clinical setting,% Ground-based EMS Air-medical EMS ED/ICU setting Other Years of experience Mean (±SD) Number of jobs,% ≥2 jobs Employment status,% Full-time Part-time Volunteer Number of shifts worked last month Mean (±SD) Most common shift length worked,% >12-hr 12-hr 12-hour shift schedules and lowest for individuals working 12-hour shifts (p < 0.0001). Mean intershift recovery was lower for EMS workers with poor sleep quality (p < 0.0001), excessive daytime sleepiness (p < 0.05), and severe
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RECOVERY AMONG EMS SHIFT WORKERS
TABLE 2. Comparison of study sample with previous research
Prehosp Emerg Care Downloaded from informahealthcare.com by University of Otago on 07/14/15 For personal use only.
Previous research
Mean age in years Sex,% Male Female Certification/license,% EMT-basic Paramedic Nurse Physician Other Employment status,% Full-time Part-time Volunteer
Study sample Combined sample of EMS workers (N = 450)
EMT-Teamwork survey study32
LEADS sample33
High-response EMS sample34
NHTSA workforce report35
ROC study EMS agencies36
National survey of EMS safety culture37
40.0
36.9
—
—
35
—
—
61 39
72.3 27.7
72.9 27.1
71.8 28.2
71–77 23–29
— —
73.2 26.8
35 39 17 2 7
28.7 61.4 — — 9.9
58.1 34.6 — — —
50.7 49.3 — — —
72 22 — — —
58.2 34.2 — — —
19.4 62.1 8.0 — 10.5
66 17 16
71.7 30.2 6.6
— — —
— — —
89 11 —
— — —
77.6 20.6 1.8
mental and/or physical fatigue while at work (p < 0.0001) (Table 3). The proportion of EMS workers with low recovery (0–40 on OFER-IR scale) was highest among workers who rated their own general health as fair or poor (51.6%), when compared to workers who rated health as good (22.3%) or excellent (24.5%; p < 0.05; Table 3). The proportion of EMS workers with moderate/high to high recovery (50–100) was highest among those working >12-hour shifts (61.6%), followed by 12-hour shifts 12-hour shifts
Prehosp Emerg Care Downloaded from informahealthcare.com by University of Otago on 07/14/15 For personal use only.
ABSTRACT Objective. Shift workers regularly report sleep problems, fatigue, and the need for recuperative rest between shifts (intershift recovery). We sought to characterize intershift recovery among emergency medical services (EMS) workers and the role of worker demographics and work-related factors. Methods. We combined cross-sectional survey data from two studies of EMS shift workers who completed standardized instruments, including the Occupational Fatigue Exhaustion Recovery (OFER) scale. A multivariable regression identified demographic and work factors most strongly associated with intershift recovery. Results. Mean intershift recovery among 450 EMS workers varied by clinical setting, general health status, length of work shift, sleep quality score, fatigue score, and daytime sleepiness. Recovery was better for EMS workers who report greater satisfaction with their schedule, higher for shift schedules >12 hours, and lowest for individuals who usually work 12-hour shifts. Conclusion. In this sample of EMS workers, greater recovery between shifts is associated with satisfaction with scheduling and longer shift length. There were weaker associations of recovery with health status, sleep quality, and workplace fatigue. Future studies should address the relationship of intershift recovery with time off between shifts, workload, and workplace safety and performance. Key words: sleep; fatigue; shift work; recovery; EMS PREHOSPITAL EMERGENCY CARE 2015;19:365–375
INTRODUCTION Shift work is defined as “any arrangement of work hours other than standard daylight hours.”1 Shift work
Received August 12, 2014 from the Department of Emergency Medicine, Carolinas HealthCare System Medical Center, Charlotte, North Carolina (PDP), Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (MDW, CWC, DMY), and Department of Psychiatry and Clinical Translational Science, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania (DJB). Revision received November 6, 2014; accepted for publication November 11, 2014. The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
METHODS Overview of Study Design and Study Sample
Address correspondence to P. Daniel Patterson, Department of Emergency Medicine, Carolinas HealthCare System Medical Center, 1000 Blythe Blvd., 304J MEB, Charlotte, NC 28203, USA. E-mail: [email protected]
We used cross-sectional survey data from two separate studies of EMS workers in the United States.
doi: 10.3109/10903127.2014.995847
365
Prehosp Emerg Care Downloaded from informahealthcare.com by University of Otago on 07/14/15 For personal use only.
366 We pooled data to improve the representativeness of our EMS worker target population. EMS workers are employed as an emergency medical technician (EMT)-basic, -intermediate, or -paramedic. Another EMS worker group includes licensed prehospital nurses or EMS physicians who work as medical directors of EMS organizations. We surveyed EMS workers attending two regional conferences in the northeastern United States between February and March 2014 using an experimental questionnaire, the Sleep, Fatigue, and Alertness Behavior (SFAB) survey.25 The goal of the SFAB study was to develop a reliable and valid survey tool for measuring EMS worker alertness behaviors, which include, but are not limited to, behaviors such as 1) taking naps or taking rest breaks at work,26−31 2) consuming caffeinated beverages on duty to stay alert,32 3) doing physical exercise while on the job,33,34 or 4) use of talking/conversation with colleagues as a form of mental exercise to stay alert. A convenience sample of 355 workers completed the SFAB survey, representing approximately 45% of potentially eligible survey participants attending the conferences.25 The second set of survey data comes from the baseline assessment of 100 EMS workers who voluntarily participated in the SleepTrackTXT pilot randomized clinical trial (clinicaltrials.gov NCT02063737).35 Aims of the SleepTrackTXT trial included 1) determining feasibility of using text messages to assess fatigue and sleepiness in real time, and 2) assessing impact of sending textmessage strategies for fatigue reduction on end of shift fatigue.35
Study Protocol The SFAB study collected data using a paper-based tool. EMS workers attending the conferences completed a survey if meeting the following eligibility criteria: 1) active EMS clinician in the western Pennsylvania region; 2) certified or licensed as an emergency medical technician at the basic, paramedic, or flight paramedic level, a prehospital/emergency nurse, or an EMS physician who provides both online and off-line medical oversight of EMS clinicians; and 3) 18 years of age or older. For the second sample, we collected SleepTrackTXT study data at baseline using a secure electronic survey tool after each EMS worker gave informed consent.
Measurements EMS workers in both studies answered the following established survey scales: the Pittsburgh Sleep Quality Index (PSQI, 18 items),36 the Epworth Sleepiness Scale (ESS, 8 items),37 the Chalder Fatigue Questionnaire (CFQ, 11 items),2,4,38 items from the general affect subscale and social/family subscale of the Schedule Attitudes Survey (SAS, 5 items),39 and the Occupational Fatigue, Exhaustion, Recovery Scale (OFER, 15
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items).40 The OFER includes three subscales each with five items: the Chronic Fatigue subscale (OFER-CF), the Acute Fatigue subscale (OFER-AF), and the Intershift Recovery subscale (OFER-IR). We collected response options for each of the established surveys using previously validated methods for each scale and calculated summary composite scores.36,38,40 Sleep quality scores ≥6 indicate poor sleep quality, CFQ scores >4 indicate severe mental and/or physical fatigue, higher scores on the ESS indicate worsening daytime sleepiness, and higher scores on the OFER-IR indicate greater ability to recover between shifts.36−38,40 The PSQI, ESS, and CFQ have been used previously in EMS worker study samples and have shown positive psychometric properties of reliability and construct validity.2,4,41 We calculated an SAS composite score by rescaling Likert responses (strongly agree, disagree, neither agree or disagree, agree, and strongly agree) on a 0–100 scale and dividing the sum by five (one item with opposing valence was reverse coded). We used 0–100 scaling to facilitate comparison and interpretation with other key outcomes, such as the OFER, which also uses a 0–100 scale. In this study, higher SAS composite scores are interpreted as greater dissatisfaction with one’s work schedule. The developer gave permission to use the OFER. Demographic variables captured in both studies include age, sex, license/certification, type of work setting, number of clinical jobs, years of experience, full-time employment status, number of shifts worked in previous month, length of shift most commonly worked, self-perceived health status, and height/weight. We collected age as a continuous variable and then stratified into five categories based on previous research by Winwood and colleagues.6 Categories of license/certification include EMT-basic, paramedic, nurse, physician, and other. Type of work setting was stratified as ground-based EMS, airmedical EMS, emergency department, intensive care unit, and other. Number of clinical jobs was dichotomized into 1 or ≥2. We collected “years of experience” as continuous and reported as a categorical variable to align with previous research of EMS workers: 0–10 years, 11–20 years, and ≥21 years.2 Similarly, we stratified employment status into full-time, part-time, and volunteer after collecting the “number of shifts worked in previous month” as continuous data. The post hoc categorization of shifts was >12-hour shift, 12-hour shift, and 12 hours, were overweight or obese, and reported poor sleep quality and high levels of fatigue on most measures of sleep/fatigue (Table 1). Scores on the PSQI and other measures of sleep or fatigue are comparable to scores reported in previous studies of EMS workers.2,4 The demographics of our study sample are similar to EMS worker samples taken in other studies using convenience and random sampling techniques (Table 2).44−49 Figure 1 highlights the proportion of EMS workers responding (slightly agree, agree, or strongly agree) to the five items that comprise the OFER-IR. The mean
368
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Prehosp Emerg Care Downloaded from informahealthcare.com by University of Otago on 07/14/15 For personal use only.
TABLE 1. Demographic characteristics of EMS workers
Mean age (±SD) Sex,% Male Female Certification/license,% EMT-basic Paramedic Nurse Physician Other Clinical setting,% Ground-based EMS Air-medical EMS ED/ICU setting Other Years of experience Mean (±SD) Number of jobs,% ≥2 jobs Employment status,% Full-time Part-time Volunteer Number of shifts worked last month Mean (±SD) Most common shift length worked,% >12-hr 12-hr 12-hour shift schedules and lowest for individuals working 12-hour shifts (p < 0.0001). Mean intershift recovery was lower for EMS workers with poor sleep quality (p < 0.0001), excessive daytime sleepiness (p < 0.05), and severe
P. D. Patterson et al.
369
RECOVERY AMONG EMS SHIFT WORKERS
TABLE 2. Comparison of study sample with previous research
Prehosp Emerg Care Downloaded from informahealthcare.com by University of Otago on 07/14/15 For personal use only.
Previous research
Mean age in years Sex,% Male Female Certification/license,% EMT-basic Paramedic Nurse Physician Other Employment status,% Full-time Part-time Volunteer
Study sample Combined sample of EMS workers (N = 450)
EMT-Teamwork survey study32
LEADS sample33
High-response EMS sample34
NHTSA workforce report35
ROC study EMS agencies36
National survey of EMS safety culture37
40.0
36.9
—
—
35
—
—
61 39
72.3 27.7
72.9 27.1
71.8 28.2
71–77 23–29
— —
73.2 26.8
35 39 17 2 7
28.7 61.4 — — 9.9
58.1 34.6 — — —
50.7 49.3 — — —
72 22 — — —
58.2 34.2 — — —
19.4 62.1 8.0 — 10.5
66 17 16
71.7 30.2 6.6
— — —
— — —
89 11 —
— — —
77.6 20.6 1.8
mental and/or physical fatigue while at work (p < 0.0001) (Table 3). The proportion of EMS workers with low recovery (0–40 on OFER-IR scale) was highest among workers who rated their own general health as fair or poor (51.6%), when compared to workers who rated health as good (22.3%) or excellent (24.5%; p < 0.05; Table 3). The proportion of EMS workers with moderate/high to high recovery (50–100) was highest among those working >12-hour shifts (61.6%), followed by 12-hour shifts 12-hour shifts
