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Emergency Medicine Australasia (2014) 26, 139–144
doi: 10.1111/1742-6723.12216
ORIGINAL RESEARCH
What paramedics think about when they think about fatigue: Contributing factors Jessica L PATERSON,1 Sarah SOFIANOPOULOS2 and Brett WILLIAMS3 1 Appleton Institute, Central Queensland University, Adelaide, South Australia, Australia, 2Operations Department, Ambulance Victoria, Melbourne, Victoria, Australia, and 3Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia
Abstract Objective: Paramedic fatigue is associated with burnout, attrition, sick leave, work disability, physical and mental health complaints and impaired performance. However, no studies have addressed how fatigue is understood by paramedics. The present study addresses this shortcoming by exploring factors paramedics recognise as contributors to fatigue. Methods: Forty-nine (12F; 38 years ± 9.7 years) Australian paramedics completed a survey on perceived causes of performance impairing fatigue. A total of 107 responses were systematically coded following principles common to qualitative data analysis: data immersion, coding, categorisation and theme generation. Results: Six themes emerged: working time, sleep, workload, health and wellbeing, work–life balance and environment. Consistent with a scientific understanding of fatigue, prior sleep and wake, time of day and task-related factors were often identified as contributing to fatigue. In other cases, paramedics’ attributions deviated from a scientific understanding of direct causes of fatigue. Conclusions: These findings demonstrate that paramedics have a broad understanding of fatigue. It is critical to take this into account when dis-
cussing fatigue with paramedics, particularly in the case of fatigue education or wellness programmes. These data highlight areas for intervention and education to minimise the experience of paramedic fatigue and the negative health and safety outcomes for paramedics and patients as a result. Key words: fatigue, shift work, sleep, work hour, workload.
Introduction Paramedics are a critical community resource, providing emergency prehospital care to individuals in crisis. Paramedics typically work shift work schedules that involve the organisation of working hours across the entire 24 h day.1 Shift work requires individuals to work when they are biologically and environmentally inclined to sleep, and vice versa. This mismatch can result in significant fatigue, which is associated with performance impairments and negative health outcomes in paramedic populations,2,3 and in operational settings more generally.4–8 There are three primary causes of fatigue consistently identified in the literature: (i) sleep/wake history, (ii) circadian factors, and (iii) task-related factors.8 In terms of sleep/wake history,
Correspondence: Dr Jessica L Paterson, Appleton Institute, Central Queensland University, PO Box 42, Goodwood, Adelaide, SA 5034, Australia. Email: jessica.paterson@ cqu.edu.au Jessica L Paterson, PhD, Senior Post-Doctoral Research Fellow; Sarah Sofianopoulos, BSc, Bachelor of Emergency Health (Paramedic) (Hons), Ambulance Paramedic; Brett Williams, PhD, Associate Professor, Head of Department. Accepted 7 February 2014
Key findings • Sleep/wake history, time of day and task-related factors were identified as contributing to fatigue. • Paramedics often defined factors contributing to fatigue in practical terms, for example long shifts and workload. • In some cases, paramedics identified indirect contributors to fatigue such as poor sleep hygiene, poor diet and understaffing.
both reduced sleep and extended wake are associated with fatigue.6 Indeed, shift-workers might experience sleep reductions of up to 4 h before morning shifts and following night shifts. 4 Furthermore, the sleep of shift-workers is more likely to occur at times other than during the biological night, representing the role of circadian factors. Circadian rhythms regulate different functions of the body, such as the ability to initiate and maintain sleep, to an approximately 24.2 h cycle.5 Wake that occurs out of synchrony with the circadian drive for wakefulness is characterised by impaired functioning and increased fatigue. In turn, sleep that occurs out of synchrony with the circadian drive for sleep is of reduced restorative value, leading to fatigue. Finally, there are multiple task-related factors associated with fatigue, including workload and time-on-task.7 Existing research reveals that paramedic fatigue is associated with worker burnout and attrition,9,10 sick leave and work disability,3 health complaints, such as headaches and gastrointestinal illness,2 depression, anxiety and
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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stress. 11,12 Paramedic fatigue also impacts upon operational performance and patient and public safety. In one study, 88% of a sample of paramedics reported experiencing fatigue that affected their work performance and almost half of the respondents reported falling asleep while driving.11 Difficulty remembering emergency service protocol,9 difficulty operating the ambulance9 and increased risk of being involved in an ambulance accident10 have also been identified as a result of paramedic fatigue. Research has gone some of the way towards quantifying the risks associated with fatigue for paramedics. Patterson et al.13 suggest ‘within shift interventions’ to mitigate fatigue for paramedics. The authors suggest the use of designated rest periods as a potential intervention but acknowledge that these rest periods might be differentially effective and/or practical for different people and workplaces. In their recent review, Dawson et al. 14 described a series of fatigue reduction strategies used in industries where a reduction in working time was impractical or unsafe (e.g. healthcare and aviation). These strategies were found to be specific to each profession and workplace and to assist in the management of fatigue. It might be the case that there are strategies already in use or easily integrated into paramedic practice that might mitigate fatigue. However, a critical first step to identifying effective interventions is to understand the way fatigue is operationally understood and experienced by paramedics. No studies to date have addressed this question. The present study explores the factors paramedics recognise as significant contributors to fatigue. This will highlight areas for intervention and education to minimise fatigue and the associated negative health and safety outcomes.
Methods Study design The present study used qualitative methods to determine the factors paramedics recognise as contributors to fatigue. A sample of convenience was used. Qualitative methods are considered most appropriate for developing
the ‘theoretical underpinning’ of future quantitative research.15 Given the limitations in current knowledge regarding paramedic fatigue, the present study sought to provide a basis for future research efforts in this area.
Study protocol and setting Data were collected as part of the demographic questionnaire from a larger cross-sectional survey study of paramedics assessing various aspects of sleep, fatigue and well-being. 11 Participants were asked to provide their age, sex and years of employment by an ambulance service as a shift worker (working hours outside of 08.00 hours to 17.00 hours Monday through Friday, response categories 20 years). Participants were then asked: 1. Have you experienced fatigue in the last 6 months? (Y/N) 2. If so, what do you believe this is a result of? (Free text response) 3. Do you believe this fatigue has affected your performance at work? (Y/N) Participants were also asked to indicate if they had ever been diagnosed with narcolepsy, restless leg syndrome, obstructive or central sleep apnoea (Y/N) and if they had, whether they were currently receiving treatment (Y/N). The survey instrument was distributed at the National Symposium for the Journal of Emergency Primary Health Care in April 2010. There were approximately 100 attendees at the conference from around Australia. Attendees were made aware of the nature of the survey and where they could collect a copy should they wish to participate. Participants were provided with a study information sheet, the survey instrument and a pre-paid return envelope. Informed consent was implied through completion of the survey. The completed survey could be returned via a locked drop-box located at the conference centre or return post.
well as how many completed surveys were excluded, are detailed in Figure 1. The majority of participants had been employed by an ambulance service for between 5–10 years (n = 20) and 10– 15 years (n = 12). Seven participants had been employed for 20 years and three for 15–20 years.
Data analysis Many of the 49 participants attributed their fatigue to multiple causes. As such, there were a total of 107 responses for analysis. A general inductive approach to data analysis was used. 16 This approach allows key themes to emerge organically from raw data using data immersion, coding, categorisation and theme generation.17 JP conducted the initial reading, coding and categorisation of responses. These analyses resulted in six themes (see Results). An independent coder was then given a subset of the full dataset (24 responses chosen at random) and asked to assign each response to one of the six themes, or to indicate if the response fit into multiple themes. Overall, there was a 95% agreement rate between coders. Coded data were then presented to SS and BW, both qualified paramedics, to determine the validity of the coding process. This process, known as a member check, is important for establishing the credibility of findings, as it allows ‘participants in the settings studied . . . the chance to comment on whether the categories and outcomes . . . relate to their personal experiences’.16
Results Six themes emerged from the 107 responses to ‘what do you believe this (your fatigue) is a result of?’ The relative weighting of these themes, and the number of associated responses, is represented in Figure 2. Each theme, subtheme, the number of responses associated with each subtheme and an example of responses in included in Table 1 and detailed below.
Study population Data from 49 paramedics (12F; mean age 38 years ± 9.7 years) were the focus of the present study. The number of participants included in the study, as
Working time One of the most common reasons cited for fatigue related to ‘working time’ was night shift. Long night shifts and
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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Work–life Environment balance (3 responses) (6 responses) Health and well-being (8 responses) Working time (42 responses)
Workload (15 responses)
Sleep (33 responses)
Figure 2. Relative weighting of each analytic theme and number of responses associated with each theme.
night shifts. Poor quality sleep was also cited. For example, ‘interrupted sleep patterns’, ‘lack of sleep quality’ and ‘broken sleep patterns’. Finally, a small number of responses highlighted issues related to sleep hygiene including ‘poor sleep facilities’ or a ‘home environment not conducive to sleep’.
Workload The majority of responses related to workload were ‘high or excessive workload’. Responses specified that both ‘high utilisation/workload’ and ‘busy workload’ were associated with fatigue. An additional response specified that ‘increasing workload on night duty’ was associated with fatigue. A small number of responses classified as workload were related to understaffing, particularly ‘inadequate/decreasing crew’. Figure 1. Number of participants included in the study after inclusion/exclusion criteria were applied.
an inability to rest during night shifts were specifically associated with fatigue and performance impairment, as were inconsistent or late rest breaks. Variation in meal times, which reportedly led to ‘eating on the run’ or ‘late or no meal break(s)’, was also reported. Participants also reported fatigue as a result of working beyond their specified shift finish time, which also resulted in reduced recovery opportunity between shifts. For example, it was stated that ‘extra after duty work cuts into sleep time’.
Sleep Insufficient sleep was the dominant reason given for fatigue in this category, such as ‘lack of sleep’ or ‘difficulty sleeping adequately before shifts’ and ‘not enough rest periods between shifts’. Sleep difficulties were also reported including an inability to sleep because of ‘insomnia despite fatigue’, being ‘not a good sleeper’ and ‘changes to circadian rhythms’. Indeed, there was a subgroup of responses related to difficulty obtaining sleep between
Health and well-being Responses related to health and wellbeing factors included dietary factors, such as ‘too much alcohol’ and ‘eating food with lack of sustenance’. Reduced exercise was specified, for example ‘reduced ability to exercise leading to weight gain’. There were also general well-being concerns, such as ‘exhaustion’ and ‘mood change’.
Work–life balance Responses related to work-life balance issues included ‘family’ and ‘study’ commitments. For example, ‘trying to do too much’ and ‘not adequately
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TABLE 1.
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Themes, subthemes, number of responses and examples
Theme
No. responses
Example of responses
Night shift Rest breaks
15 10
Health and well-being
Shift work Overtime Long shifts Insufficient sleep Sleep difficulties Sleep hygiene High/excessive workload Understaffing –
7 6 4 16 12 5 13 2 8
Work–life balance Environment
– –
Long shifts, inability to rest Inconsistent, late or an absence of rest breaks: variation in meal times Cumulative effect of shift work Working beyond shift end time Reduced opportunity for recovery Lack of sleep, difficulty sleeping before shifts Insomnia despite fatigue, being ‘not a good sleeper’ Poor sleep facilities Busy workload Inadequate/decreasing crew Too much alcohol, reduced ability to exercise, exhaustion Family and study commitments Rural area, hot weather
Working time
Sleep
Workload
Sub-theme
6 3
preparing self for night shift’. Extended commute to work was also associated with significant fatigue.
Environment There were a small number of responses citing environmental factors contributing to fatigue. These responses included being located in a ‘rural area’, being exposed to ‘hot weather’ and being ‘not adequately prepared for heatwaves/bushfire crises’.
Discussion The present study is the first to identify factors that paramedics self-report as contributing to fatigue. In line with a scientific understanding of fatigue, sleep/wake history, time of day and task-related factors were identified as contributing to fatigue. However, paramedics often defined these factors in practical terms. For example, insufficient sleep, long shifts, night shifts, workload and the timing of rest breaks were all cited as contributing to paramedic fatigue. In some cases, paramedics’ attributions of fatigue deviated from a scientific understanding of direct causes of fatigue. Poor sleep hygiene was one such factor. Paramedics reported poor sleep facilities, including noise from family members and home environments not conducive to sleep. These factors presumably lead to insufficient sleep, extended wake or circa-
dian misalignment of sleep/wake and, consequently, fatigue.8 Similarly, poor diet, alcohol consumption and inability to exercise were identified as contributing to fatigue. These findings are consistent with previous research demonstrating a link between lifestyle, demographic factors, sleep and fatigue.18,19 Factors, such as poor sleep hygiene and lifestyle factors, presumably result in reduced sleep or prolonged wake, which are recognised as direct contributors to fatigue.8,18 As such, poor sleep hygiene and lifestyle factors might be thought of as indirect contributors to fatigue. These findings highlight that the factors identified in previous research as directly contributing to fatigue do not adequately explain all instances of fatigue for paramedics. Figure 3 demonstrates the relationship between both indirect and direct contributors to fatigue identified in this paramedic sample. Perhaps what these data best demonstrate are some of the reasons why it might be difficult for paramedics to gain sufficient sleep to mitigate fatigue between shifts. This highlights areas for intervention or education. For example, sleep hygiene education, particularly focused on strategies for creating a home environment conducive to sleep, might be useful. Positive sleep hygiene behaviours have been associated with better sleep quality in other healthcare samples. 20 Strategies to ensure paramedics are able to access healthy food options and time for ex-
Figure 3. A model demonstrating the relationship between indirect and direct contributors to fatigue in paramedics.
ercise, despite shift work rosters, might also mitigate the influence of these factors on self-reported fatigue. Indeed, a recent review of measures to counteract the negative consequences of shift work recommends exercise as an effective countermeasure for fatigue.21 There are also within shift interventions targeted at contributors to fatigue identified in the present study that might assist in mitigating fatigue. For example, inconsistent or late rest breaks were often cited as contributing to performance impairing fatigue.
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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Regular within-shift rest breaks are recognised as an effective way to manage fatigue risk in occupational settings.7 Although this might be complex from an operational point of view, protected break times are likely to significantly moderate performance-affecting fatigue for paramedics.22 These findings demonstrate that paramedics have a broad understanding of ‘fatigue’ and factors contributing to fatigue. It might be critical to take this into account when discussing fatigue with paramedic populations, particularly in the case of education or wellness programmes. This is of particular importance given the potentially serious nature of errors in healthcare,23 and recent evidence showing a link between fatigue and safety in EMS providers.24 To some extent, fatigue risk might be managed by formal policies and procedures. It might also be the case, however, that paramedics employ informal fatiguerelated risk reduction strategies. Indeed a recent review identified the presence of these strategies in multiple shift working populations, including healthcare.14 For example, doctors woken when on-call were asked if they had been woken and, if so, were asked to reiterate their instructions until the caller was satisfied that the doctor was adequately alert to be giving clinical advice.14 Future research should identify and promote protective behaviours that paramedics can employ to safeguard themselves, their patients and the general public when experiencing fatigue at work. This is critical given that there will always be a need for emergency 24 h healthcare and, as such, there might be no shift system that will eliminate fatigue.
Limitations Given the survey measure used, our ability to elicit detailed responses from paramedics was limited. Furthermore, ‘fatigue’ is a multidimensional construct, and there is no current consensus on the definition. This might have influenced responses. However, many shift workers receive education regarding fatigue as it relates to sleep, wake and work, which might have overcome this to some extent. The aim of the present study was to deter-
mine the level and nature of paramedic’s understanding of fatigue. As such, to define fatigue for participants might have confounded findings. Participants were a relatively small sample of convenience, which might limit the external validity of findings. In particular, differences in understanding fatigue might exist between rural and urban paramedics, particularly given recent evidence showing significant differences in the magnitude of subjective fatigue in these groups.25 Similarly, there might be differences between paramedics that work in partnerships or teams, compared with paramedics who operate alone. Analysis of these potential differences should be the focus of future research. Given the paucity of similar research in the area (only three published studies examining fatigue in Australian paramedics),11,12,25 the present paper is intended to establish the need for larger studies investigating fatigue in Australian paramedics. The findings of the present study clearly indicate that continued research into this issue is necessary and provide an important first step on which to base future research efforts.
Conclusions Fatigue poses a significant risk to the health, safety and well-being of paramedics, as well as to the communities they serve. These findings highlight that factors identified in previous scientific research do not adequately explain all instances of fatigue for paramedics. This highlights ways to manage fatigue risk for paramedics. This will help safeguard paramedics from occupational burnout and other adverse outcomes, and ensure the ongoing safe delivery of EMS to the public.
Author contributions JLP conducted the data analysis and was the primary author of the manuscript. SS, together with BW, designed the study protocol and collected the data.
Competing interests None declared.
References 1. Costa G. The problem: shiftwork. Chronobiol. Int. 1997; 14: 89–98. 2. Aasa U, Brulin C, Ängquist K, Barnekow-Bergkvist M. Work-related psychosocial factors, worry about work conditions and health complaints among female and male ambulance personnel. Scand. J. Caring Sci. 2005; 19: 251–8. 3. van der Ploeg E, Kleber RJ. Acute and chronic job stressors among ambulance personnel: predictors of health symptoms. Occup. Environ. Med. 2003; 60(Suppl 1): i40–i6. 4. Åkerstedt T. Shift work and disturbed sleep/wakefulness. Occup. Med. (Lond). 2003; 53: 89–94. 5. Czeisler CA, Duffy JF, Shanahan TL et al. Stability, precision, and near24-hour period of the human circadian pacemaker. Science 1999; 284: 2177–81. 6. Dawson D, McCulloch K. Managing fatigue: it’s about sleep. Sleep Med. Rev. 2005; 9: 365–80. 7. Williamson A, Friswell R. Fatigue in the workplace: causes and countermeasures. Fatigue Biomed. Health Behav. 2013; 1: 81–98. 8. Williamson A, Lombardi DA, Folkard S, Stutts J, Courtney TK, Connor JL. The link between fatigue and safety. Accid. Anal. Prev. 2011; 43: 498– 515. 9. Pirrallo RG, Loomis CC, Levine R, Woodson BT. The prevalence of sleep problems in emergency medical technicians. Sleep Breath. 2012; 16: 149– 62. 10. Studnek JR, Fernandez AR. Characteristics of emergency medical technicians involved in ambulance crashes. Prehosp. Disaster Med. 2008; 23: 432–7. 11. Sofianopoulos S, Williams B, Archer F, Thompson B. The exploration of physical fatigue, sleep and depression in paramedics: a pilot study. J. Emerg. Prim. Health Care 2011; 9: Article 990435. 12. Courtney JA, Francis AJP, Paxton SJ. Caring for the carers: fatigue, sleep, and mental health in Australian paramedic shift-workers. Aust. N. Z. J. Organisational Psychol. 2010; 3: 32– 43. 13. Patterson PD, Weaver MD, Hostler D, Guyette FX, Callaway CW, Yealy
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DM. The shift length, fatigue, and safety conundrum in EMS. Prehosp. Emerg. Care 2012; 16: 572–6. Dawson D, Chapman J, Thomas M. Fatigue-proofing: a new approach to reducing fatigue-related risk using the principles of error management. Sleep Med. Rev. 2012; 16: 167– 75. Walsh B, Cone DC, Meyer EM, Larkin GL. Paramedic attitudes regarding prehospital analgesia. Prehosp. Emerg. Care 2013; 17: 78– 87. Thomas DR. A general inductive approach for analyzing qualitative evaluation data. Am. J. Eval. 2006; 27: 237–46. Green J, Willis K, Hughes E et al. Generating best evidence from qualitative research: the role of data analysis. Aust. N. Z. J. Public Health 2007; 31: 545–50.
18. Di Milia L, Smolensky MH, Costa G, Howarth HD, Ohayon MM, Philip P. Demographic factors, fatigue, and driving accidents: an examination of the published literature. Accid. Anal. Prev. 2011; 43: 516–32. 19. Paterson JL, Dorrian J, Clarkson L, Darwent D, Ferguson SA. Beyond working time: factors affecting sleep behaviour in rail safety workers. Accid. Anal. Prev. 2012; 45(Suppl): 32–5. 20. Brick CA, Seely DL, Palermo TM. Association between sleep hygiene and sleep quality in medical students. Behav. Sleep Med. 2010; 8: 113–21. 21. Pallesen S, Bjorvatn B, Magerøy N, Saksvik IB, Waage S, Moen BE. Measures to counteract the negative effects of night work. Scand. J. Work Environ. Health 2010; 36: 109–21.
22. Folkard S, Tucker P. Shift work, safety and productivity. Occup. Med. (Lond). 2003; 53: 95–101. 23. O’Connor RE, Slovis CM, Hunt RC, Pirrallo RG, Sayre MR. Eliminating errors in emergency medical services: realities and recommendations. Prehosp. Emerg. Care 2002; 6: 107–13. 24. Patterson PD, Weaver MD, Frank RC et al. Association between poor sleep, fatigue, and safety outcomes in emergency medical services providers. Prehosp. Emerg. Care 2012; 16: 86– 97. 25. Courtney JA, Francis AJP, Paxton SJ. Caring for the country: fatigue, sleep and mental health in Australian rural paramedic shiftworkers. J. Community Health 2013; 38: 178–86.
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Emergency Medicine Australasia (2014) 26, 139–144
doi: 10.1111/1742-6723.12216
ORIGINAL RESEARCH
What paramedics think about when they think about fatigue: Contributing factors Jessica L PATERSON,1 Sarah SOFIANOPOULOS2 and Brett WILLIAMS3 1 Appleton Institute, Central Queensland University, Adelaide, South Australia, Australia, 2Operations Department, Ambulance Victoria, Melbourne, Victoria, Australia, and 3Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia
Abstract Objective: Paramedic fatigue is associated with burnout, attrition, sick leave, work disability, physical and mental health complaints and impaired performance. However, no studies have addressed how fatigue is understood by paramedics. The present study addresses this shortcoming by exploring factors paramedics recognise as contributors to fatigue. Methods: Forty-nine (12F; 38 years ± 9.7 years) Australian paramedics completed a survey on perceived causes of performance impairing fatigue. A total of 107 responses were systematically coded following principles common to qualitative data analysis: data immersion, coding, categorisation and theme generation. Results: Six themes emerged: working time, sleep, workload, health and wellbeing, work–life balance and environment. Consistent with a scientific understanding of fatigue, prior sleep and wake, time of day and task-related factors were often identified as contributing to fatigue. In other cases, paramedics’ attributions deviated from a scientific understanding of direct causes of fatigue. Conclusions: These findings demonstrate that paramedics have a broad understanding of fatigue. It is critical to take this into account when dis-
cussing fatigue with paramedics, particularly in the case of fatigue education or wellness programmes. These data highlight areas for intervention and education to minimise the experience of paramedic fatigue and the negative health and safety outcomes for paramedics and patients as a result. Key words: fatigue, shift work, sleep, work hour, workload.
Introduction Paramedics are a critical community resource, providing emergency prehospital care to individuals in crisis. Paramedics typically work shift work schedules that involve the organisation of working hours across the entire 24 h day.1 Shift work requires individuals to work when they are biologically and environmentally inclined to sleep, and vice versa. This mismatch can result in significant fatigue, which is associated with performance impairments and negative health outcomes in paramedic populations,2,3 and in operational settings more generally.4–8 There are three primary causes of fatigue consistently identified in the literature: (i) sleep/wake history, (ii) circadian factors, and (iii) task-related factors.8 In terms of sleep/wake history,
Correspondence: Dr Jessica L Paterson, Appleton Institute, Central Queensland University, PO Box 42, Goodwood, Adelaide, SA 5034, Australia. Email: jessica.paterson@ cqu.edu.au Jessica L Paterson, PhD, Senior Post-Doctoral Research Fellow; Sarah Sofianopoulos, BSc, Bachelor of Emergency Health (Paramedic) (Hons), Ambulance Paramedic; Brett Williams, PhD, Associate Professor, Head of Department. Accepted 7 February 2014
Key findings • Sleep/wake history, time of day and task-related factors were identified as contributing to fatigue. • Paramedics often defined factors contributing to fatigue in practical terms, for example long shifts and workload. • In some cases, paramedics identified indirect contributors to fatigue such as poor sleep hygiene, poor diet and understaffing.
both reduced sleep and extended wake are associated with fatigue.6 Indeed, shift-workers might experience sleep reductions of up to 4 h before morning shifts and following night shifts. 4 Furthermore, the sleep of shift-workers is more likely to occur at times other than during the biological night, representing the role of circadian factors. Circadian rhythms regulate different functions of the body, such as the ability to initiate and maintain sleep, to an approximately 24.2 h cycle.5 Wake that occurs out of synchrony with the circadian drive for wakefulness is characterised by impaired functioning and increased fatigue. In turn, sleep that occurs out of synchrony with the circadian drive for sleep is of reduced restorative value, leading to fatigue. Finally, there are multiple task-related factors associated with fatigue, including workload and time-on-task.7 Existing research reveals that paramedic fatigue is associated with worker burnout and attrition,9,10 sick leave and work disability,3 health complaints, such as headaches and gastrointestinal illness,2 depression, anxiety and
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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stress. 11,12 Paramedic fatigue also impacts upon operational performance and patient and public safety. In one study, 88% of a sample of paramedics reported experiencing fatigue that affected their work performance and almost half of the respondents reported falling asleep while driving.11 Difficulty remembering emergency service protocol,9 difficulty operating the ambulance9 and increased risk of being involved in an ambulance accident10 have also been identified as a result of paramedic fatigue. Research has gone some of the way towards quantifying the risks associated with fatigue for paramedics. Patterson et al.13 suggest ‘within shift interventions’ to mitigate fatigue for paramedics. The authors suggest the use of designated rest periods as a potential intervention but acknowledge that these rest periods might be differentially effective and/or practical for different people and workplaces. In their recent review, Dawson et al. 14 described a series of fatigue reduction strategies used in industries where a reduction in working time was impractical or unsafe (e.g. healthcare and aviation). These strategies were found to be specific to each profession and workplace and to assist in the management of fatigue. It might be the case that there are strategies already in use or easily integrated into paramedic practice that might mitigate fatigue. However, a critical first step to identifying effective interventions is to understand the way fatigue is operationally understood and experienced by paramedics. No studies to date have addressed this question. The present study explores the factors paramedics recognise as significant contributors to fatigue. This will highlight areas for intervention and education to minimise fatigue and the associated negative health and safety outcomes.
Methods Study design The present study used qualitative methods to determine the factors paramedics recognise as contributors to fatigue. A sample of convenience was used. Qualitative methods are considered most appropriate for developing
the ‘theoretical underpinning’ of future quantitative research.15 Given the limitations in current knowledge regarding paramedic fatigue, the present study sought to provide a basis for future research efforts in this area.
Study protocol and setting Data were collected as part of the demographic questionnaire from a larger cross-sectional survey study of paramedics assessing various aspects of sleep, fatigue and well-being. 11 Participants were asked to provide their age, sex and years of employment by an ambulance service as a shift worker (working hours outside of 08.00 hours to 17.00 hours Monday through Friday, response categories 20 years). Participants were then asked: 1. Have you experienced fatigue in the last 6 months? (Y/N) 2. If so, what do you believe this is a result of? (Free text response) 3. Do you believe this fatigue has affected your performance at work? (Y/N) Participants were also asked to indicate if they had ever been diagnosed with narcolepsy, restless leg syndrome, obstructive or central sleep apnoea (Y/N) and if they had, whether they were currently receiving treatment (Y/N). The survey instrument was distributed at the National Symposium for the Journal of Emergency Primary Health Care in April 2010. There were approximately 100 attendees at the conference from around Australia. Attendees were made aware of the nature of the survey and where they could collect a copy should they wish to participate. Participants were provided with a study information sheet, the survey instrument and a pre-paid return envelope. Informed consent was implied through completion of the survey. The completed survey could be returned via a locked drop-box located at the conference centre or return post.
well as how many completed surveys were excluded, are detailed in Figure 1. The majority of participants had been employed by an ambulance service for between 5–10 years (n = 20) and 10– 15 years (n = 12). Seven participants had been employed for 20 years and three for 15–20 years.
Data analysis Many of the 49 participants attributed their fatigue to multiple causes. As such, there were a total of 107 responses for analysis. A general inductive approach to data analysis was used. 16 This approach allows key themes to emerge organically from raw data using data immersion, coding, categorisation and theme generation.17 JP conducted the initial reading, coding and categorisation of responses. These analyses resulted in six themes (see Results). An independent coder was then given a subset of the full dataset (24 responses chosen at random) and asked to assign each response to one of the six themes, or to indicate if the response fit into multiple themes. Overall, there was a 95% agreement rate between coders. Coded data were then presented to SS and BW, both qualified paramedics, to determine the validity of the coding process. This process, known as a member check, is important for establishing the credibility of findings, as it allows ‘participants in the settings studied . . . the chance to comment on whether the categories and outcomes . . . relate to their personal experiences’.16
Results Six themes emerged from the 107 responses to ‘what do you believe this (your fatigue) is a result of?’ The relative weighting of these themes, and the number of associated responses, is represented in Figure 2. Each theme, subtheme, the number of responses associated with each subtheme and an example of responses in included in Table 1 and detailed below.
Study population Data from 49 paramedics (12F; mean age 38 years ± 9.7 years) were the focus of the present study. The number of participants included in the study, as
Working time One of the most common reasons cited for fatigue related to ‘working time’ was night shift. Long night shifts and
© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
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FACTORS CONTRIBUTING TO PARAMEDIC FATIGUE
Work–life Environment balance (3 responses) (6 responses) Health and well-being (8 responses) Working time (42 responses)
Workload (15 responses)
Sleep (33 responses)
Figure 2. Relative weighting of each analytic theme and number of responses associated with each theme.
night shifts. Poor quality sleep was also cited. For example, ‘interrupted sleep patterns’, ‘lack of sleep quality’ and ‘broken sleep patterns’. Finally, a small number of responses highlighted issues related to sleep hygiene including ‘poor sleep facilities’ or a ‘home environment not conducive to sleep’.
Workload The majority of responses related to workload were ‘high or excessive workload’. Responses specified that both ‘high utilisation/workload’ and ‘busy workload’ were associated with fatigue. An additional response specified that ‘increasing workload on night duty’ was associated with fatigue. A small number of responses classified as workload were related to understaffing, particularly ‘inadequate/decreasing crew’. Figure 1. Number of participants included in the study after inclusion/exclusion criteria were applied.
an inability to rest during night shifts were specifically associated with fatigue and performance impairment, as were inconsistent or late rest breaks. Variation in meal times, which reportedly led to ‘eating on the run’ or ‘late or no meal break(s)’, was also reported. Participants also reported fatigue as a result of working beyond their specified shift finish time, which also resulted in reduced recovery opportunity between shifts. For example, it was stated that ‘extra after duty work cuts into sleep time’.
Sleep Insufficient sleep was the dominant reason given for fatigue in this category, such as ‘lack of sleep’ or ‘difficulty sleeping adequately before shifts’ and ‘not enough rest periods between shifts’. Sleep difficulties were also reported including an inability to sleep because of ‘insomnia despite fatigue’, being ‘not a good sleeper’ and ‘changes to circadian rhythms’. Indeed, there was a subgroup of responses related to difficulty obtaining sleep between
Health and well-being Responses related to health and wellbeing factors included dietary factors, such as ‘too much alcohol’ and ‘eating food with lack of sustenance’. Reduced exercise was specified, for example ‘reduced ability to exercise leading to weight gain’. There were also general well-being concerns, such as ‘exhaustion’ and ‘mood change’.
Work–life balance Responses related to work-life balance issues included ‘family’ and ‘study’ commitments. For example, ‘trying to do too much’ and ‘not adequately
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TABLE 1.
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Themes, subthemes, number of responses and examples
Theme
No. responses
Example of responses
Night shift Rest breaks
15 10
Health and well-being
Shift work Overtime Long shifts Insufficient sleep Sleep difficulties Sleep hygiene High/excessive workload Understaffing –
7 6 4 16 12 5 13 2 8
Work–life balance Environment
– –
Long shifts, inability to rest Inconsistent, late or an absence of rest breaks: variation in meal times Cumulative effect of shift work Working beyond shift end time Reduced opportunity for recovery Lack of sleep, difficulty sleeping before shifts Insomnia despite fatigue, being ‘not a good sleeper’ Poor sleep facilities Busy workload Inadequate/decreasing crew Too much alcohol, reduced ability to exercise, exhaustion Family and study commitments Rural area, hot weather
Working time
Sleep
Workload
Sub-theme
6 3
preparing self for night shift’. Extended commute to work was also associated with significant fatigue.
Environment There were a small number of responses citing environmental factors contributing to fatigue. These responses included being located in a ‘rural area’, being exposed to ‘hot weather’ and being ‘not adequately prepared for heatwaves/bushfire crises’.
Discussion The present study is the first to identify factors that paramedics self-report as contributing to fatigue. In line with a scientific understanding of fatigue, sleep/wake history, time of day and task-related factors were identified as contributing to fatigue. However, paramedics often defined these factors in practical terms. For example, insufficient sleep, long shifts, night shifts, workload and the timing of rest breaks were all cited as contributing to paramedic fatigue. In some cases, paramedics’ attributions of fatigue deviated from a scientific understanding of direct causes of fatigue. Poor sleep hygiene was one such factor. Paramedics reported poor sleep facilities, including noise from family members and home environments not conducive to sleep. These factors presumably lead to insufficient sleep, extended wake or circa-
dian misalignment of sleep/wake and, consequently, fatigue.8 Similarly, poor diet, alcohol consumption and inability to exercise were identified as contributing to fatigue. These findings are consistent with previous research demonstrating a link between lifestyle, demographic factors, sleep and fatigue.18,19 Factors, such as poor sleep hygiene and lifestyle factors, presumably result in reduced sleep or prolonged wake, which are recognised as direct contributors to fatigue.8,18 As such, poor sleep hygiene and lifestyle factors might be thought of as indirect contributors to fatigue. These findings highlight that the factors identified in previous research as directly contributing to fatigue do not adequately explain all instances of fatigue for paramedics. Figure 3 demonstrates the relationship between both indirect and direct contributors to fatigue identified in this paramedic sample. Perhaps what these data best demonstrate are some of the reasons why it might be difficult for paramedics to gain sufficient sleep to mitigate fatigue between shifts. This highlights areas for intervention or education. For example, sleep hygiene education, particularly focused on strategies for creating a home environment conducive to sleep, might be useful. Positive sleep hygiene behaviours have been associated with better sleep quality in other healthcare samples. 20 Strategies to ensure paramedics are able to access healthy food options and time for ex-
Figure 3. A model demonstrating the relationship between indirect and direct contributors to fatigue in paramedics.
ercise, despite shift work rosters, might also mitigate the influence of these factors on self-reported fatigue. Indeed, a recent review of measures to counteract the negative consequences of shift work recommends exercise as an effective countermeasure for fatigue.21 There are also within shift interventions targeted at contributors to fatigue identified in the present study that might assist in mitigating fatigue. For example, inconsistent or late rest breaks were often cited as contributing to performance impairing fatigue.
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FACTORS CONTRIBUTING TO PARAMEDIC FATIGUE
Regular within-shift rest breaks are recognised as an effective way to manage fatigue risk in occupational settings.7 Although this might be complex from an operational point of view, protected break times are likely to significantly moderate performance-affecting fatigue for paramedics.22 These findings demonstrate that paramedics have a broad understanding of ‘fatigue’ and factors contributing to fatigue. It might be critical to take this into account when discussing fatigue with paramedic populations, particularly in the case of education or wellness programmes. This is of particular importance given the potentially serious nature of errors in healthcare,23 and recent evidence showing a link between fatigue and safety in EMS providers.24 To some extent, fatigue risk might be managed by formal policies and procedures. It might also be the case, however, that paramedics employ informal fatiguerelated risk reduction strategies. Indeed a recent review identified the presence of these strategies in multiple shift working populations, including healthcare.14 For example, doctors woken when on-call were asked if they had been woken and, if so, were asked to reiterate their instructions until the caller was satisfied that the doctor was adequately alert to be giving clinical advice.14 Future research should identify and promote protective behaviours that paramedics can employ to safeguard themselves, their patients and the general public when experiencing fatigue at work. This is critical given that there will always be a need for emergency 24 h healthcare and, as such, there might be no shift system that will eliminate fatigue.
Limitations Given the survey measure used, our ability to elicit detailed responses from paramedics was limited. Furthermore, ‘fatigue’ is a multidimensional construct, and there is no current consensus on the definition. This might have influenced responses. However, many shift workers receive education regarding fatigue as it relates to sleep, wake and work, which might have overcome this to some extent. The aim of the present study was to deter-
mine the level and nature of paramedic’s understanding of fatigue. As such, to define fatigue for participants might have confounded findings. Participants were a relatively small sample of convenience, which might limit the external validity of findings. In particular, differences in understanding fatigue might exist between rural and urban paramedics, particularly given recent evidence showing significant differences in the magnitude of subjective fatigue in these groups.25 Similarly, there might be differences between paramedics that work in partnerships or teams, compared with paramedics who operate alone. Analysis of these potential differences should be the focus of future research. Given the paucity of similar research in the area (only three published studies examining fatigue in Australian paramedics),11,12,25 the present paper is intended to establish the need for larger studies investigating fatigue in Australian paramedics. The findings of the present study clearly indicate that continued research into this issue is necessary and provide an important first step on which to base future research efforts.
Conclusions Fatigue poses a significant risk to the health, safety and well-being of paramedics, as well as to the communities they serve. These findings highlight that factors identified in previous scientific research do not adequately explain all instances of fatigue for paramedics. This highlights ways to manage fatigue risk for paramedics. This will help safeguard paramedics from occupational burnout and other adverse outcomes, and ensure the ongoing safe delivery of EMS to the public.
Author contributions JLP conducted the data analysis and was the primary author of the manuscript. SS, together with BW, designed the study protocol and collected the data.
Competing interests None declared.
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