Seeking Shift Work Solutions

Guilty. John could not believe what he’d just heard. Just six short months earlier, he’d been working as a paramedic for the local EMS service. One night while driving his partner and their patient to the hospital, something happened. The problem is that John simply does not remember the wreck. He repeated over and over during his testimony that he’d felt fine even though he was approaching the end of a 24-hour shift. He had worked many such shifts before without any problem, and in fact the 24/48 rotation his service provided was his preferred choice because of his personal schedule.

During the trial John heard a lot about sleep deprivation, circadian rhythms, fatigue and even microsleep. He had no idea. He’d never learned about any of this in paramedic school, nor had his employer ever given him any information about how to keep from getting fatigued or the risks associated with long shifts. It didn’t seem fair. John was just trying to get ahead. Like he said in his testimony, he was just doing what so many other paramedics do to succeed: going to school full-time, working his 24/48 and a part-time job to help make ends meet, and helping with his two kids when he could. How could he be convicted of vehicular homicide? He didn’t even remember the wreck.

Shift Work and Fatigue

John’s situation, while hypothetical in this instance, has the potential to be very real. The problem is that, like many other industries, EMS is a 24/7 operation. This requires that services choose schedules that best accommodate around-the-clock operation. EMS schedules and hours worked range widely, from 8 hours a shift to 24. Historically, the shift length preferred by both employees and employers has been 24 hours, followed by 48 off between shifts. A close second is the 12-hour shift, either days, nights or, in some cases, a rotation of both.

In organizations where call volume is slow and employees have time to sleep while on duty, the risks of sleep deprivation and fatigue may be reduced. However, today rural, suburban and urban services alike are becoming busier, because of increases in call volume both absolute and relative to static or reduced staffing. These increases in workload are magnifying the stresses placed on staff, resulting in increases in loss of sleep and fatigue.

Hours worked overall by U.S. employees have risen steadily over the past several decades. With this, the time slept each day has decreased. In 1910 the average sleep time was 9 hours a day. By 1975 that had dropped to 7.5, and today it’s 6.8. More than a third of adults get less than the recommended 7.5–8 hours of sleep each night.¹ In EMS, this reduction is compounded by the 24/7 needs of the industry. Today the majority of departments responding to surveys still report 24-hour shifts as their primary pattern. A 2009 survey indicated more than 54% of EMS services still use 24-hour shifts, around 29% use 12-hour shifts, and only 7% report using either 8- or 10-hour shifts.²

The 24-hour shift structure is often chosen out of tradition, convenience for both employers and employees, or economic reasons. In fact, as EMS organizations become busier and employees are increasingly unable to sleep on duty, extended shifts can pose serious concerns to the health and safety of both employees and patients. The problems can be compounded when employees are allowed to work multiple shifts in a row, part-time jobs, or when their personal schedules preclude adequate sleep between shifts.

The traditional response is to utilize shorter shifts. However, that still leaves a large potential for problems. Managers must do more to assure a complete approach to the challenges associated with the need for 24/7 operations and shifts longer than 8 hours. EMS leaders should work proactively to educate the workforce about the risks of shift work and identify those who may be most at risk of performance and safety issues. One of the most powerful barriers to reducing sleep loss and fatigue is the culture of the medical workplace, which often equates hours on the job and hours without sleep with professionalism and dedication to patient care.³

Questions that relate to the ambulance industry and paramedic/EMT staffing include:

• How long can paramedics and EMTs be expected to work before fatigue creates an unacceptable level of risk?

• How much time for rest between shifts is required to keep fatigue from interfering with subsequent shifts?

• Can/should employers restrict off-duty activities such as part-time jobs or school activities?

• What are the legal risks to both employees and employers related to extended shifts and any fatigue that results?

• What are the potential detrimental health effects associated with extended shifts and lack of appropriate sleep cycles?

• What steps can be taken by both employers and employees to assure employees are well rested and risks associated with fatigue are minimized?

• And finally, whose problem is it, really—the employer, the employee or both?

Circadian Rhythm and Sleep Basics

The need for sleep and body’s pattern of restorative sleep are regulated by a two-process model involving interaction between the homeostatic drive for sleep, which regulates the length and depth of sleep, and the endogenous circadian rhythm (i.e., biological clock), which influences the internal organization of sleep and timing and duration of sleep cycles.³

The circadian rhythm is regulated by the hypothalamus and involves the secretion of the sleep-inducing hormone melatonin. The endogenous rhythm is characterized by predictable periods of maximum sleepiness, usually between 3–5 a.m., and maximum wakefulness during the day. Adults who get fewer than five hours of sleep a night force the homeostatic drive to sleep to increase sharply. Shift work can interrupt the normal circadian rhythm of sleep, resulting in individuals fighting the need to sleep during the overnight hours, when there is a heightened need to sleep, and trying to sleep during the day, when the body’s endogenous process is attempting to produce a heightened sense of alertness.

Any misalignment of sleep time and daily circadian patterns affects the quality and quantity of sleep attained. For instance, sleep cycles that begin at 11 p.m. will lead to higher quality and more consolidated sleep than those that begin at 11 a.m.

Sleep patterns are defined by two distinct sleep stages: rapid eye movement (REM) sleep and non-REM sleep. The latter is further divided into four stages of its own. REM and non-REM stages alternate during the sleep cycle, but generally non-REM sleep dominates the first third of the night, and REM sleep the last third. When sleep is either shortened or fragmented, which often occurs during shift work, it results in an inadequate period of consolidated sleep, and very little time spent in the most important stages (stages 3 and 4 and REM).

If awakened during a sleep period, as during extended EMS shifts, how alert a person is depends on their stage of sleep at the time of awakening. During stage 1 or 2 of non-REM sleep, a person is more likely to awaken feeling alert and refreshed. When awakened during REM sleep, people feel alert and often remember their dreams. However, when awakened from stage 3 or 4 of non-REM sleep, people may experience what is known as sleep inertia, or a state of profound grogginess accompanied by reduced performance.

Fatigue and Its Effects

Fatigue stems from inadequate rest and results in impaired physical and mental abilities. Factors that contribute to fatigue include the time of day a person works, the length of time engaged in work activities (i.e., shift length) and the quality and amount of sleep obtained during and surrounding work hours.

There are numerous industry and individual factors that can contribute to employee fatigue. These include understaffed rosters requiring overtime, personnel working multiple jobs, poor scheduling practices, work-related stress, and environmental factors such as aggressive deployment plans and poor workload management. Individual factors can include age, fitness level, medical conditions, social circumstances, family considerations and the desire for further education (see Table 1).

Fatigue can be classified as either acute or chronic. Acute fatigue is a short-term fatigue experienced as a direct consequence of excessive physical or mental activity. Chronic fatigue occurs over time with a gradual buildup of tiredness often related to a need for restorative sleep. Chronic fatigue effects are magnified by the fact that people’s perceived fatigue and actual fatigue are often not aligned. This can result in people being more tired than they realize or are willing to admit. Thus, it is important for both those affected by fatigue and those who work with them to understand and look for indicators of the effects of fatigue. These are listed in Table 2.

Cognition, Employee Performance and Potential for Error

Research has suggested a linear relationship between fatigue and error rates, and in fact that errors caused by fatigue are comparable to errors made under the influence of alcohol.⁴ It has also found higher levels of negative behavior correlating to sleep deprivation, and that a person going without sleep for 24 hours experiences impairment equivalent to a blood alcohol level of 0.10%.⁵

Findings of this nature should give us pause. No one would allow an employee to work while intoxicated; however, EMS providers work every day while fatigued. The ability of a paramedic or EMT to function at a high level of cognition and with precise decision-making capacity can affect the outcomes of critical patients. Researchers have found numerous cognitive dimensions affected by fatigue.

• Comprehension involves the understanding and interpretation of noticeable cues. It requires the ability to draw on previous knowledge. Paramedics must initiate treatment processes from memory of past experience and protocol. Fatigue could cause a mistake due to misdiagnosis or inability to recall the correct treatment process.

• Projection is the ability to project the current situation into the future. It is important for paramedics and EMTs to predict treatment outcomes based on memories of previous treatments and patient encounters. Fatigue affects memory recall and can reduce the ability to relate experiences to current situations when deciding courses of action.

• Mental simulation ability refers to mental imagery and spatial ability. Paramedics must be able to mentally simulate events when moving critical patients in order to minimize the impact on the patient’s condition or the treatment being applied.

• Performance insight involves the ability to self-monitor one’s performance level and fatigue, and recognize its impact on memory, spatial ability, comprehension, motor function and reaction times.

• Controlling emotion. Paramedics are often in emotion-provoking situations, which can negatively influence decision-making.

Legal Implications

The U.S. Department of Transportation identifies fatigue as the No. 1 safety problem in transportation operations, with a cost of more than $12 billion per year, and NHTSA estimates drowsiness is the primary causal factor in more than 100,000 police-reported motor vehicle crashes each year, resulting in 76,000 injuries and 1,500 deaths.⁶ As a result many states are establishing laws pertaining to driving while distracted, including driving while drowsy. New Jersey now has what is known as Maggie’s Law, which specifically provides that a “knowingly fatigued” driver who causes a fatal accident can be convicted of vehicular homicide. Fatigue in this instance is defined as having been without sleep for a period in excess of 24 consecutive hours. Even in states without specific laws, criminal negligence charges may be levied against drivers who operate while drowsy. One case recently occurred in Georgia when an ambulance operator was charged with reckless driving after he fell asleep while transporting a patient. Witnesses said the ambulance was across the center line for more than 1.5 miles prior to a head-on crash that injured five.⁷

In addition to criminal penalties, fatigued employees may be held liable for injuries they cause under civil law. Additionally, employers can be held liable in civil suits as well under the doctrine of respondeat superior, and could be liable to the public for damages caused by their employees. Additionally, if an employer has knowledge of an employee’s fatigued status, the employer may also be at risk for negligently allowing its fatigued employee to cause an accident or injury to a patient.

A Shared Governance

Employees sometimes place the burden of fatigue on management, which controls shift schedules, duration and frequency. Conversely, employers tend to believe employees work too much and overextend themselves by skirting rules on part-time employment and off-duty activities. Both are right in the sense that neither side can solve our industry’s schedule problems independently. Properly addressing issues of shift work, fatigue and risk takes a cooperative effort.

What can employers do to manage fatigue?

• Identify at-risk workers—Sleep apnea is associated with increased daytime sleepiness, and there are a host of other health conditions that can interrupt employee sleep patterns and the quality of sleep both on and between shifts.

Day versus night preference associated with age poses risks. In general, the ability to adjust to night shift work and extended shifts diminishes with age. Conversely, as studied in the trucking industry, there appears to be greater risk associated with younger drivers than older ones. Older drivers are more likely to limit their exposure to risky driving situations, whereas younger drivers are more prone to risky behavior when operating vehicles in sleep-deprived states. This issue can be particularly concerning for EMS organizations, since, for many reasons, the youngest and most inexperienced employees tend to migrate to night shifts.

• Commuting issues—The most common times of day for drowsiness-related crashes are in the morning and mid-afternoon. This also often coincides with healthcare shift work. The safest approach to this issue is simply not to drive drowsy. Employers can take an active role in this issue by educating staff about the dangers and providing alternative means of transportation for tired staff members or allowing them to take naps before driving home after shifts.

• Structuring work hours—Shift duration, patterns and sequencing unfortunately have yet to be comprehensively studied in the EMS setting; thus the industry tends to look at other facets of healthcare and other industries for information on structuring work hours. Due to the wide variation in current EMS work structures and staffing patterns, it is difficult to make specific recommendations regarding ideal shift structures. However, principles from other healthcare disciplines and industries may be applicable when examining our industry’s shift structures.

In general, fixed shifts are better than rotating shifts, and short shifts are better than longer ones. Shift durations impact both employee and patient safety. Studies show significant increases in vehicle accidents following 24-hour shifts as opposed to shorter shifts.3 Additionally, there is increased risk of medical errors in patient care when working extended shifts. Generally it is recommended that shifts be designed such that employees are able to get at least 7–8 hours of sleep for every 24-hour period. If this is not possible, then shifts should be shortened to 12 hours or less.

Generally, starting times that don’t disrupt the circadian drive to sleep between 3–5 a.m. are better. Thus, 8 a.m. is better than 7 a.m., which is is better than 6 a.m. to begin a shift.

Rotating shifts should generally be avoided. Most rotating schedules change too rapidly to allow circadian rhythm adjustment. However a rotation pattern is chosen, it is better to rotate forward than backward. This is more palatable physiologically because the body’s circadian rhythm tends to run slow, making it easier to delay sleep than to advance it.

?• Regulation—Opinions vary greatly about the need for regulation of work hours and employee activities. Other industries have struggled with acceptance of and adherence to rules they’ve established. Some commercial vehicle industries that attempted to impose regulatory measures found them ineffective, causing a decrease in desired behaviors when punitive actions were enforced. Only positive feedback for compliance, not penalties for violations, created a significant increase in health- and safety-promoting behaviors.⁸

What can employees do to manage fatigue?

• Sleep hygiene and naps—Good sleep habits can improve sleep quality, making it more restorative against the fatigue associated with shift work. For the principles of sleep hygiene, see Table 3.³ Naps, both before the starts of shifts and during them, can be used to provide temporary relief. For those working nights, a two-hour nap in the late afternoon or evening before work can improve alertness. On duty, a 15–20-minute nap every 2–3 hours can significantly mitigate performance declines during extended shifts. However, the duration of a nap must be monitored to avoid sleep inertia or profound grogginess if the person is awakened during the deeper stages of sleep. Those awakened during these deep stages can experience profound grogginess for 30 minutes or longer, especially if they are already experiencing chronic sleep deprivation.

• Regulation of personal schedules—Regulation of personal time is often difficult for persons working in emergency services. However, given the nature of extended shifts, it is important that shift workers ensure they are getting enough rest between shifts. This may mean a redesign of school, family and part-time employment schedules. Attempting to work back-to-back shifts should be avoided, particularly if it forces a person to work more than 18–24 hours without sleep.

Additionally, work to educate family and friends about the importance of restorative sleep, and seek out their support for good sleep hygiene. This can also include neighbors who tend to daytime activities (e.g., cutting their lawns) during the sleep time of an employee working shifts.

Conclusion

Extended and irregular shift patterns create significant risk for both employees and employers in EMS. These include higher rates of accidents, increases in medical errors and declines in proficiencies, higher turnover rates, and lower employee morale. Unfortunately, there is no single solution identified for these problems. To date there is still little research specific to EMS and fatigue issues and outcomes. Therefore, we must continue to develop, test and share strategies unique to our profession. Tradition, bias and personal opinions about shift schedules cannot trump fatigue and its well-demonstrated impact. Our profession and our patients deserve this.

References

1. National Sleep Foundation. Sleep in America/Adult Sleep Habits and Styles Poll 2005, www.sleepfoundation.org/category/article-type/sleep-america-polls.

2. Williams DM. JEMS 2009 salary & workplace survey. J Emerg Med Serv 34(10): 30–8, 42, Oct 2009.

3. Owens JA. Sleep loss and fatigue in healthcare professionals. J Perinat Neonatal Nurs 21(2): 92–100, Apr–Jun 2007.

4. Dawson D, McCulloch K, Baker A. Extended Working Hours in Australia: Counting the Costs, www.drewdawson.com/downloads/reports/extended_work_hours.pdf, 2001.

5. Fletcher A, Lamond L, van den Heuvel CJ, Dawson D. Prediction of performance during sleep deprivation and alcohol intoxication using a quantitative model of work-related fatigue. Sleep Res Online 5(2): 67–75, 2003.

6. Lyznicki JM, Doege TC, Davis RM, et al. Sleepiness, driving, and motor vehicle crashes. JAMA 279: 1,908–13, 1998.

7. Lukachik J. EMS Driver Charged with Reckless Driving. Chattanooga Times Free Press,www.timesfreepress.com/news/2010/oct/20/ems-driver-charged-reckless-driving.

8. Elliot DL, Kuehl KS. Effects of Sleep Deprivation on Fire Fighters and EMS Responders. IAFC, 2007.

Steve Cotter, MBA, NREMT-P, is director of Piedmont Medical Center EMS in Rock Hill, SC. He has been a paramedic and director for both rural and urban EMS services for 19 years.