How effective are Fatigue Risk Management Systems (FRMS)? A review

A Guided Comparative Analysis of Fatigue Frameworks in Australasian Ambulance Services

OBJECTIVE

Paramedics work in a complex, unpredictable environment, subject to many external stressors including critically unwell patients, dangerous driving conditions, and prolonged shift work. Paramedic fatigue from these and other occupational demands is well documented. Ambulance services attempt to safeguard paramedics from fatigue using internal policies or procedures - a type of Fatigue Risk Management Systems (FRMSs). This study reviews ambulance service fatigue frameworks to understand the current situation in fatigue management in paramedicine, and to identify fatigue monitoring tools, strategies, and other components of these frameworks that are designed to protect personnel.

METHODS

This study involved a qualitative document thematic content analysis. All eleven statutory ambulance services across Australia, New Zealand, and Papua New Guinea, represented by the Council of Ambulance Authorities, were contacted and invited to participate. Fatigue frameworks were collated and entered into NVivo where data extraction occurred through three a priori areas (fatigue, fatigue mitigation tools & fatigue management).

RESULTS

Nine of the eleven ambulance services provided fatigue documentation, with one declining to participate, and one did not respond to invitations. Through thematic analysis and abstraction, seven themes were identified: fatigue definition, consequences of fatigue, sources of fatigue, signs and symptoms of fatigue, fatigue-related incidents, fatigue monitoring tools, and fatigue mitigation. There was also poor alignment between provided frameworks and established FRMSs components.

CONCLUSION

Our findings provide an initial insight into existing ambulance service fatigue frameworks across Australia, New Zealand, and Papua New Guinea. The many inconsistencies in frameworks between ambulance services highlight an opportunity to develop a more consistent, collaborative approach that follows evidence-based FRMSs guidelines.

European Society of Anaesthesiology and Intensive Care consensus document on sustainability: 4 scopes to achieve a more sustainable practice

Climate change is a defining issue for our generation. The carbon footprint of clinical practice accounts for 4.7% of European greenhouse gas emissions, with the European Union ranking as the third largest contributor to the global healthcare industry's carbon footprint, after the United States and China. Recognising the importance of urgent action, the European Society of Anaesthesiology and Intensive Care (ESAIC) adopted the Glasgow Declaration on Environmental Sustainability in June 2023. Building on this initiative, the ESAIC Sustainability Committee now presents a consensus document in perioperative sustainability. Acknowledging wider dimensions of sustainability, beyond the environmental one, the document recognizes healthcare professionals as cornerstones for sustainable care, and puts forward recommendations in four main areas: direct emissions, energy, supply chain and waste management, and psychological and self-care of healthcare professionals. Given the urgent need to cut global carbon emissions, and the scarcity of evidence-based literature on perioperative sustainability, our methodology is based on expert opinion recommendations. A total of 90 recommendations were drafted by 13 sustainability experts in anaesthesia in March 2023, then validated by 36 experts from 24 different countries in a two-step Delphi validation process in May and June 2023. To accommodate different possibilities for action in high- versus middle-income countries, an 80% agreement threshold was set to ease implementation of the recommendations Europe-wide. All recommendations surpassed the 80% agreement threshold in the first Delphi round, and 88 recommendations achieved an agreement >90% in the second round. Recommendations include the use of very low fresh gas flow, choice of anaesthetic drug, energy and water preserving measures, "5R" policies including choice of plastics and their disposal, and recommendations to keep a healthy work environment or on the importance of fatigue in clinical practice. Executive summaries of recommendations in areas 1, 2 and 3 are available as cognitive aids that can be made available for quick reference in the operating room.

How much advance notice do workers need? A review and theoretical framework for determining advance notice periods for unpredictable work

Regulatory guidance materials for fatigue management typically advise that employees be provided with days or weeks of advance notice of schedules/rosters. However, the scientific evidence underpinning this advice is unclear. A systematic search was performed on current peer reviewed literature addressing advance notice periods, which found three relevant studies. A subsequent search of grey literature to determine the quality of evidence for the recommendation for advance notice periods returned 37 relevant documents. This review found that fatigue management guidance materials frequently advocated advance notice for work shifts but did not provide empirical evidence to underpin the advice. Although it is logical to suggest that longer notice periods may result in increased opportunities for pre-work preparations, improved sleep, and reduced worker fatigue, the current guidance appears to be premised on this reasoning rather than empirical evidence. Paradoxically, it is possible that advance notice could be counterproductive, as too much may result in frequent alterations to the schedule, particularly where adjustments to start and end times of the work period are not uncommon (e.g., road transport, rail). To assist organisations in determining the appropriate amount of advance notice to provide, we propose a novel theoretical framework to conceptualise advance notice.

Interindividual variability in coherence between self-reported alertness and performance in shift workers

OBJECTIVES

Evidence indicates that self-reported measures of alertness do not always reflect performance impairments. The present study aims to explore whether subjective and objective measures of vigilance vary in the same direction in individuals working nights.

METHODS

A total of 76 police officers participated to a month-long observational study. They worked either a 2 or 3-shift system during which they self-reported alertness and completed a psychomotor vigilance task several times a day.

RESULTS

A reduction in alertness and reaction speed was observed with time awake. At the group level, changes in alertness and reaction speed with time awake were positively correlated during night shifts only. In 63.6% of the officers, changes were coherent between both variables. The other officers reported that their alertness dropped (25.5%) or improved (10.9%) whereas their performance changed in the opposite direction.

CONCLUSION

Significant interindividual variability exists in self-appraisal vigilance impairment due to night shift work.

Human factors in pelvic exenteration: themes in high-performing teams

AIM

The aim of this study was to investigate the role of human factors in pelvic exenteration and how team performance is optimized in the preoperative, intraoperative and postoperative phases.

METHOD

Qualitative analysis of focus groups was used to capture authentic human interactions that reflect real-world multiprofessional performance. Theatre teams were treated as clusters, with a particular focus group containing participants who worked together regularly.

RESULTS

Three focus groups were conducted. Four themes emerged - driving force, technical skills, nontechnical skills and operational aspects - with a total of 16 subthemes. Saturation was reached by group 2, with no new subthemes emerging after this. There was some interaction between the themes and the subthemes. Broadly speaking, driving force led to the development of specialised technical skills and nontechnical skills, which were operationalized into successful service through operational aspects.

CONCLUSION

This study of teams performing pelvic exenteration is the first in the field using this methodology. It has generated rich qualitative data with authentic insights into the pragmatic aspects of developing and delivering a service. In addition, it shows how the themes are connected or 'coupled' in a network, for example technical and non-technical skills. In a complex system, 'tight coupling' leads to both high performance and adverse events. In this paper, we report the qualitative aspects of high performance by pelvic exenteration teams in a complex sociotechnical system, which depends on tight coupling of several themes.

Pediatric nurses' fatigue descriptions in occupational injury reports: A descriptive qualitative study1

BACKGROUND

Despite the high risks associated with occupational fatigue in healthcare, few organizations require nurses to screen and report fatigue symptoms. As a result, little is known about if and how nurses would report fatigue while on the job.

OBJECTIVE

To determine if hospital-based pediatric nurses reported fatigue as part of an active injury reporting method.

METHODS

This secondary analysis of qualitative data used a descriptive design with content analysis. Data from the parent study were collected at a U.S. pediatric hospital where nurses verbally reported on-shift injuries or near misses and pre- and post-shift health status via a digital voice recorder. Researchers used content analysis to independently code data for nurses' references to fatigue. Codes were then analyzed for patterns and themes.

RESULTS

Approximately 30% (n = 104) of participants reported fatigue-related content. Emergent themes were Work Stressors, Individual Risk Factors, Fatigue Descriptors, Adverse Outcomes from Fatigue, Fatigue Buffers, Descriptors for Buffered Fatigue, and Favorable Outcomes from Buffered Fatigue. Fatigue descriptions align with prior literature, demonstrating the accuracy of the voice recorder data collection method. In addition, nurses expressed uncertainty about the appropriateness of reporting fatigue symptoms.

CONCLUSION

Findings from this study support pediatric nurses will report fatigue, when provided an opportunity. Additional efforts are needed to better understand effective ways to improve fatigue reporting among nurses, including harnessing current technology for real-time reporting and how to change the culture around fatigue reporting.

Advancing fatigue management in healthcare: risk-based approaches that enhance health service delivery

Given the need for 24/7 healthcare services, fatigue is an inevitable consequence of work in this industry. A significant body of regulatory advice and hospital services have focused primarily on restricting work hours as the primary method of mitigating fatigue-related risk. Given the inevitability of fatigue, and the limited capacity of labour agreements to control risk, this commentary explores how the principles of fatigue risk management might be applied in a healthcare setting.

A preliminary framework for managing sleep inertia in occupational settings

Sleep inertia, the temporary period of impairment experienced upon waking, is a safety hazard that has been implicated in serious work-related incidents resulting in injuries as well as the loss of life and assets. As such, sleep inertia warrants formal management in industries where personnel are required to undertake their role soon after waking (e.g. emergency services, engineers, and health care). At present, there is a lack of practical, evidence-based guidance on how sleep inertia could be formally managed at an organizational level. We propose a preliminary framework for managing sleep inertia based on the translation of research findings into specific work procedure modifications/control mechanisms. Within the framework, work procedure modifications/control mechanisms to manage sleep inertia are organized into three levels: (1) modifications/controls that eliminate the chance of sleep inertia, (2) modifications/controls that reduce sleep inertia severity, and (3) modifications/controls that manage the risk of errors during sleep inertia. Practical considerations, limitations, and areas of further research are highlighted for each modification/control to help determine how readily each control measure could be implemented by industries at present. A guide for organizations to use this preliminary framework of sleep inertia management is put forward, as well as the next research priorities to strengthen the utility and evidence base of the framework. This paper is part of the Sleep and Circadian Rhythms: Management of Fatigue in Occupational Settings Collection.

Nighttime working as perceived by Italian anesthesiologists: a secondary analysis of an international survey

BACKGROUND

No data are available on the working conditions and workload of anesthesiologists during perioperative nighttime work in Italy and on the perceived risks.

RESULTS

We analyzed 1085 responses out of the 5292 from the whole dataset. Most of the responders (76%) declared working a median of 12 consecutive hours during night shifts, with an irregular nightshift schedule (70%). More than half of the responders stated to receive a call 2-4 (40%) or 5 times or more (25%) to perform emergency procedures and/or ICU activities during night shifts. More than 70% of the responders declared having relaxation rooms for nighttime work (74%) but none to be used after a nightshift before going back home (82%) and no free meals, snacks, or beverages (89%). Furthermore, almost all (95%) of the surveyed anesthesiologists declared not having received specifical training or education on how to work at night, and that no institutional program has been held by the hospital to monitor fatigue or stress for night workers (99%). More than half of the responders stated having the possibility, sometimes (38%) or always (45%), to involve another colleague in difficult medical decisions and to feel comfortable, sometimes (31%) or always (35%), to call the on-call colleague. Participants declared that nighttime work affects their quality of life extremely (14%) or significantly (63%), and that sleep deprivation, fatigue, and current working conditions may reduce performance (67%) and increase risk for the patients (74%).

CONCLUSIONS

Italian anesthesiologists declare current nighttime practice to negatively affect their quality of life, and their performance, and are thus concerned for their patients' safety. Proper education on night work, starting from traineeship, and implementing institutional programs to monitor stress and fatigue of operators and to support them during nighttime work could be a mean to improve nighttime work conditions and safety for both patients and healthcare workers.

Fatigue as a Cause of Professional Dissatisfaction Among Chinese Nurses in Intensive Care Unit During COVID-19 Pandemic

Aim

To clarify the mediating role of burnout and the moderating role of turnover intention in the association between fatigue and job satisfaction among Chinese nurses in intensive care units (ICU) during the COVID-19 pandemic.

Methods

A cross-sectional survey of fifteen provinces in China was conducted, using an online questionnaire, from December 2020 to January 2021, during the COVID-19 pandemic. A total of 374 ICU nurses (effective response rate: 71.37%) provided sufficient responses. Sociodemographic factors, job demographic factors, fatigue, burnout, job satisfaction, and turnover intention were assessed using questionnaires. General linear modeling (GLM), hierarchical linear regression (HLR) analysis, and generalized additive modeling (GAM) were performed to examine all the considered research hypotheses.

Results

Fatigue was found to be negatively and significantly associated with job satisfaction. Moreover, burnout played a partial mediating role and turnover intention played a moderating role in the relationship between fatigue and job satisfaction.

Conclusion

Over time, a state of physical and mental exhaustion and work weariness among Chinese ICU nurses potentially results in job burnout and consequently promotes the level of job dissatisfaction. The results also found that turnover intention played a moderating role in the relationship between burnout and job satisfaction. Specific policies could be considered to eliminate nurses' fatigue and negative attitudes during times of public health emergencies.

Shift Happens: Emergency Physician Perspectives on Fatigue and Shift Work

Research has shown that shiftworkers experience poor sleep and high levels of fatigue. Although considerable research has been performed on fatigue within many shift-work occupations, very little has been done with emergency physicians (EPs). This qualitative study was conducted with the goal of gaining insight into EPs' perceptions of fatigue at work. Twenty EPs from an academic medical center participated in virtual interviews, with nine open-ended questions asked in a semi-structured interview format. Twelve common topics with four main themes emerged from the interviews. Three of these common themes included sources of fatigue (including both work- and home-related sources), consequences of fatigue (including impacts on individuals and performance), and prevention and mitigation strategies to cope with fatigue. The fourth main theme was the belief in the inevitability of fatigue due to high cognitive load, emotionally taxing work experiences, work unpredictability, and the 24/7 shift-work nature of emergency medicine. EPs' experiences with fatigue are consistent with but extend those of other types of shiftworkers. Our findings suggest that EPs tend to incorporate the inevitability of fatigue at work into their identity as EPs and experience a sense of learned helplessness as a result, suggesting areas for future interventions.

Shift work organization on nurse injuries: A scoping review

BACKGROUND

Extended work hours and shift work can result in mistimed sleep, excessive sleepiness, and fatigue, which affects concentration and cognition. Impaired concentration and cognition negatively affect employee safety.

OBJECTIVE

To examine the evidence of the impact of shift work organization, specifically work hours and scheduling, on nurse injuries including needlestick and sharps injuries, drowsy driving and motor vehicle crashes, and work-related accidents causing a near miss or actual injury to the nurse.

METHODS

A scoping review was conducted using search results from five bibliographic databases.

RESULTS

Through database searching, 7788 articles were identified. During the title and abstract screening, 5475 articles were excluded. Full text screening eliminated 1971 articles. During the data extraction phase, 206 articles were excluded leaving 34 articles from 14 countries in the scoping review. The results of the review suggest a strong association in nurses between long work hours and overtime and an increased risk for needlestick and sharps injuries, drowsy driving and motor vehicle crashes, and other work-related accidents. Rotating shifts increase the risk for needlestick and sharps injuries and other work-related accidents while night and rotating shifts increase the risk for drowsy driving and motor vehicle crashes.

CONCLUSIONS

Proper management of work hours and scheduling is essential to maximize recovery time and reduce or prevent nurse injuries. Nurse leaders, administrators, and managers, have a responsibility to create a culture of safety. This begins with safe scheduling practices, closely monitoring for near miss and actual nurse injuries, and implementing evidence-based practice strategies to reduce these occurrences.

Fatigue Risk Management Systems Diagnostic Tool: Validation of an Organizational Assessment Tool for Shift Work Organizations

Background

This study aimed to determine and define the elements of an Fatigue Risk Management System (FRMS) diagnostic tool to assist an organization in systematically assessing its level of implementation of an FRMS.

Methods

A modified Delphi process was used involving 16 participants with expertise in sleep science, chronobiology, and fatigue risk management within occupational settings. The study was undertaken in two stages 1) review of elements and definitions; 2) review of statements for each element. Each stage involved an iterative process, and a consensus rule of ≥ 60% was applied to arrive at a final list of elements, definitions, and statements.

Results

Stage 1: a review of elements (n = 12) and definitions resulted in a final list of 14 elements and definitions with a consensus of ≥ 60% achieved after 2 Delphi rounds. Stage 2: a review of statements (n = 131) resulted in a final list of 119 statements with a consensus of ≥ 60% achieved after 2 Delphi rounds.

Conclusion

The final FRMS diagnostic tool will enable an organization to systematically assess the level of implementation of their current FRMS and identify gaps and opportunities to reduce risk.

Unravelling the Complexity of Irregular Shiftwork, Fatigue and Sleep Health for Commercial Drivers and the Associated Implications for Roadway Safety

Fatigue can be a significant problem for commercial motor vehicle (CMV) drivers. The lifestyle of a long-haul CMV driver may include long and irregular work hours, inconsistent sleep schedules, poor eating and exercise habits, and mental and physical stress, all contributors to fatigue. Shiftwork is associated with lacking, restricted, and poor-quality sleep and variations in circadian rhythms, all shown to negatively affect driving performance through impaired in judgment and coordination, longer reaction times, and cognitive impairment. Overweight and obesity may be as high as 90% in CMV drivers, and are associated with prevalent comorbidities, including obstructive sleep apnea, hypertension, and cardiovascular and metabolic disorders. As cognitive and motor processing declines with fatigue, driver performance decreases, and the risk of errors, near crashes, and crashes increases. Tools and assessments to determine and quantify the nature, severity, and impact of fatigue and sleep disorders across a variety of environments and populations have been developed and should be critically examined before being employed with CMV drivers. Strategies to mitigate fatigue in CMV operations include addressing the numerous personal, health, and work factors contributing to fatigue and sleepiness. Further research is needed across these areas to better understand implications for roadway safety.

Research gaps and needs for preventing worker fatigue in the transportation and utilities industries

BACKGROUND

The transportation and utilities industries include establishments engaged in the movement of passengers and freight, or the provision of public power, water, and other services. Along with the warehousing industry, they make up the US National Occupational Research Agenda's Transportation, Warehousing and Utilities (TWU) industry sector. In 2018 the sector composed 5% of the US workforce, with approximately 8 million workers. TWU workers experienced 19% of all fatalities among U.S. workers in 2018 and 7% of total occupational injuries and illnesses.

METHODS

Around-the-clock operations, heavy workloads, long and irregular shifts, complicated schedules, and time pressures characterize work across the US TWU sector. However, there are considerable differences in worker priorities and concerns between TWU industries. Major areas of concern within the sector include disparities in work schedules; required training for employee fatigue awareness and prevention; physical and mental job demands; and safety culture.

RESULTS

Strategies for fatigue mitigation are critical to reduce the prevalence of injuries, safety-critical events, and crashes in TWU workers. Further research on the incidence and characterization of fatigue among TWU workers will guide the development of effective mitigation strategies. The influence of work scheduling on missed sleep opportunities and disrupted circadian rhythms should be determined. Evaluation of fatigue mitigation strategies can lead to the adoption of the most effective ones for each TWU industry.

CONCLUSION

Implementation of effective strategies is critical for the health, safety, wellbeing, and productivity of workers in the TWU sector.

National strategy on the integration of sleep and circadian rhythms into public health research and policies: Report from the Canadian Sleep and Circadian Network

Scientists in sleep and circadian rhythms, public health experts, healthcare providers, partners, and stakeholders convened in 2020 for a 2-day meeting organized by the Canadian Sleep and Circadian Network to develop a national strategy for the integration of sleep and circadian rhythms into public health and policies in Canada. The objective of this paper is to present the national strategy that emerged from this meeting of 60 participants from across Canada. The meeting focused on 4 key target priorities: (1) atypical working schedules, (2) sleep and circadian rhythms of children and adolescents, (3) insomnia, and (4) impact of sleep apnea on health. Following constructive discussions over 2 days, it was decided that the following 4 strategic objectives should be prioritized to accelerate the integration of sleep and circadian rhythms into public health policies in Canada: (1) Increase public health sleep and circadian rhythm research, (2) Increase public health education and knowledge mobilization on sleep, (3) Inform and support public health sleep interventions and policies, and (4) Promote sleep health training. The participants recommended that research and public health efforts should address the needs along the continuum of sleep health. The committee noted that strategies and interventions could differ across contexts, settings, sectors, and jurisdictions. The national strategy also identified high-priority research questions in public health and recommended mechanisms to build research capacity, providing a path forward for the integration of sleep and circadian rhythms into public health research and policies.