Seeking Shift Work Solutions

Shift work can harm sleep, and sleep loss can lead to fatigue and errors—how is that impacting you and your patients?

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

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