What paramedics think about when they think about fatigue: Contributing factors

ORIGINAL RESEARCH

What paramedics think about when they think aboutfatigue: Contributing factorsJessica L PATERSON,1 Sarah SOFIANOPOULOS2 and Brett WILLIAMS3

1Appleton 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

AbstractObjective: Paramedic fatigue is asso-ciated with burnout, attrition, sickleave, work disability, physical andmental health complaints and im-paired performance. However, nostudies have addressed how fatigue isunderstood by paramedics. The presentstudy addresses this shortcoming byexploring factors paramedics recog-nise as contributors to fatigue.Methods: Forty-nine (12F; 38 years ±9.7 years) Australian paramedics com-pleted a survey on perceived causes ofperformance impairing fatigue. A totalof 107 responses were systematicallycoded following principles common toqualitative data analysis: data immer-sion, coding, categorisation and themegeneration.Results: Six themes emerged: workingtime, sleep, workload, health and well-being, work–life balance and environ-ment. Consistent with a scientificunderstanding of fatigue, prior sleepand wake, time of day and task-relatedfactors were often identified as con-tributing to fatigue. In other cases,paramedics’ attributions deviated froma scientific understanding of directcauses of fatigue.Conclusions: These findings demon-strate that paramedics have a broadunderstanding of fatigue. It is criticalto take this into account when dis-

cussing fatigue with paramedics, par-ticularly in the case of fatigueeducation or wellness programmes.These data highlight areas for inter-vention and education to minimise theexperience of paramedic fatigue andthe negative health and safety out-comes for paramedics and patients asa result.

Key words: fatigue, shift work, sleep,work hour, workload.

IntroductionParamedics are a critical communityresource, providing emergencyprehospital care to individuals in crisis.Paramedics typically work shift workschedules that involve the organisa-tion of working hours across the entire24 h day.1 Shift work requires indi-viduals to work when they are bio-logically and environmentally inclinedto sleep, and vice versa. This mis-match can result in significant fatigue,which is associated with performanceimpairments and negative healthoutcomes in paramedic populations,2,3

and in operational settings moregenerally.4–8

There are three primary causes offatigue consistently identified in the lit-erature: (i) sleep/wake history, (ii) cir-cadian factors, and (iii) task-relatedfactors.8 In terms of sleep/wake history,

both reduced sleep and extended wakeare associated with fatigue.6 Indeed,shift-workers might experience sleepreductions of up to 4 h before morningshifts and following night shifts.4

Furthermore, the sleep of shift-workersis more likely to occur at times otherthan during the biological night, rep-resenting the role of circadian factors.Circadian rhythms regulate differentfunctions of the body, such as the abilityto initiate and maintain sleep, to an ap-proximately 24.2 h cycle.5 Wake thatoccurs out of synchrony with the cir-cadian drive for wakefulness is char-acterised by impaired functioning andincreased fatigue. In turn, sleep thatoccurs out of synchrony with the cir-cadian drive for sleep is of reduced re-storative value, leading to fatigue.Finally, there are multiple task-relatedfactors associated with fatigue, includ-ing workload and time-on-task.7

Existing research reveals that para-medic fatigue is associated with workerburnout and attrition,9,10 sick leave andwork disability,3 health complaints,such as headaches and gastrointesti-nal illness,2 depression, anxiety and

Correspondence: Dr Jessica L Paterson, Appleton Institute, Central Queensland Uni-versity, PO Box 42, Goodwood, Adelaide, SA 5034, Australia. Email: [email protected]

Jessica L Paterson, PhD, Senior Post-Doctoral Research Fellow; Sarah Sofianopoulos,BSc, Bachelor of Emergency Health (Paramedic) (Hons), Ambulance Paramedic; BrettWilliams, PhD, Associate Professor, Head of Department.

Accepted 7 February 2014

Key findings• Sleep/wake history, time of day

and task-related factors wereidentified as contributing tofatigue.

• Paramedics often defined factorscontributing to fatigue in prac-tical terms, for example longshifts and workload.

• In some cases, paramedics iden-tified indirect contributors tofatigue such as poor sleep hygiene,poor diet and understaffing.

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Emergency Medicine Australasia (2014) 26, 139–144 doi: 10.1111/1742-6723.12216

© 2014 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

stress.11,12 Paramedic fatigue alsoimpacts upon operational perfor-mance and patient and public safety.In one study, 88% of a sample of para-medics reported experiencing fatiguethat affected their work performanceand almost half of the respondents re-ported falling asleep while driving.11

Difficulty remembering emergencyservice protocol,9 difficulty operatingthe ambulance9 and increased risk ofbeing involved in an ambulance acci-dent10 have also been identified as aresult of paramedic fatigue.

Research has gone some of the waytowards quantifying the risks associ-ated with fatigue for paramedics. Pat-terson et al.13 suggest ‘within shiftinterventions’ to mitigate fatigue forparamedics. The authors suggest theuse of designated rest periods as a po-tential intervention but acknowledgethat these rest periods might be dif-ferentially effective and/or practical fordifferentpeopleandworkplaces. In theirrecent review, Dawson et al.14 de-scribed a series of fatigue reductionstrategies used in industries where a re-duction in working time was imprac-tical or unsafe (e.g. healthcare andaviation). These strategies were foundto be specific to each profession andworkplace and to assist in the man-agement of fatigue. It might be the casethat there are strategies already in useor easily integrated into paramedic prac-tice that might mitigate fatigue.However, a critical first step to iden-tifyingeffective interventions is tounder-stand the way fatigue is operationallyunderstood and experienced by para-medics. No studies to date have ad-dressed this question. The present studyexplores the factors paramedics rec-ognise as significant contributors tofatigue. This will highlight areas forintervention and education to mini-mise fatigue and the associated nega-tive health and safety outcomes.

MethodsStudy design

The present study used qualitativemethods to determine the factors para-medics recognise as contributors tofatigue. A sample of convenience wasused. Qualitative methods are consid-ered most appropriate for developing

the ‘theoretical underpinning’ of futurequantitative research.15 Given the limi-tations in current knowledge regard-ing paramedic fatigue, the present studysought to provide a basis for future re-search efforts in this area.

Study protocol and setting

Data were collected as part of the de-mographic questionnaire from a largercross-sectional survey study of para-medics assessing various aspectsof sleep, fatigue and well-being.11

Participants were asked to provide theirage, sex and years of employment byan ambulance service as a shift worker(working hours outside of 08.00 hoursto 17.00 hours Monday through Friday,response categories <5 years, 5–10years, 11–15 years, 16–20 years or >20years). 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 af-

fected your performance at work?(Y/N)

Participants were also asked to indi-cate if they had ever been diagnosedwith narcolepsy, restless leg syndrome,obstructive or central sleep apnoea(Y/N) and if they had, whether theywere currently receiving treatment(Y/N).

The survey instrument was distrib-uted at the National Symposium forthe Journal of Emergency PrimaryHealth Care in April 2010. There wereapproximately 100 attendees at theconference from around Australia. At-tendees were made aware of the natureof the survey and where they couldcollect a copy should they wish to par-ticipate. Participants were providedwith a study information sheet, thesurvey instrument and a pre-paidreturn envelope. Informed consent wasimplied through completion of thesurvey. The completed survey could bereturned via a locked drop-box locatedat the conference centre or return post.

Study population

Data from 49 paramedics (12F; meanage 38 years ± 9.7 years) were the focusof the present study. The number ofparticipants included in the study, as

well as how many completed surveyswere excluded, are detailed in Figure 1.The majority of participants had beenemployed by an ambulance service forbetween 5–10 years (n = 20) and 10–15 years (n = 12). Seven participantshad been employed for <5 years, sevenfor >20 years and three for 15–20 years.

Data analysis

Many of the 49 participants attribut-ed their fatigue to multiple causes.As such, there were a total of 107responses for analysis. A general in-ductive approach to data analysis wasused.16 This approach allows keythemes to emerge organically from rawdata using data immersion, coding, cat-egorisation and theme generation.17 JPconducted the initial reading, codingand categorisation of responses. Theseanalyses resulted in six themes (seeResults). An independent coder wasthen given a subset of the full dataset(24 responses chosen at random) andasked to assign each response to oneof the six themes, or to indicate if theresponse fit into multiple themes.Overall, there was a 95% agreementrate between coders. Coded data werethen presented to SS and BW, bothqualified paramedics, to determine thevalidity of the coding process. Thisprocess, known as a member check, isimportant for establishing the cred-ibility of findings, as it allows ‘par-ticipants in the settings studied . . . thechance to comment on whether thecategories and outcomes . . . relate totheir personal experiences’.16

ResultsSix themes emerged from the 107 re-sponses to ‘what do you believe this(your fatigue) is a result of?’ The rela-tive weighting of these themes, and thenumber of associated responses, is rep-resented in Figure 2. Each theme, sub-theme, the number of responsesassociated with each subtheme and anexample of responses in included inTable 1 and detailed below.

Working time

One of the most common reasons citedfor fatigue related to ‘working time’was night shift. Long night shifts and

140 JL PATERSON ET AL.


an inability to rest during night shiftswere specifically associated with fatigueand performance impairment, as wereinconsistent or late rest breaks. Vari-ation in meal times, which reported-ly led to ‘eating on the run’ or ‘late orno meal break(s)’, was also reported.Participants also reported fatigue as aresult of working beyond their speci-fied shift finish time, which also re-sulted in reduced recovery opportunitybetween shifts. For example, it wasstated that ‘extra after duty work cutsinto sleep time’.

Sleep

Insufficient sleep was the dominantreason given for fatigue in this cat-egory, such as ‘lack of sleep’ or ‘dif-ficulty sleeping adequately before shifts’and ‘not enough rest periods betweenshifts’. Sleep difficulties were also re-ported including an inability to sleepbecause of ‘insomnia despite fatigue’,being ‘not a good sleeper’ and ‘changesto circadian rhythms’. Indeed, therewas a subgroup of responses relatedto difficulty obtaining sleep between

night shifts. Poor quality sleep was alsocited. For example, ‘interrupted sleeppatterns’, ‘lack of sleep quality’ and‘broken sleep patterns’. Finally, a smallnumber of responses highlighted issuesrelated to sleep hygiene including ‘poorsleep facilities’ or a ‘home environ-ment not conducive to sleep’.

Workload

The majority of responses related toworkload were ‘high or excessiveworkload’. Responses specified thatboth ‘high utilisation/workload’ and‘busy workload’ were associated withfatigue. An additional response speci-fied that ‘increasing workload on nightduty’ was associated with fatigue. Asmall number of responses classified asworkload were related to understaff-ing, particularly ‘inadequate/decreasingcrew’.

Health and well-being

Responses related to health and well-being factors included dietary factors,such as ‘too much alcohol’ and ‘eatingfood with lack of sustenance’. Reducedexercise was specified, for example‘reduced ability to exercise leading toweight gain’. There were also generalwell-being concerns, such as ‘exhaus-tion’ and ‘mood change’.

Work–life balance

Responses related to work-life balanceissues included ‘family’ and ‘study’commitments. For example, ‘tryingto do too much’ and ‘not adequately

Figure 1. Number of participants included in the study after inclusion/exclusion cri-teria were applied.

Work–lifebalance

(6 responses)

Environment(3 responses)

Workingtime

(42 responses)

Sleep(33 responses)

Workload(15 responses)

Health andwell-being

(8 responses)

Figure 2. Relative weighting of each ana-lytic theme and number of responses as-sociated with each theme.

FACTORS CONTRIBUTING TO PARAMEDIC FATIGUE 141


preparing self for night shift’. Extend-ed commute to work was also asso-ciated with significant fatigue.

Environment

There were a small number of re-sponses citing environmental factorscontributing to fatigue. These re-sponses included being located in a‘rural area’, being exposed to ‘hotweather’ and being ‘not adequatelyprepared for heatwaves/bushfire crises’.

DiscussionThe present study is the first to iden-tify factors that paramedics self-reportas contributing to fatigue. In line witha scientific understanding of fatigue,sleep/wake history, time of day andtask-related factors were identified ascontributing to fatigue. However, para-medics often defined these factors inpractical terms. For example, insuffi-cient sleep, long shifts, night shifts,workload and the timing of rest breakswere all cited as contributing to para-medic fatigue.

In some cases, paramedics’ attribu-tions of fatigue deviated from a sci-entific understanding of direct causesof fatigue. Poor sleep hygiene was onesuch factor. Paramedics reported poorsleep facilities, including noise fromfamily members and home environ-ments not conducive to sleep. Thesefactors presumably lead to insuffi-cient sleep, extended wake or circa-

dian misalignment of sleep/wake and,consequently, fatigue.8 Similarly, poordiet, alcohol consumption and inabil-ity to exercise were identified as con-tributing to fatigue. These findings areconsistent with previous research dem-onstrating a link between lifestyle, de-mographic factors, sleep andfatigue.18,19 Factors, such as poor sleephygiene and lifestyle factors, presum-ably result in reduced sleep or pro-longed wake, which are recognised asdirect contributors to fatigue.8,18 Assuch, poor sleep hygiene and lifestylefactors might be thought of as indi-rect contributors to fatigue. These find-ings highlight that the factors identifiedin previous research as directly con-tributing to fatigue do not adequate-ly explain all instances of fatigue forparamedics. Figure 3 demonstrates therelationship between both indirect anddirect contributors to fatigue identi-fied in this paramedic sample.

Perhaps what these data best dem-onstrate are some of the reasons whyit might be difficult for paramedics togain sufficient sleep to mitigate fatiguebetween shifts. This highlights areas forintervention or education. Forexample, sleep hygiene education, par-ticularly focused on strategies for cre-ating a home environment conduciveto sleep, might be useful. Positive sleephygiene behaviours have been associ-ated with better sleep quality in otherhealthcare samples.20 Strategies toensure paramedics are able to accesshealthy food options and time for ex-

ercise, despite shift work rosters, mightalso mitigate the influence of thesefactors on self-reported fatigue. Indeed,a recent review of measures to counter-act the negative consequences of shiftwork recommends exercise as an ef-fective countermeasure for fatigue.21

There are also within shift interven-tions targeted at contributors to fatigueidentified in the present study thatmight assist in mitigating fatigue. Forexample, inconsistent or late restbreaks were often cited as contribut-ing to performance impairing fatigue.

TABLE 1. Themes, subthemes, number of responses and examples

Theme Sub-theme No. responses Example of responses

Working time Night shift 15 Long shifts, inability to restRest breaks 10 Inconsistent, late or an absence of rest breaks: variation

in meal timesShift work 7 Cumulative effect of shift workOvertime 6 Working beyond shift end timeLong shifts 4 Reduced opportunity for recovery

Sleep Insufficient sleep 16 Lack of sleep, difficulty sleeping before shiftsSleep difficulties 12 Insomnia despite fatigue, being ‘not a good sleeper’Sleep hygiene 5 Poor sleep facilities

Workload High/excessive workload 13 Busy workloadUnderstaffing 2 Inadequate/decreasing crew

Health and well-being – 8 Too much alcohol, reduced ability to exercise,exhaustion

Work–life balance – 6 Family and study commitmentsEnvironment – 3 Rural area, hot weather

Figure 3. A model demonstrating the re-lationship between indirect and direct con-tributors to fatigue in paramedics.



Regular within-shift rest breaks are rec-ognised as an effective way to managefatigue risk in occupational settings.7

Although this might be complex froman operational point of view, protect-ed break times are likely to signifi-cantly moderate performance-affectingfatigue for paramedics.22

These findings demonstrate thatparamedics have a broad understand-ing of ‘fatigue’ and factors contribut-ing to fatigue. It might be critical totake this into account when discuss-ing fatigue with paramedic popula-tions, particularly in the case ofeducation or wellness programmes.This is of particular importance giventhe potentially serious nature of errorsin healthcare,23 and recent evidenceshowing a link between fatigue andsafety in EMS providers.24 To someextent, fatigue risk might be managedby formal policies and procedures. Itmight also be the case, however, thatparamedics employ informal fatigue-related risk reduction strategies. Indeeda recent review identified the pres-ence of these strategies in multiple shiftworking populations, includinghealthcare.14 For example, doctorswoken when on-call were asked if theyhad been woken and, if so, were askedto reiterate their instructions until thecaller was satisfied that the doctor wasadequately alert to be giving clinicaladvice.14 Future research should iden-tify and promote protective behav-iours that paramedics can employ tosafeguard themselves, their patients andthe general public when experiencingfatigue at work. This is critical giventhat there will always be a need foremergency 24 h healthcare and, assuch, there might be no shift systemthat will eliminate fatigue.

Limitations

Given the survey measure used, ourability to elicit detailed responses fromparamedics was limited. Furthermore,‘fatigue’ is a multidimensional con-struct, and there is no current consen-sus on the definition. This might haveinfluenced responses. However, manyshift workers receive education re-garding fatigue as it relates to sleep,wake and work, which might haveovercome this to some extent. The aimof the present study was to deter-

mine the level and nature of parame-dic’s understanding of fatigue. As such,to define fatigue for participants mighthave confounded findings. Partici-pants were a relatively small sampleof convenience, which might limit theexternal validity of findings. In par-ticular, differences in understandingfatigue might exist between rural andurban paramedics, particularly givenrecent evidence showing significant dif-ferences in the magnitude of subjec-tive fatigue in these groups.25 Similarly,there might be differences betweenparamedics that work in partner-ships or teams, compared with para-medics who operate alone. Analysis ofthese potential differences should bethe focus of future research. Given thepaucity of similar research in the area(only three published studies examin-ing fatigue in Australian paramed-ics),11,12,25 the present paper is intendedto establish the need for larger studiesinvestigating fatigue in Australian para-medics. The findings of the presentstudy clearly indicate that continuedresearch into this issue is necessaryand provide an important first stepon which to base future researchefforts.

ConclusionsFatigue poses a significant risk to thehealth, safety and well-being of para-medics, as well as to the commu-nities they serve. These findingshighlight that factors identified in pre-vious scientific research do not ad-equately explain all instances of fatiguefor paramedics. This highlights waysto manage fatigue risk for paramed-ics. This will help safeguard paramed-ics from occupational burnout andother adverse outcomes, and ensure theongoing safe delivery of EMS to thepublic.

Author contributions

JLP conducted the data analysis andwas the primary author of the manu-script. SS, together with BW, designedthe study protocol and collected thedata.

Competing interests

None declared.

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What paramedics think about when they think about fatigue: Contributing factors