Q&A: Guidance offers solutions to ‘major drivers of fatigue’ in health care workers

Experts said they developed new guidance that stakeholders can use to design a shift work duration that “effectively balances the need to meet operational demands with the need to manage fatigue-related risks.”

Shift work disorder, “a type of circadian rhythm sleep disorder characterized by complaints of insomnia or excessive sleepiness that occurs in relation to work hours being scheduled during the usual sleep period,” affects 28% to 52% of health care workers, according to a previously published systematic review.

Tailored approaches to resolving the consequences of shift work disorder — not just among those in health care — are necessary, Indira Gurubhagavatula, MD, MPH, an associate professor of clinical medicine at the University of Pennsylvania and director of the Sleep Medicine Clinic at the Veterans’ Affairs Medical Center in Philadelphia, and colleagues wrote. They recently published their guidance on shift work in the Journal of Sleep Medicine.

In an interview with Healio Primary Care, Gurubhagavatula discussed the guidance, the role that health care professionals play in implementing it and more.

Healio Primary Care: How do these new principles change the status quo in determining how long professionals could or should work at one time ?

Gurubhagavatula: Traditionally, working time arrangements were primarily focused on addressing physical fatigue. Duty hours regulations prescribed specific thresholds, which defined the maximum number of hours someone could work per shift and a minimum length of time off between shifts. (For example, 16-hour or 28-hour maximum shift duration for some health care trainees with an average of 1 day off during a 7-day span). This type of arrangement accounts for the fact that the longer we are awake, the more likely we are to experience physical fatigue.

This one-size-fits-all approach doesn’t even begin to scrape the surface in terms of how many other factors can contribute to a worker’s fatigue. For example, time-of-day effects (night vs. day shift or afternoon vs. morning), biological factors (whether the person is a morning type or evening type, age, health conditions), length of commute, whether the work is safety sensitive or not, what sorts of staffing are available, the accumulation of fatigue over multiple shifts and many other factors.

Additionally, we now know that cognitive work (in addition to physical work) can also contribute to the accumulation of fatigue over the course of a shift, and work schedules and timing need to account for this type of fatigue as well. For example, someone who does a lot of lifting and carrying can grow progressively fatigued as their shift goes on, but so can someone who is parsing large amounts of data and exercising clinical judgement in a high-volume medical setting.

Our guidance seeks to address these additional factors.

Healio Primary Care: What prompted these changes?

Gurubhagavatula: A number of factors influenced our decision to develop new guidance.

The proportion of people who work non-traditional shifts is high — many jobs now require night or rotating shifts, or extended work hours during evenings or weekends; many also work second jobs for income. So, the proportion of the population affected by this issue is enormous.

In health care, duty hours regulations applied to medical trainees; attending physicians’ work hours have not received the same attention. Physician and nursing worker shortages and documentation needs have led to greater hours worked in general.

Existing rules do not take into account the concept of mental fatigue or the idea that fatigue can result from more than just number of hours worked. Fatigue can also be due to misalignment of work schedules with the biological clock, number of hours slept or the number of hours the person has spent awake. The risk for errors, injuries and reduced productivity can be impacted by many other biological, social and occupational variables as well.

The American Academy of Sleep Medicine and the Sleep Research Society recognize that a large body of scientific evidence has now accumulated, which can now guide us in formulating new, scientifically informed policies around work shift length and timing. These principles can help design working time arrangements that can improve workplace safety, worker health and performance. It’s a win-win for employers, employees, patients and communities.

Healio Primary Care: What role does the health care community have in implementing these principles?

Gurubhagavatula: The health care community can be helpful in a number of ways.

First and foremost is to ask patients about work schedules: Does the patient work non-traditional shifts/night shifts/long work hours? Do they work second jobs? Do they have caregiver responsibility or a long commute that can reduce the time available for sleep?

Ask about sleep schedules: How much sleep are they getting and is it restful? Do they get rest breaks at work?

Ask about fatigue and its impact: Are they experiencing fatigue at work? Have they had incidents/accidents related to fatigue? Are they making mistakes? Have they been fired, resigned or quit because of fatigue or its consequences? Do they feel drowsy when driving, especially during the commute home?

Ask about sleep habits and symptoms of sleep disorder: Do they keep a regular bedtime and wake-up time? How much caffeine or alcohol do they consume? Are they getting enough exercise? Do they allow sufficient opportunity for sleep daily? Do they have any symptoms of common sleep disorders such as sleep apnea? Insomnia? Restless legs? Sleep phase disorders?

Then, educate patients about the importance of sleep health, the effects of shift work and chronic sleep deprivation and the dangers of drowsy driving, and diagnose and treat common sleep disorders. Help engage the patient in managing their own sleep health. Partner with the patient to institute a fatigue countermeasures plan that is tailored to that patient’s needs.

Health care systems also need to reckon with the impact of work shift lengths on their own workforce. We hope that our guidance generates discussion, new attention and tangible policy shifts that address fatigue across a much broader segment of the health care workforce.

Healio Primary Care: How might these principles impact the day‐to‐day functions of a health care system?

Gurubhagavatula: These principles help address some of the major drivers of fatigue in the health care workforce.

Fatigued workers are more likely to make mistakes — both errors of commission and errors of omission — which can impact patient care and lead to worse clinical outcomes and greater costs to patients and health systems. These workers are more likely to call out sick or be absent, become injured, fall asleep while driving or have a crash (especially during the drive home) perform worse on standardized tests (if they are learners), make mistakes in ordering or interpreting tests, take longer to complete tasks, need do-overs or experience “presenteeism” — whereby the worker is present but underproductive — experience burnout, which has been occurring in epidemic proportions or leave the job. In this last instance, employers then may have to deal with the costs and inconvenience of addressing turnover.

Implementing these principles can improve safety for both workers and patients, improve worker retention and satisfaction, possibly reduce burnout and result in cost savings for institutions.

Day-to-day, this may mean considering a variety of options such as limiting calls and requests during circadian “low” points so that workers are allowed some uninterrupted rest when possible; allowing autonomy in scheduling so that “night owls” and “morning larks” can choose shift schedules that better align with their biological traits, when possible; using forward-rotating rather than backward-rotating shifts for 24/7 operations; providing safe transportation home after an extended shift; having sufficient staffing so that workers have adequate rest opportunities; providing nap rooms if appropriate; allowing workers to work at the top of their skill level to optimize task distribution and efficiency and avoid overtaxing some workers disproportionately; and designing electronic record systems and payer documentation requirements for simplicity and efficiency so that off-hours work can be minimized and rest opportunities created.

Healio Primary Care: What other policies and regulations are needed to reduce fatigue and sleepiness in the workplace? How can the health care community help bring these policies and regulations to fruition?

Gurubhagavatula: Reducing fatigue and sleepiness in the workplace demands a shared responsibility from many stakeholders. The needs and solutions within one particular group, community, specialty or job position may vary greatly from those of another. An analysis of the risk-benefit tradeoffs (which we describe in our guidance) needs to occur before implementing fatigue countermeasures that are effective as well as acceptable to workers and employers and sustainable.

Our guidance offers a number of factors and countermeasures that can be reviewed, weighed and adopted as appropriate. Ongoing surveillance to make sure the plan is working as designed, without unintended negative consequences, is also needed.

Our team is hopeful that these guiding principles will encourage creativity and dialogue and help design working time arrangements that promote worker health and safety, improve patient satisfaction and outcomes and also prove to be economically viable.

References:

D'Ettorre G, et al. Med Lav. 2018;doi: 10.23749/mdl.v109i2.6960.

Guruvhagavatula I, et al. J Clin Sleep Med. 2021;doi:10.5664/jcsm.9512.