This paper analyses the effects of fatigue on remote and offshore medics, their performance and the inherent risk of diminished patient care. Fatigue poses a dilemma for the urban care provider; this is often exacerbated in rural areas as shift relief may not always be available. Mental health, behavior, alertness and clinical performance can all be affected and it is often problematic for the remote care giver to maintain adequate measures to prevent a lapse into fatigue given their limited resources. Analyzing different time/resource management techniques will provide possible mitigating solutions that should promote longevity of both the worker and the project.
Effects of Shift Work on Fatigue in the Remote and Offshore Medic
A direct correlation between occupational fatigue and performance has been discussed and ultimately linked to negative safety outcomes in a variety of sectors (1). Little has been done to research remote medical services and how critical rest is in providing adequate care. This paper will review the effects of fatigue on the remote and offshore worker using established urban studies and contrasting the results against rural factors. Although “There is no standard definition of shift work universally (2)” we can however, in this context, take it to mean a normal working time frame set out by the employer to safely manage working hours.
Even external factors such as heat can have a major impact on the maximum amount of workable hours. A comparison of the effects of working hours and fatigue in remote settings would allow us to highlight the potential risks and therefore highlight potential solutions and how we might mitigate them through a variety of management techniques. Inadequate management of resources in a remote setting can often lead to a shortened longevity of a project and restrict the working scope of the personnel involved. Correlating past studies and information will allow us to analyze the most appropriate management techniques and help us to better apply ones that focus on fatigue reduction; whilst ensuring the appropriateness for the remote environment in question.
Studies around the world have brought to the forefront issues of mental health amongst paramedics and other sector workers as long ago as 2004, demonstrating links to poor sleep and extended hours (3,12,18). Whilst the Health and Safety Executive (HSE) in the UK provides guidelines on the effect of shift work on the remote and offshore worker, this is largely based on the emergent patterns in the offshore industry which falls under their jurisdiction (6).
The HSE, whilst providing guidelines for the offshore environment, does not provide much information regarding the remote environment. The offshore environment is highly regulated and shift work patterns are controlled and adhered to in a very strict fashion. A remote medical practitioner, in a local clinic project in the Amazon for example, would be unlikely to have the opportunity to adhere to such a rigid timetable and flexibility must be observed.
The effects of sleep deprivation on an active individual are assessed at length in a study by Akerstedt and, Gillberg (1). Whilst not directly related to the remote medical worker, it does however place the participants of the study under similar sleep deprived circumstances which may be encountered when adequate shift relief is not common place due to their being kept awake for the entire night. This will help to show, alongside other quantifiable studies, the physiological evidence that sleep deprivation affects the circadian rhythm and increases the risk of accidents (5-6,9,13,15,18-20).
Identifying modifiable factors in the remote workers´ tolerance to fatigue, such as diet and lifestyle versus those that are aligned directly with the pattern and number of hours worked is important (2,7-8,11,17). Management practices will need to be based on flexile criteria and methods which will promote better health (physical and mental) and wellbeing of the remote worker. (12,14-17,19,21).
Existing studies of paramedics and nurses (3,12) will allow us to show the effect of fatigue in familiar surroundings. When comparing this with a remote setting, where a worker might not have access to family, friends or familiar foods, allows us to show the additional effects of fatigue that are imposed due to the conditions.
A pertinent source in this paper will be the work completed in studies regarding Australian Rural Paramedic shift workers (4) and comparing it with that of the Emergency Medical Services (EMS) studies in urban settings in a variety of countries (3). Various studies have drawn correlations between EMS fatigue and safety issues (5,9,13,15-16,18-21) and have included methodology such as the Chalder Fatigue Questionnaire (Annex 1) to create an empirical resource for comparison.
HSE sources will also be analyzed to provide a framework with which to compare ideal scenario management techniques from the offshore sector with that of the remote setting. An example of which is “schedules include managed meal times, segregated shifts and daytime darkness for night workers (6)”. These predetermined and proven methods will help put forward a base of ideas that can be adapted to that of the remote medical worker.
Ultimately, patient care is paramount and any identifiable and even preventable lapses in care should be open to discussion. Fatigue can be discussed in an immediate sense but long term burn-out and mental health issues that occur as a result can be included within the definition. Shift work is often used in remote environments and evidence shows that employees with a higher degree of flexibility in their sleep patterns are more satisfied and show more amenability towards shift work patterns (7, 17). Mental resilience also plays a key role in people’s attitudes and outcomes in difficult settings (21). This self-control can be extended to include additional and flexible napping opportunities within the workplace as well as the use of artificial lighting techniques in which darkness or coloured lighting is imposed as and when is needed (8). Limiting shifts to less than 12 hours has also been shown to be highly effective (19).
Studies have shown a positive correlation between fatigue and the potential increased risk of accidents or negative incidents in the work environment in paramedics working extended shift patterns (9,12-13,16,20).
Figure 1: “Conceptual model of the relationship between demanding work schedules and occupational injuries and illnesses (9)”.
Flexible management styles have been proven to be more effective at not only managing the short term fatigue aspects but also mitigating the long term effects and preventing burn-out (10). There is also evidence indicating that not only time management but allowing or enforcing periods of exercise can help prevent fatigue and allow a medical worker to adapt better to the shift work pattern (11).
The stress of being constantly on call in a remote area and having to make tough life or death decisions, possibly entirely on ones own, could hypothetically be compared to the stress of an ICU practitioner and studies have shown that the longer the practitioner is exposed to stress, the more detrimental the effect on their well-being, irrespective of down time or days off (12). In addition to the complications arising in the provider health and patient care there is also the risk of impaired judgement in related activities such as driving. Fatigue and longer working hours have been shown to correlate and cause more road traffic accidents than any other symptom, including intoxication (13), and have even been shown to increase its likelihood (16,20). The remote medical provider may often have to drive considerable distances to reach patients, depending on the type of operational remit they are operating under.
Having analyzed the available evidence, an open and flexible system of shift management, that avoids monotonous task repetition (15), will enable increased longevity of not only the remote and offshore practitioner but the project itself. Ensuring diminished risk of health problems, incidents or lapses in patient care and or burn-out can be achieved via a relaxed approach to napping, engaging practitioners in an exercise regime (11) and providing an adjusted ambiance such as reduced lighting (6-8) or sound proofing; or even sleep inducing substances where appropriate (17). This can be difficult to enforce in remote settings and mitigating circumstances will need to be taken into account such as security, space and available resources. However, it should be possible to use these suggestions as a framework for an appropriate Crew Resource Management (CRM) system to be implemented that reflects the environmental constraints. This should include regular communication and adaptability. It should also include cross checking of work by practitioners to attempt to avoid rushed or impaired decisions that arise due to fatigue. CRM is relatively new in a healthcare setting but early studies, such as those conducted by O´Connor, O´Dea & Keogh, have demonstrated that the effects are positive (22).
The majority of studies in this field have focused on the wellbeing of urban EMS and offshore workers, much more could be done to look into remote practitioners to ensure the best possible strategies are being implemented. HSE does provide guidance, as mentioned, for offshore medics but fails to address the concerns of remote projects outside of the oil and gas industry and their staff (6). The offshore industry in the UK has been highly regulated and falls under the rules of the European Union. Meanwhile projects that are conducted outside of that remit may not adhere so strictly to said regulation.
A further point to focus on is the advent of telemedicine with its use growing dramatically. It is important that access to mental health care provision or telemental health (TMH) is available to the remote practitioner where possible. Researchers have concluded: “The published scientific literature on TMH reveals strong and consistent evidence of the feasibility of this modality of care and its acceptance by its intended users, as well as uniform indication of improvement in symptomology and quality of life among patients across a broad range of demographic and diagnostic groups. (14)”. This can be achieved either through satellite phone conversations, video link or even simple SMS communication. Regular contact between the remote practitioner and their family may help quash any feelings of isolation and act as a form of informal counseling. Opportunities to talk directly with management and be open about problems or issues can be extremely beneficial and often allow problems to be solved before they arise.
Having analyzed a variety of effects of fatigue on practitioners both in an urban and rural setting, it is clear that particular emphasis must be placed on burn-out and mental health issues. Whilst there is strong evidence that general fatigue can lead to increased errors in paramedical practice, it is worth noting that wellbeing and mental health play a larger role in the long term. There are a number of management techniques that can be taken into account when considering options for remote medical projects. Crew Resource Management is on the rise in the health care environment and should certainly be considered as an option as it encompasses both the improvement of both hard and soft skills through regular mediation. These regular discussions can also include debriefings which may lead to information on sleeping arrangements, hard skill improvements and other best practice concepts being shared amongst coworkers.
Emotional health and poor sleep cycles go hand in hand. Using the techniques listed above and tackling the problems together, should lead to better outcomes and a reduction in risk. Well rested practitioners show better cognitive responses and generally have less work related incidents. Whilst being difficult to exercise this in a remote environment, enforced down time may well need to be implemented for the good of both the remote practitioner and the project.
An effective management strategy for minimizing the effects of fatigue in the remote practitioner, should include the following:
- Reduce shift work to ideally less than 12 hours.
- Allow flexible napping opportunities, dependent on the individual’s needs, especially during night shifts.
- Healthy food and exercise opportunities should be given to all employees.
- Mental health problems can be aided with TMH and every opportunity and encouragement should be given to practitioners to make use of these facilities.
- Lighting systems may have to be put into place to convert rooms depending on the type of shift work.
- Restrictions should be placed on driving home after a long shift and adequate facilities provided to ensure practitioners can rest before committing to a journey where they may be the driver.
- An appropriate shift work pattern should be considered for night work where necessary. The circadian rhythm takes time to adapt and short shifts such as 3 days on and 3 days off have proven ineffective in the oil and gas sector due to timeframe needed to adjust circadian rhythm. Longer shifts such as 4 weeks on and 4 weeks off have been shown to be more beneficial.
- Crew Resource Management should be applied and regular reviews should be undertaken. A dynamic approach to CRM will increase the longevity of both practitioner and project and prevent errors due to poor communication as a result of fatigue.
Fatigue is an ever present risk in the remote practitioner, and it is up to both the individual and management structure to identify early strategies to prevent it having unwanted effects upon the individual. Managing fatigue in a remote environment is always going to be a challenge, regardless of the plans put in place, yet every effort must be made to prevent providers falling foul of prolonged exposure to fatigue and it leading to burn-out or mental health problems.
Jimmy McSparron is a Wilderness EMT/HSAR Tech and post-graduate student of Remote and Offshore Medicine with the Royal College of Surgeons of Edinburgh. Originally from the UK, he has been running SAR operations at extreme altitudes and in the jungle for almost a decade. He is a special forces instructor and has trained different units around the world in everything from jungle survival to helicopter operations.
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