General effects of work settings and organizational factors on EMS provider

By guest authors Billy Rutherford and Gerald P. Krueger

This is the fourth Vitals article in the EMS Operator Fatigue series. In the previous articles we covered introductory information about our daily need for sufficient quantity of quality sleep, the nature of operator alertness, fatigue on the job and their impacts on performance. We provided insights into the body’s daily circadian physiological rhythms and offered a few pointers about work-rest scheduling.  In this article we address some organizational and environmental considerations for influencing operator alertness, fatigue, and performance of EMS operations.

General effects of EMS fatigue
It’s not easy to pinpoint the full influence of operator fatigue in EMS operations.  However, it is apparent that particularly long work structures, modest to severe sleep deprivation, and in some cases expending physical energy in EMS response calls contributes to compromised levels of on-the-job alertness and performance degradation. Fatigue affects one’s ability to perform at the highest levels of acceptable patient care in which are deemed emergency situations. Fatigue can affect how well we handle a patient in need, how safely we operate the ambulance and how safely we drive home from our place of work after putting in arduous long working hours.  In medical centers where interns and residents put in excessively long shifts, drowsy driver ride-home accidents are fairly common.

Work settings
EMS providers work in a variety of settings including those in private companies for cities, counties, clinics, hospitals, etc. The work settings we could address vary tremendously but our comments are directed mostly to the community of EMS providers working or volunteering in organizations that provide on call and emergency response. 

Job descriptions, work structure, long working hours, scheduling, frequency of response calls, and characteristics of individual employees all interact when we are discussing operator fatigue and on-the-job alertness. 

Work shift scheduling
Shift schedules are based on local needs and preferences.  A study report sanctioned by the International Fire Chiefs Association (Elliot & Kuehl, 2007) identified such work shift differences as day and night shifts of 10-14 hours long, fire departments using three shifts deployed in rotations, 24 hours on 48 hours off formats, alternate 24 hour rotations in an on-off-on-off then 4 off schedule (depending on nuances, called ¾, modified Detroit or modified Berkeley schedules), and 19 variations on those basic three platoon rotation patterns were found to be in use.  The most apparent shift is the 24 hour shift.  Other settings include working schedules of 48 hours on duty and 96 hours off duty. The report indicated many fire fighters have a work week that averages 48 to 56 hours not counting overtime. The report also indicated that EMS provider’s shift structures vary even more widely than fire fighters’ schedules because EMS providers often work for agencies smaller than fire departments. Generally, EMS providers average about 54 hours on duty per week.

We cannot discuss all nuances of EMS staffing patterns in this short article. Suffice it to say, these all matter very much in terms of their impact on an EMS provider’s ability to obtain sufficient quality sleep, the ability to maintain high levels of alertness, and performance on the job.

Holding down other jobs and fatigue development
We cannot ignore the fact that in some EMS settings, providers also hold down other jobs as well.  The number of additional work hours and the nature of that outside work undoubtedly affect EMS provider alertness and fatigue.

Organizational support, fatigue management initiatives
Perhaps the singular message we wish to convey in these short articles is: EMS providers should become aware, attuned to the nuances of operator fatigue, and its influence on performance in their particular operations.  Developing a modest fatigue management program for the work station can go a long way toward making life more palatable.

Persons in leadership positions at all levels should become better informed about worker fatigue and its potential impact not only on the quality of care for emergency patients but for the well-being of the providers. Careful selection of alternate work schedule structures can improve performance which results in employees being more productive, have them feeling better about themselves, their work, their amount to less family, and social disruption attributable to their jobs. 

Fatigue and alertness training
A short 2-3 hour training session on operator fatigue and alertness may be the simplest way to begin the process.  Participating in fatigue training will heighten awareness of all employees on the importance of obtaining quality sleep to manage their levels of alertness for best on-the-job performance. A recent observation inquired whether an EMS provider who is identified as being “too tired to drive the ambulance” should instead be rendered to providing medical care to a patient in the back of the ambulance. Does it make sense to transfer the drowsy worker to accompany the patient?  Getting employees to discuss the topics briefly outlined in this short Vitals article series in a short fatigue and alertness training session could help. 

In-house sleeping arrangements
Another way to begin the process might be to examine the sleeping accommodations provided at the facility for those who spend time sleeping there, i.e. for those taking naps between runs, working overnight shifts, or those who live at the facility for several days per week, etc.  Separate sleeping facilities are not provided in some stations but could be arranged. Common courtesies of remaining quiet while others attempt to sleep can usually be improved. These modifications and other fatigue countermeasures could go a long way to improving EMS operations.

Summary
A variety of work structures, work shift schedules, and outside influences all affect EMS provider fatigue levels. Organizational support of fatigue management programs can begin by providing fatigue and alertness training for all employees by making simple fixes to in-the-station sleeping accommodations. Sensitivity to the needs for sleep by others can improve alertness levels of all EMS providers.

Next Issue: In the next Vitals newsletter we will cover some guidelines for developing fatigue management at your organization.


About the Authors:

Billy Rutherford, MS, President of American Integrated Training Systems, Inc. has managed the development of the USDOT Emergency Vehicle Operator Course (Ambulance).  Billy also managed the development of over 500 hours of Pre-Hospital Computer/Internet Based training.  He has been conducting EVOC Train-the-Trainer Courses Nationwide for over 20 years.  Billy serves as an Expert Witness on cases where there was a serious injury or death when an emergency vehicle was involved.

Gerald P. Krueger, Ph.D., CPE, a research psychologist, is also a certified ergonomist who has spent much of the last 20 years examining issues of commercial driver alertness and driver fatigue (i.e., truck and bus drivers).  Jerry has published numerous articles, and taught courses for DOT on driver fatigue and health and wellness.  He also serves as an expert witness on cases of driver fatigue and driver performance.

In an attempt to stay abreast of NHTSA progress on their research initiative, Billy Rutherford and Jerry Krueger are participating in periodic EMS stakeholders’ meetings on these important topics to all EMS providers.

The information provided in this article is intended for general informational purposes only and should not be considered as all encompassing, or suitable for all situations, conditions, and environments. Please contact us or your attorney if you have any questions.

For safety or risk management questions or suggestions, please contact Markel.

Email us