Shift Work and fatigue

1. Shift Work and fatigue Prof Philippa Gander PhD, FRSNZ Director, Sleep/Wake Research Centre

2. Outline • Legal requirements • What is fatigue? • Effects of fatigue and shift work • A more comprehensive approach to managing fatigue and shift work • Conclusions

3. HSE Amendment Act (2002) • Fatigue is a hazard than can cause harm • Employers must: • take all practicable steps to prevent harm occurring to employee • adopt a systematic approach to identifying, assessing, and controlling hazards at work. • Employees must: • Arrive fit for work. • Behave safely in the workplace • Cooperate in safety, report hazards • Shift work is a cause of fatigue • Any work pattern that displaces sleep time • New Health and Safety at Work Act • Government intent - into force from 1 April 2015

4. What is fatigue? • Fatigue • A physiological state of reduced mental or physical performance capability • Results from sleep loss or extended wakefulness, circadian phase, or workload (mental and/or physical activity) • Can impair a person’s alertness and ability to work safely and efficiently • Two approaches for managing fatigue • Working time limits • One size fits all • Fatigue risk management • Measure and manage actual fatigue levels and risk Manage the hazard

5. Effects of fatigue and shift work Patient safety Nurse safety, health, well being Physiological effects of shift work

6. Long Hours and Safety (11,516 nurses) Olds DM, Clarke SP (2010) Journal of Safety Research 41: 153-162 Adjusted for nurse characteristics: sex, unit type, age, years of experience as RN, education level, hospital -level staffing, temporary employment, dependents at home, union membership, nursing education outside the USA Needlestick injuries also adjusted for risk factors including starting IVs, routine phlebotomy on last shift, presence of sharps safety devices

7. Shift Work, Sleep, &Safety (365 nurses) Work Days Non-Work Days • 119/365 nurses on rotating (≥4 day/evening shifts, ≥4 night shifts per month) • 2x more likely to nod off driving to or from work • 2x more likely to report accidents/errors due to sleepiness (work-related and driving) • Gold DR et al (1992) American Journal of Public Health 82:1011-1014

8. Nurses: Shift Work and Family Lushington et al., 1997

9. Shift work is a physiological challenge Light sensitive circadian pacemaker in the SCN doesn’t adapt • Trying to work when least functional • Eating at physiologically inappropriate times • Trying to sleep when primed for wake • sleep at night is not just a social convention • Shift work = displaced sleep

10. Sleep and Health • Shift work restricts sleep • Population-based studies - usual sleep < 7 hours increases risk of: • obesity, impaired glucose tolerance, type 2 diabetes mellitus, cardiovascular disease, poor general health and premature mortality • Experimental sleep restriction studies - potential mechanisms • increased caloric intake, decreased physical activity and/or altered thermoregulation, impaired glucose metabolism, increases in blood pressure, sympathetic nervous system activity, and inflammatory markers of cardiovascular risk

11. Shift work a carcinogen? • International Agency for Research on Cancer (IARC) (2007) conclusion, based on: • Limited evidence in humans for the carcinogenicity of shift-work that involves night work • Sufficient evidence in experimental animals for the carcinogenicity of light during the daily dark period (“biological night”) Shift work that involves circadian disruption is probably carcinogenic to humans (Group 2A)

12. A more comprehensive approach Identify fatigue hazards A fatigue risk matrix Other ways of identifying fatigue hazards Act on identified fatigue hazards

13. The perfect roster is permanent day work • Managing sleep opportunities • how fast is sleep debt building up? • how long since 2 full nights of sleep in a row? • Managing risks at work • how tired are staff going to be on this shift? • how difficult are the work demands/conditions? • how long should they keep going? • Getting people home safely • Managing work/life balance • each person reacts differently • regular, predictable work patterns help time management • fair distribution of weekends off • staff input in roster design, management

14. AMA Total Risk Score (last week)

15. Total Risk Score, 1366 NZ RMOs

16. Not only long hours, NZ RMOs Adjusted for: gender, age, sleep habits, number of dependents, commute times, position, time studying, frequency of adequate supervision

17. Data for hazard identification • Incident reports • is fatigue included as a possible contributing factor? • who analyses them? • trends? feedback to staff? • Analyse planned versus actual work patterns • Fatigue reports? • An effective safety reporting culture distinguishes between • unintentional human errors - a normal part of human behaviour managed within the safety system • deliberate violations of rules and established procedures – a disciplinary matter dealt with outside the safety system • A roster risk assessment matrix for nurses

18. Fatigue risk assessment & mitigation • How are other identified hazards managed? • Organizational structures, accountability • all practicable steps • Shared responsibility

19. Conclusions • Shift work and fatigue affect • Patient safety • Nurse safety, health, wellbeing • Shift work and fatigue risk management requires: • More than managing hours of work • Rosters • Identify hazard(s), asses risk, mitigate, monitor • shared responsibility (a ‘whole of life issue’) • workforce/management collaboration • a shared knowledge base • education/training on causes of fatigue, management strategies