If only it were that simple: just tell people to get their 8 hours of sleep and develop perfect work schedules, or invent a “magic bullet” that eliminates fatigue, manages the safety risks, and is effective for everyone. Managing the fatigue-related risks in health care is much more complicated. Health care tasks can be very different, so there are diverse operational requirements. The people themselves are very different, so individual differences related to age, gender, experience, sleep need, and many other factors vary widely. The sleep and circadian physiology that underlies fatigue, sleepiness, and performance decrements are complex. Historical precedents are difficult to change, and longstanding practices can be resistant to progress. All of health care is contending with the economics associated with the modern practice of medicine, and addressing any significant patient safety issue will involve cost/benefit scrutiny.
These real-world challenges clearly show that effectively managing fatigue in any 24/7 operational setting is a complex endeavor, with no single or simple solution. Given our human physiological design that includes a requirement for sleep and the powerful control and effects of the circadian clock, it is impractical to believe that fatigue can be eliminated from around-the-clock activities. However, there is no question that the safety-related risks associated with fatigue and impaired alertness can be managed better than current practice.
An extensive scientific literature exists that demonstrates the risks and costs associated with fatigue in health care.1,2 It is clear that health care providers suffer from acute sleep loss, cumulative sleep debt, prolonged periods of continuous wakefulness, and circadian disruption. This physiological disruption is associated with decreased alertness and performance and an increase in errors and risks, including provider car crashes.1-3 No doubt, ongoing research will further define these risks and elaborate the additional outcomes of fatigue in medical practice. However, it is critical to now move beyond just documenting that fatigue is present in 24/7 health care activities and has negative effects on performance and safety. It is time to test and implement effective strategies and approaches that will manage the known risks associated with fatigue in health care.
Classically, the most widely used approach to address fatigue in operational settings is through “hours-of-service” (HOS) regulations. Typically, these regulations establish specific off-duty requirements intended to provide rest opportunities and duty time limitations to prevent extended periods of work and wakefulness. An HOS approach also might address total work hours in a certain number of days or an identified number of days off for recovery. In some HOS structures, the work time within a duty period also has specific limits, for example, drive time for commercial truck operators and flight time for commercial pilots. Recently, the Accreditation Council for Graduate Medical Education (ACGME) utilized this same historical approach to establish intern and resident work hour limitations. There is no question that “HOS” are necessary but insufficient to effectively manage fatigue-related risks. This is true because allowing people to work without limitations will clearly engender fatigue, and providing minimal off-duty periods to prevent acute sleep loss and recovery periods to “zero” cumulative sleep debt are basics of managing fatigue. However, given the complexities previously identified, a general HOS structure cannot be expected to cover every circumstance or individual in health care.
Though an HOS approach is necessary, 2 examples illustrate its limitations. While an off-duty period maybe mandated, this does not guarantee that an individual will obtain required sleep during this time. Whether an individual chooses to remain awake and active, has sleep disturbed by external factors (e.g., noisy environment, sick child), is afflicted with one of the almost 90 identified sleep disorders or a multitude of other possibilities, that individual may not obtain sufficient sleep. Acute sleep loss, regardless of etiology, will degrade subsequent alertness and performance.
Another example involves night work that requires a health care provider to be awake when biologically programmed for sleep by the circadian clock and then attempt to sleep during the day when programmed for wakefulness. Therefore, anyone working through the night is at risk for degraded alertness and performance and the associated errors related to the circadian time of day. Generally, people do not physiologically adjust to night work,4 and successive nights of work increase safety risks.5 While light administration has been used successfully in the laboratory to adjust circadian phase,6 the effective, practical and economically feasible application of this strategy to diverse work settings has yet to be realized. Therefore, the circadian clock will continue to create a physiological fatigue risk for individuals working at night. There is no HOS structure in existence that fully addresses this circadian component; in fact, most policies do not incorporate specific circadian elements because they are so complex.
Alertness Management Program
A comprehensive alertness management approach offers the greatest opportunity to address these issues and involves a multi-component program that includes education, alertness strategies, scheduling practices, healthy sleep, and scientific and policy support.7 An overview of this approach and each component is provided to illustrate the opportunity that a comprehensive alertness management approach offers.
Component 1: Education
Education is the foundation for any effort to address fatigue. At a minimum, the educational component should provide information about the risks associated with fatigue, the physiological mechanisms that underlie fatigue, and available approaches to reduce risks and optimize performance and alertness during operations. Consider that the basis for any significant attitude and behavior change begins with education. Health care provides many such examples where changes in diet, exercise, and smoking begin with educational programs that include information about risks and behavior change. This same approach is a critical first element for any fatigue or alertness management program.
While it is critical to provide an appropriate off-duty sleep opportunity, there is no guarantee that an individual will use the time for sleep. Perhaps the only acceptable approach to address this issue involves providing effective education that portrays the risks associated with not obtaining required sleep before work. It is unlikely that “bed checks” or technological monitoring of individuals to validate sleep will be readily accepted or adopted soon. Similarly, the circadian clock will continue to create physiological risks during the nighttime window of circadian low. It is critical that night workers be informed about this period of reduced alertness and performance, and utilize strategies to manage it.
This education should be provided to all segments within a health care organization. Often, these educational efforts will focus on trainees and physicians. However, nurses, technicians, pharmacists, maintenance personnel, and anyone working irregular schedules are potentially at risk and should be offered, at least, basic fatigue education. Also, a one-time “session” is less likely to create behavior change than information provided in multiple forums and formats and continually over time. Integrating fatigue education into an ongoing program creates the opportunity for this information to become a part of the corporate culture.
Component 2: Alertness Strategies
A second component of a comprehensive alertness management program involves alertness strategies. Beyond just information, the alertness strategies component should include two elements: 1) specific guidance on the effective use of strategies, and 2) establishing appropriate policies and support for implementation of strategies. For example, two well-studied and effective fatigue countermeasures involve planned naps and strategic use of caffeine.8,9 However, it is critical that individuals understand the basics of their effective use. How long should naps be? What is the best timing? What should be done to avoid sleep inertia? These are important considerations to obtain optimal results from naps. In a similar way, information about the strategic and effective use of caffeine will increase the benefits obtained. For example, what dose is needed to enhance alertness and mental functioning, how much caffeine is contained in different drinks and food, and what will be the best timing for ingesting caffeine as an alertness strategy? Examples of some answers to these questions and other strategy implementation information is available in other sources.2,7,10
Another important element of this information should be to assist individuals in discriminating which strategies have a proven scientific basis for their effectiveness and use. When confronted with potential recommendations on “how to stay awake on the job” from a variety of sources (e.g., friends, co-workers, media), what criteria might an individual use to determine their value, efficacy, and safety.
The implementation of alertness strategies often requires policies and corporate support. An explicit policy on the use of planned naps is useful in a variety of ways. First, the policy provides an explicit sanction for the use of planned naps in the context of the work environment. Second, it can delineate specific procedures, timing, and circumstances for its use. Third, it is a mechanism to address any potential concerns about misuse. Beyond policies, corporate support might include the creation of specific nap rooms or some space conducive to obtaining a planned rest period. Also, while some may focus on the use of naps during low workload periods on shift, they can be an invaluable alertness strategy prior to a drive home after a work period. In relation to caffeine, if information about its effective strategic use is provided, then it is critical to have mechanisms in place to make it available when needed.
Similar to the education component, alertness strategies information and policies should be distributed through multiple forums and formats and on an ongoing basis. One example of an integrated education and alertness strategies tool was a video developed on behalf of the American Society of Anesthesiologists.11 This short video includes some basics of fatigue risks and the underlying physiological mechanisms, and concludes with guidance and modeling of how to apply alertness strategies in a health care setting.
Component 3: Scheduling Policies and Practices
The third component of a comprehensive alertness management program involves scheduling policies and practices. At a minimum, this component should focus on 2 core issues. First, a basic “fatigue” analysis can be conducted to determine from a system’s perspective how alertness and performance could be affected by current scheduling policies and practices. This might involve an examination of minimum off-duty times, shift lengths, policies on multiple shifts, consecutive duty periods, recovery opportunities, and other factors. There are at least 14 potential scheduling-related factors that can be evaluated as they relate to alertness and performance.7 This analysis can identify both strengths and vulnerabilities in current scheduling. Second, based on the system analysis, the scheduling strengths should be reinforced and even extended whenever possible. The vulnerabilities identified present an opportunity to adjust scheduling policies and practices to address fatigue-related risks and enhance alertness and performance.
It should be noted explicitly that scheduling issues are the most complex and contentious elements of any comprehensive alertness management program. Scheduling significantly affects both individual health care providers and the organization. From an individual perspective, scheduling policies and practices will affect income, family, and social activities, and off-duty mood and performance.
Component 4: Healthy Sleep
The fourth component of a comprehensive alertness management program involves healthy sleep. At a minimum, this should involve providing information about the existence of the almost 90 sleep disorders that can be diagnosed and treated. Some of the sleep disorders known to affect health and safety, such as sleep apnea or shift work sleep disorder, should be emphasized.12-14 Information can outline classic signs and symptoms, as well as, the potential health and safety risks that may be associated. In this context, information should include resources that identify accredited sleep disorders clinics available for referral, and possibly the extent of insurance coverage for these services. Beyond information and referral sources, it is possible to have a work-based diagnostic and treatment program that identifies and treats individuals with sleep apnea.
Component 5: Scientific and Policy Support
The fifth component of a comprehensive alertness management program involves scientific and policy support. A guiding principle for the program should be the scientific foundation of all alertness management activities. Whenever possible and available, scientific data should be used to guide and create a foundation for each program component. Whether it is the core material provided in the educational activities or examination of scheduling practices, fatigue-related scientific knowledge can create a basis for guiding action.
A central ingredient of a comprehensive alertness management program involves the integration of activities and multiple approaches to address fatigue. The use of these various components provides a more extensive intervention that acknowledges the complex factors that can create fatigue-related risks. Some issues may be most amenable to educational activities, while others may require explicit changes in scheduling practices or overt sanctioning of certain alertness strategies (e.g., naps). An integrated program will ensure that information in the educational component is consistently represented in the strategies and scheduling activities and that the alertness strategies component is supported by appropriate policy. This integration can be a critical element to the success of a comprehensive alertness management program.
The scientific data are clear: fatigue creates safety and health risks in 24/7 operational settings, including health care. Given the complex factors that underlie fatigue, no single or simple solution can be expected to eliminate fatigue-related risks in health care. There are historical approaches, such as HOS policies, that are necessary, but insufficient to fully address the complexity. However, a comprehensive alertness management approach offers an opportunity to address the complex nature of fatigue and reduce the known risks. As more data demonstrating the safety and health risks continue to emerge, it is critical that health care settings move forward with interventions that address fatigue and promote alertness, performance, and safety. If action is not taken, then health care itself may be viewed as hypocritical when attempting to address these same issues with patients or in other occupational settings. However, the current status of efforts in health care regarding fatigue also represents an important and unique opportunity. By acknowledging and addressing fatigue related risks, health care can be a model for other around-the-clock environments and provide leadership on effective interventions that can improve the alertness, safety, and health of our 24/7 society.
Dr. Rosekind is President and Chief Scientist of Alertness Solutions, Cupertino, CA.
- Gaba DM, Howard SK. Fatigue among clinicians and the safety of patients. N Engl J Med 2002;347:1249-55.
- Howard SK, Rosekind MR, Katz JD, et al. Fatigue in anesthesia: implications and strategies for patient and provider safety. Anesthesiology 2002;97:1281-94.
- Barger LK, Cade BE, Ayas NT, et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med 2005;352:125-34.
- Gander PH, Gregory KB, Connell LJ, et al. Flight crew fatigue IV: overnight cargo operations. Aviat Space Environ Med 1998;69(9 Suppl):B26-36.
- Folkard S, Tucker P. Shift work, safety and productivity. Occup Med (Lond) 2003;53:95-101.
- Horowitz TS, Cade BE, Wolfe JM, et al. Efficacy of bright light and sleep/darkness scheduling in alleviating circadian maladaptation to night work. Am J Physiol Endocrinol Metab 2001;281:E384-91.
- Rosekind MR. Managing work schedules: an alertness and safety perspective. In: Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. Philadelphia: Elsevier Science, (in press).
- Committee on Military Nutrition (Institute of Medicine). Caffeine for the sustainment of mental task performance: formulations for military operations. Washington, DC: National Academy of Sciences, 2001.
- Rosekind MR, Graeber RC, Dinges DF, et al. Crew factors in flight operations IX: effects of planned cockpit rest on crew performance and alertness in long-haul operations. NASA Technical Memorandum #108839. Moffett Field, CA: NASA, 1994.
- Rosekind MR, Gander PH, Connell LJ, et al. Crew factors in flight operations X: Alertness management in flight operations. NASA Technical Memorandum #1999-208780. Moffett Field, CA: NASA, 1999.
- Howard SK, Gaba DM, Rosekind MR. Fatigue: Implications for the Anesthesiologist. American Society of Anesthesiologists Patient Safety Videotape Series, Program 29. Park Ridge, IL: American Society of Anesthesiologists, Inc., 1998. Available on the web at: https://www.apsf.org/resource_center/educational_tools/video_library.mspx. (Accessed March 8, 2005)
- Drake CL, Roehrs T, Richardson G, et al. Shift work sleep disorder: prevalence and consequences beyond that of symptomatic day workers. Sleep 2004;27:1453-62.
- Teran-Santos J, Jimenez-Gomez A, Cordero-Guevara J. The association between sleep apnea and the risk of traffic accidents. N Engl J Med 1999;340:847-51.
- The International Classification of Sleep Disorders (Revised): Diagnostic and Coding Manual. Westchester, IL: American Academy of Sleep Medicine, 2001.