Introduction
The contemporary world depends on staff members that work under irregular schedules throughout the day (Joyce et al., 2009). Most of these staff members are in crucial work divisions like the paramedic division. Paramedics work irregular shifts throughout the week. Consequently, they sleep for fewer hours than required, in most cases. For paramedics working during night shifts, they sleep for fewer hours than their colleagues who work during the day shift. Moreover, paramedics working during night shifts sleep poorly. Poor sleep during night shifts results in fatigue, impaired alertness, drowsiness during the day, and substandard work performance. Apart from mental and physical problems caused by shift work, it may also lead to domestic disputes and social disturbances (Joyce et al., 2009). Shift work is associated with numerous health complications, which include cardiovascular diseases, reproductive complications, obesity, cancer, and depression. At times, shift work compels paramedic staff members to change their behavior in an attempt to cope with the challenges posed by the nature of their work. For instance, paramedics engage in substance abuse as a way of coping with stress caused by shift work (Joyce et al., 2009).
Paramedics work under a range of clinical abilities, which can be poignant or practical. Therefore, management skills are vital when dealing with critical patients, where experience is paramount, and drifts in concentration or error in judgment may lead to fatality (Joyce et al., 2009). Since paramedics offer exceptionally crucial services, it is imperative to look at the various challenges they face during their day-to-day operations. This topic is crucial since by understanding the challenges encountered by paramedics, their working conditions can be improved, and thus improve the quality of the services they offer. Numerous terms will be used in the literature review. These words include Circadian rhythm, sleep debt, and fatigue among others.
Definition of terms
- Circadian rhythm: This refers to an innate cyclical rhythm that is harmonised with the 24-hour lunar day and sustained by the light and dark cycle and controlling metabolic, physiological, and biological activities.
- Fatigue: This refers to a condition of tiredness, which affects both the body and the mind making it hard for individuals to operate optimally.
- Sleep debt: Refers to deficiency of cumulative sleep built up over a long period. Sleep debt leads to physical and mental fatigue.
In the next section, this paper will look at the various negative effects of shift work on paramedics. The paper will evaluate the differences between sleep in normal setting and in paramedic arena. Moreover, the paper will focus on behavioural changes and long-term health issues that result from shift work. The paper will then give recommendations to overcome these health issues.
Methods
The purpose of the review is to analyse the existing literature on paramedic service providers that focus on the effects of shift work on sleep. The electronic databases used in the review include Medline and NCBI. The key words used in the search strategy included words used in a recent study by Takeyama et al. on the same subject, viz. “‘sleep disorder’; ‘sleep deprivation’; ‘shift work’; ‘fatigue’, ‘occupational stress’, and ‘circadian rhythm’” (2009, pp.206). All articles that contained information relating to sleep disorder or disturbance, work-related stress, and fatigue in the paramedics environment were considered. The selected articles were all written in English. Editorials and letters were excluded. Abstracts and tittles of interest were scrutinised to identify pertinent articles before retrieving the full text of the selected articles. Other articles were obtained from the references in the selected papers.
Discussion
Sleep in normal setting and in paramedic work shift
There is a significant difference between sleep in the normal setting and sleep in the paramedic arena. While people working under normal settings have an established sleeping schedule, paramedics do not have a regular sleeping schedule that they follow. For the paramedics, they are supposed to be always alert to respond to any distress call. Hence, while people working in the normal setting sleep for over eight hours, paramedics sleep for fewer hours. For paramedics, their sleeping period is not defined precisely and they may be compelled to take short naps during their shift (Winwood, Winefield, & Lushington, 2006).
For paramedics, the normal patterns and constant circadian rhythm are disrupted compelling the body to adapt to being awake at a time when it is supposed to be asleep (Winwood, Winefield, & Lushington, 2006). Circadian rhythm is affected by sunlight. Sunlight slows down the rate of melatonin secretion thus reducing chances of one falling asleep. Melatonin is responsible for causing sleep in humans, and is mostly secreted at night. Working at night reduces the rate of melatonin secretion and thus exposes individuals to sleeping disorders during the day. On the other hand, people working under the normal settings have enough sleeping time. Hence, their bodies attain a balance in circadian rhythm thus not experiencing disorders in their sleeping pattern.
Health issues associated with shift work
Sleep deprivation
Paramedics suffer a long-term sleep deprivation. Their career requires them to be conscious of their surroundings. Consequently, most of the time, they are required to be alert and sleep for few hours. Over 50 percent of the available time, paramedics working in the big cities and busy centres sleep for less than two hours in a day. Hence, they spend at least twenty-two hours working (Frakes & Kelly, 2007). This persistent sleep deprivation leads to most of the paramedics experiencing health complications. As paramedics operate under irregular working schedule, it is hard for them to manage their sleeping time. At times, they are recalled to duty immediately after finishing their shift. Hence, they end up not sleeping, leading to most of them experiencing sleep debt. To remain alert throughout their duty, some paramedics prefer taking coffee (Frakes & Kelly, 2007). In return, this affects their normal sleeping habits when they return home from duty. Other paramedics opt to remain alert during the day so that they may sleep early during the night, and try to attain a normal sleep cycle. However, because of the irregularity of their schedule, they are unable to compensate for their sleep debt (Frakes & Kelly, 2007). Some paramedics opt to sleep during the day to compensate for sleep debt without knowing that it affects their sleep cycle.
Shift work deprives ambulance paramedic staffs of their sleep leading to accumulation of sleep and eventually suffering from sleep debt. At times, such staff members may fall asleep even when executing their duties or while driving because of fatigue (Ganza, 2006). Numerous cases of fatal accidents are reported among the ambulance personnel when executing their duties. For instance, in the United States, a paramedic officer died in a fatal car accident. According to Ganza (2006), the long hours worked by ambulance staff members lead to fatigue and stress. At times, staff members suffer from depression making it hard for them to coordinate their activities. Fatigue caused by shift work not only poses a threat to public safety, but also results in loss of life among the paramedics. To arrive at this conclusion, Ganza investigated the cause of fatal car accidents reported in the United States that involved ambulance personnel. He found that, all the accidents were due to fatigue caused by the nature of work the victims engaged in. The study is supported by similar medical literature conducted by Marcus and Louglin and found out that medical residents are vulnerable to car accidents particularly after their shift (Marcus & Louglin, 1996).
Fatigue
Fatigue is a condition of weariness that impinges on both the body and brain making the victim incapable of performing maximally. Fatigue emanates from varied sources like poor diet, sleep disturbances, and lack of invigorating sleep. Occupational stress and shift work also lead to fatigue (Costa, 2003). Fatigue affects concentration, alertness, performance, and mood leading to reduced productivity. Fatigue is blamed for most of the workplace accidents relative to alcohol and drugs. Emergency medical services lead to fatigue and poor sleep quality. Paramedics make one of the groups of healthcare providers that suffer from sleep disorders and fatigue. Paramedics carry heavy equipments as they respond to distress calls. Besides, they walk up and down the buildings and a number of stairs in the various buildings. Moreover, they carry injured and ailing people out of intricate places. All these activities subject them to immense fatigue. Paramedic job is more physically challenging compared to other tasks. Staff members respond to repetitive calls and have limited time to rest. Hence, they get exhausted and this phenomenon impairs their level of concentration and accuracy. This aspect underlines why paramedics report numerous errors when executing their duties.
According to AbuAlRub (2004), shift work leads to low employee performance and increased errors at workplaces. Shift work subjects paramedics to occupational stress. In return, paramedics show poor work efficiency, burnout, decreased job satisfaction, poor quality, and quantity of care, and increased errors. AbuAlRub carried out a study on American and non-American paramedics using a correlation descriptive survey. Two hundred and sixty-three American paramedics and forty non-American paramedics participated in the study. Data was collected through the Internet and the participants responded to a set of structured questionnaires. The study employed varied analysis techniques like hierarchical regression, Pearson product-moment correlations, McCain and Marklin Social Integration Scale.
From the study, it was identified that paramedic performance depends on the magnitude of occupational stress. Employees suffering from fatigue-related stress recorded numerous errors when executing their duties. Cases reported in 2007 among the paramedic officers confirmed AbuAlRub’s study. For instance, a Victorian paramedic inadvertently gave morphine, in place of epinephrine, to a 78-year-old patient suffering from cardiac arrest during a resuscitation process. After investigation, the paramedic officer was pronounced to be suffering from fatigue.
Behavioural changes due to shift work
There is limited literature on the impacts of shift work on behavioural changes among the paramedics. As paramedics try to cope with health problems caused by shift work, they tend to engage in substance abuse. Some of the behavioural changes adopted to help in dealing with challenges caused by uneven work schedule are at times detrimental to paramedic service providers. Trinkoff and Storr (1998) carried out a study to investigate the effects of shift work on alcohol, cigarettes, and drug abuse among the paramedics. The researchers sent questionnaires to 3,917 paramedic employees who responded under the condition of anonymity. Participants were to account for their past year’s trend in smoking coupled with alcohol and drug use. After investigating varied work schedule features such as shift, weekends, shift length, and overtime, the researchers identified that individuals that worked under shift work had high propensity to substance abuse. Staffs working in night shifts claimed that they consumed a lot of alcohol, coupled with intense smoking. On the other hand, paramedics that worked in rotational shifts reported to consume a lot of alcohol. In spite of the findings, the study did not consider other factors like job demand, which might push workers to engage in substance use. Consequently, it is not clear that shift work contributes to substance use, or the habit is fuelled by other factors as job demand in collaboration with shift work.
Long-term health issues
A study that relates shift work to health conditions like cardiovascular diseases, diabetes, obesity, and gastrointestinal problems, is available. The study conducted by Berger and Hobbs (2006) revealed that, working under irregular shift work schedules may lead to an individual suffering from a range of undesirable health complications like cardiovascular, cancer and obesity. It was realised that shift work leads to cancer threats. This was after a study was conducted on paramedic workers. In 2007, a World Health Organization (WHO) subcommittee reached the conclusion that, shift work was somewhat one of the agents that cause cancer. The committee observed that individuals working in nightshifts had 50 percent chances of contracting breast cancer. Besides, there is evidence that shift work subjects employees to prostrate and colorectal cancer (Aasa et al, 2005). In spite of the study proving that shift work leads to cancer, it is not yet clear for how long an individual is supposed to be in shift work to suffer from cancer.
Additional research and recommendations
The long-term wellbeing and health of the paramedic workers rest on their capacity to cope with challenges posed by their schedules. The current literature does not ascertain if schedules that stimulate recurrent circadian rhythm phase changes lead to schedule acceptance or cause schedule intolerance, rhythm desynchronization, and negative health effects (Crowley et al., 2004). To assist paramedics and other shift workers cope with health challenges, a study has to be conducted to identify all the factors that might help in shift work adaptation. Scholars need to explore lifestyle and environmental factors that affect circadian inclination to come up with better mechanisms for helping shift workers. Although sleep deprivation and fatigue are said to be the main causes of health problems experienced by paramedics, it is not clear how long it takes these staff members to show symptoms. Further investigation is required to determine the degree of sleep deprivation that leads to these complications. Besides, there is a need for a study to ascertain if paramedic fatigue is attuned to the terms of offering safe and quality pre-hospital environment.
The studies carried on this subject prove that, paramedic workers experience health problems because of fatigue and stress caused by poor scheduling policies used by their employers. Consequently, to surmount this, the scheduling policies ought to be changed. Shifts that follow a clockwise rotation do not affect the circadian rhythm. Paramedics need to sleep before and after a shift to reduce the chances of suffering from fatigue. In addition, paramedic workers have a role to play in alleviating these health problems (Winwood, Winefield, & Lushington, 2006). Workers should engage in regular physical exercises as they help in synchronization of the circadian rhythm. It is imperative that paramedic workers avoid taking caffeine and fast foods before sleeping. Such foods affect one’s sleep thus leading to sleep debt. Apart from physical exercise and checking on diet, paramedic workers ought to maintain close social and personal relations with people that have experience in the hassles of shift work (Winwood, Winefield, & Lushington, 2006). The experienced fellows would significantly help the paramedic workers in coming up with strategies to meet these hassles without difficulties, thus reducing the chances of experiencing health problems. Rosters ought to be designed in a way that workers are not assigned consecutive night shifts. Furthermore, there is a need to reduce the shift length to two 12-hour shifts every week. Rosters should ensure that, between the shifts staff members have enough time to rest.
Conclusion
As evidenced by the available studies on shift work, this career does adversely affect the amount and quality of sleep of paramedic service providers both locally and globally. Shift work has negative impacts on both the psychological and physical wellbeing of paramedics and other healthcare providers. Most of the pollsters have emphasized on the significance of emotional and mental wellbeing as dominant. As paramedics attempt to cope with challenges caused by the nature of their working environment, they engage in substance use. Most of the paramedics use substances like alcohol, cigarettes, and other drugs. Substance abuse helps the paramedic staffs cope with stress caused by shift work. Shift work is blamed for other health problems like cancer, cardiovascular disease, and diabetes that affect paramedics and other healthcare providers. Changing the working schedule for shift workers would go a long way in alleviating these health problems. The schedule should give workers enough time to rest before and after serving their shift. Behavioural changes and health problems witnessed by paramedic officers are because of fatigue since the staffs work around the clock and have limited time to sleep.
Poor scheduling amplifies the allied risk of incidents and accidents, risking personal and patient safety, like procedural or medical errors. Fatigue impairs the concentration level of these staff members leading to numerous errors as they execute their duties. There is a significant gap in the study of fatigue, sleep deprivation, and patient safety across the globe. Paramedics are regularly confronted with time conscious critical clinical rulings and high-speed driving. In most cases, paramedics respond to these situations while under intense stress. This aspect underlines the reasons why cases of paramedics causing road accidents are prevalent across the globe. Adding fatigue and sleep deprivation to this context is a possible recipe for trouble. To understand the impacts of shift work on sleep, there is a need for further research. Researchers ought to investigate the degree of sleep deprivation that causes health problems reported by shift workers.
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