Presented by: Sarita Dara, Accident Compensation Corporation at OHSIG 2014, Wednesday 10/9/14, NZI Room 6, 2.45pm

1. Analysis of work patterns and fatigue risk
associated with rotating shift work in surgical
intensive care unit nurses
presented by
Dr Sarita Dara
MBBS, MD (Aerospace Medicine), Master of Space Studies (International Space University),
Grad Dip Occupational Medicine (National University Singapore), Post Grad Dip Public Health (Massey University)
OHSIG 2014

2. Presentation Outline
1. Background
2. Objectives
3. Methods
4. Results
5. Conclusion
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3. Shift work is “any work that requires an individual to be awake when they would normally be asleep if their day was
totally unscheduled”
Composite map of the world assembled from data acquired by the Suomi NPP satellite in April and October 2012. Credit: NASA Earth Observatory/NOAA NGDC
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4. Fatigue in Healthcare
• Extended shifts, night shifts and rotating shift work are common in
healthcare domain
• Sleep deprived healthcare workers are susceptible to the effects of
fatigue on cognition (Cognitive Human Factors)
• Impact on health and safety of healthcare workers (Workplace Safety
and Health)
• Impact on patient safety (Public Health Medicine)
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5. Fatigue in healthcare
• Long working hours and night shift work is rite of passage – Medical culture
• No of hours on the job and hours without sleep is equal to professionalism and dedication to
patient care (Leape, 1994)
• Limited acceptance and awareness of fatigue
• Pilots were least likely to deny the effects of fatigue on performance as compared to physicians
- 26% pilots vs. 60 % medical respondents (Sexton et al, 2000)
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6. Hospital based iatrogenic injuries (US) – 180,000/ year ( equivalent of three jumbo jet crashes every 2 days) – (Leape, 1994)
Chartered flights
No of encounters for each fatality
Total lives lost per year
1 10 10
2
10
3
10
4
10
5
10
6
10
7
10
5
10
4
10
3
10
2
10
1
DANGEROUS
(> 1/ 1000)
REGULATED ULTRA SAFE
(< 1/ 100K)
Driving
Chemical
Manufacturing
Scheduled Airlines
European Railroads
Nuclear power
Health care
(USA)
Mountain
Climbing
Bungee Jumping
Adapted from Lucian Leape, 2002
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How does healthcare compare ?

7. Human Factors in Healthcare
“ Medical errors …eighth leading cause of death in United States and
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most of the errors are preventable (IOM, 1999)”
More commonly, errors are caused by faulty systems, processes,
and conditions that lead people to make mistakes or fail to prevent
them.
“…extended-duration work shifts in interns were associated with an
increased risk of significant medical errors, adverse events and
attentional failures …” (Barger et al, 2009)
Risk : Likelihood x Consequences

8. Managing fatigue risk in healthcare
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Fatigue Risk Management Framework – sequential phased approach
Findings of only a part of the research discussed in this presentation

9. Fatigue Risk Management System (FRMS)
• Fatigue Risk Management System (FRMS) is a new approach to managing fatigue
• “Scientifically based, data driven alternative to prescriptive hours of work limitations which
manages employee fatigue in a flexible manner appropriate to the level of risk exposure and
nature of operation.”
• Can be integrated with the health and safety management system
• FRMS is a recommended practice in the Aerospace sector (International Civil
Aviation Organisation)
• Fatigue is managed by traditional working time regulation in healthcare
• Can FRMS principles be adapted to healthcare sector to manage fatigue ?
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10. Fatigue Risk Management System
• Fatigue risk recognition and assessment
• Identify risk groups (people)
• Timing of fatigue (shifts / rotations are at increased risk)
• Impact of fatigue risk, based on the tasks performed (severity)
• Fatigue management
• Work time arrangements including shift work scheduling
• Rest scheduling and napping
• Work environment and task modification
• Individual countermeasures
• Monitoring of fatigue risk
• Continuous improvement
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11. • Work Related
• Shift duration
• Shift type (morning, afternoon or night)
• No of consecutive night shifts
• Time off work between shifts
• Nature of shift rotation
• Speed of shift work rotation
• Workload
• Non work Related
• Social and family commitments
• Life stress events
• Illness
Antecedents
Consequences
• Work related
• Performance degradation
• Diminished perception
• Problems with short term memory
• Slow reaction times
• Settling for less in performance
• Channelled concentration
• Poor decisions
• Poor communication
• Non work related
• Adverse health and safety impact
• Personal and social impact
Fatigue
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Work rosters and fatigue risk

12. Objectives
• To describe and analyse the work roster of the SICU nurses to better
define their work patterns
• To perform a fatigue risk assessment of their work roster using the
healthcare specific risk assessment tool
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13. Methods
• Surgical Intensive Care Unit (SICU) at a tertiary hospital in Singapore
• Nurses on rotating shift
• Cross sectional analysis
• SICU nurses work roster for a defined 7 day period
• Risk Assessment Framework – Australian Medical Association’s
National Code of Practice – Hours of work, shift work and rostering
for hospital doctors
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14. SICU Work Roster
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• 7 day work roster for all SICU nurses
• Inclusion criteria
• Nurses assigned to do rotating shift for the defined period of observation and
involved in the delivery of patient care
• Exclusion criteria
• Nurses not on rotating shift
• Nurses on administrative duties

15. SICU roster codes
• based on various start and end times
• basic patterns
• day
• morning
• afternoon
• night
• up to 32 types of shift work arrangements
noted
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** rest breaks is inclusive

16. Australian Medical Association’s National Code of Practice – Hours of
work, shift work and rostering for hospital doctors
S. No Risk factor Low (1 point) Significant (2 points) High (3 points)
1 Hours worked <50 hours 50 - 70 hours >70 hours
2 Shift length All shifts ≤10 hours Any 1 shift upto 14 hours Any 2 shift ≥14 hours
3 Scheduled shift hours As per scheduled shift hours Any 1 shift longer than
scheduled , but < 24 hours
Any shift longer than
scheduled , but ≥ 24 hours
4 Breaks ≥ 3 1 - 2 0
5 Overtime 0 -10 hours >10 hours >20 hours
6 On call (days) 0-2 days 3-6 days 7 days
7 Night shift 0 -1 2 ≥3
8 Rest opportunity in
between shifts
Minimum 10 hours break and
≥ 2 days free of work
Minimum 10 hours break
and 1 day free of work
< 10 hours break on at least 2
work periods and no full day
free of work
9 Shift rotation Forward rotation and
predictable cycle
Forward rotation and
changed cycle
No stable direction or speed
of rotation
10 Roster changes No changes without notice Changes to roster but
schedule predictable
Changes to roster ,
unpredictable schedule
11 Max sleep
opportunity
≥2 full nights ≥1 night of sleep < 1 night of sleep
Total points 11 22 33
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17. AMA Risk Assessment (over a 7 day period )
assumptions for analysis
1. Hours worked: calculated by adding hours at work for each shift (inclusive of breaks)
2. Shift length : Maximum shift length in 7 day period
3. Shift hours: as per schedule
4. Breaks: 1 break except for 12 hour shifts nurses who had 2 breaks
5. Overtime: < 10 hours
6. On call: Only for nurse clinicians (DLT8)
7. Night shift: work at night
8. Rest opportunity: Calculated rest opportunity in between consecutive work shifts
9. Shift rotation: as per pattern ( forward / backward predominant )
10.Roster changes : Yes ; Unpredictable
11.Maximum sleep opportunity: based on nights available for rest in between duty periods
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18. Work roster analysis: Example
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SUBJECT 25 0.00
DAY ROSTER D B TDW
1 N (2100-0730) 10.30 1.00 9.30 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
2 DO 0.00 0.00 0.00 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
3 M (0700-1430) 7.30 1.00 6.30 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
4 A6 (1300-2130) 8.30 1.00 7.30 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
5 M7 (0700-1630) 9.30 1.00 8.30 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
6 RD 0.00 0.00 0.00 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
7 A6 (1300-2130) 8.30 1.00 7.30 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
44.30 39.30
AMA
Risk factor LR SR HR
Hours worked 44.3 1
Shift length 10.30 2
Scheduled shift hours Y 1
Breaks Y 2
Overtime N 1
On call (days) N 1
Night shift Y 1
Rest opportunity in between shifts Y 0 2
Shift rotation BWD 3
Roster changes Y 3
Max sleep opportunity Y 1
TOTAL 6 6 6
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19. Results
• 75 % rosters analysed
• No two rosters had the same shift pattern
• No predictable work pattern noted
• Average working hours over a 7-day period : 43.5 hours ( Range: 25 – 55 hours)
• 82% showed weekly work duration between 40 -50 hours
• Fatigue risk score for rosters
• Mean risk score 16.98 ( Range : Minimum score 14 and maximum 21)
• Fatigue in “Significant Range”
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20. Results
• Off duty rest period ranged from 1 – 4 days
• Higher the number of off duty days , the lower the fatigue risk scores
• Off duty rest opportunity was less than 10 hours in afternoon followed by
morning shift, high fatigue risk scores
• Night duty days ranged from 0 - 3 days per 7 day study period
• 65.7% worked 2 or more nights shifts in the 7 days
• Of these, 82.6% worked 2 consecutive nights
• Higher the number of night shifts per week, greater the fatigue risk score
• At risk shifts
• Night shift ( consecutive nights , > nights per 7 day)
• Afternoon followed by morning shift (less rest opportunity and backward
rotation)
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21. • “5 days on and 2 days off” not uniformly adopted in SICU
• Key contributors to fatigue risk
• Number of night shifts in 7 days
• Duration of rest opportunity in between shifts
• Number of breaks during shift
• Nature of shift rotation
• Unpredictable changes to roster
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Conclusion

22. Conclusion
Recommendations to reduce fatigue risk for work roster
• Limit night shifts to 2 per week
• Allow rest opportunity in between shifts ( min 10 hours in between
shifts)
• Consistent application of 5 days on and 2 days off
• Shift rotation – avoid afternoon morning shift pattern
• Frequent short breaks
• Predictability in rosters
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23. Key lessons learnt
• AMA risk assessment framework - Adapted for use in nurses
• Snapshot of fatigue risk (for the defined period)
• Easy to learn and apply in operational environment / field situations
• Uses work roster as the only input
• Can be used prospectively as well as retrospectively
• Can be used a part of the overall fatigue risk management system
• Recognise, measure and monitor fatigue risk ( may help predict when used as a
prospective tool)
• Better resolution of contribution of risk factors in any particular roster
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24. Acknowledgements
• Collaborators: Taezoon, P, Tan, J., Lim, T.W., Helander, M.
• Faculty, Human Factors Lab, NTU, Singapore
• Staff and Management, SICU, Changi General Hospital, Singapore
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Thank you