Shift Happens: Emergency Physician Perspectives on Fatigue and Shift Work
Abstract
:1. Introduction
1.1. Fatigue at Work
1.2. Emergency Medicine Is Unique
1.3. Fatigue and Fatigue Interventions in Emergency Medicine
1.4. Current Study
2. Results
2.1. The Inevitability of Fatigue in Emergency Medicine (Table 2)
Inevitability of Fatigue * | Comments |
---|---|
Nature of Emergency Medicine (12/17, 28) | “I think fatigue is inevitable in emergency medicine, regardless of where you work. It’s just the nature of the beast. When you have to cover a department that it’s chaos, that literally all hours of the day, we don’t have the luxury of closing the emergency department during inconvenient hours. And you can’t get enough people to work the horrible shifts all the time” “Emergency Medicine is shift work, that’s just the reality and there’s no Emergency Medicine job that’s not shift work. And it’s very rare to find a place where you can just go and say, I only want to work day shifts on these three weekdays and do it.” “Some of the things are just inherent in properties of our job, like it or not. It’s not going to be structured. It’s not going to be one patient at a time, when I’m done with that I can move to the next one. So, I mean, there are going to be interruptions.” “And some people would say, “Well, who cares? You guys don’t work every day, Monday through Friday.” But I think because of the nature of emergency medicine where we don’t have scheduled times, we can have a whole bunch of patients at once, we can have whatever, and then the fact that you can work eight, 10, 12 h and you don’t really have any sort of scheduled... We don’t have lunch hour, right?” “ER medicine has a pretty high burnout rate, and compared to some other specialties. And I think it’s because people start getting to a point where they’re like, “Man, I’m done with the whole all over the place, it’s randomized. I don’t know if I’m working or not, and when I do work, everyone else is off.” “I think most people would have a little less trouble with being fatigued if they have all day shifts, but the department has to run all the time.” |
Nature of Emergency Medicine (12/17, 28)
2.2. Sources of Fatigue
2.2.1. Sources of Fatigue at Work (Table 3)
Sources of Fatigue | Comments |
---|---|
Shift Pattern (13/17, 35) | “Some of the fatiguing factor is that you can have quick turnarounds where you never have a set sleep wake cycle, which really, evidence is out there that obviously impacts people a lot, if you’re constantly going to bed at one night it’s 11:00 PM, the next night it’s 3:00 AM, the next day it’s 7:00 AM, you know?” “If I have a particular month that’s really heavy on nights that aren’t really grouped together well, that’s the kind of schedule that’s the hardest for me. If they’re grouped together so that you can develop some consistency over the period of say a few shifts, that’s fine. But if I have five or six night shifts in a month that are all scattered around and not next to each other, I find those months to be a lot harder, personally.” |
Work Volume (10/17, 17) | “Sometimes the volume ratio between providers and patients can be fatiguing in terms of how much you’re trying to juggle at one time, which is unique to emergency medicine, because most areas of medicine have scheduled appointments or operating room times and stuff, so you don’t have that kind of influx of patient volume and that kind of stress, which I think fatigues people as much as anything.” “I think if there’s a lack of physician coverage, that can be very fatiguing if you’re finding the departments so busy and the flow is off so that you can’t actually get any of your charting done and they just keep bringing patients back, it can be very overwhelming…” |
Blocks of Shifts (10/17, 15) | “I actually will kind of dread the beginning of those stints, but I have two coming up, so tonight is actually my last night before maternity leave, which is very exciting, but I do have two weeks of five in a row coming up with just a day off in between. I will notice that at home, I will start to be less productive; I don’t really want to do the things that I would normally do on a daily basis, because I feel like I have to conserve my energy knowing that I have these shifts coming up. It’s the same if I’m working a string of nights. I feel like I have to conserve my energy. Unfortunately, that also makes it worse, because I want to conserve my energy, so therefore I don’t want to go out and do physical things or be very social, then I can’t sleep because I haven’t been as active during the day. So it all does kind of compound negatively.” “I worked with a resident the other night who it was his fifth night shift in a row. And you could tell by halfway through the night, he was mentally on his way out, just couldn’t take a lot more. And it was my first night, so I was fresh and ready to go.” |
Fatiguing Interactions with Others at Work (7/17, 11) | “So the number one thing is interruptions … the ED doc is constantly interrupted, and you could have a nurse asking you for one thing on your left hand side, and then a tech handing you an EKG while you’re on the phone with someone. So you’re getting interrupted. Say you’re on the phone with someone, you can be interrupted like three different times while you’re on the phone. And so that leads to a lot of fatigue.” “Definitely distractions, I think … the more your attention is diverted away from what you’re doing, the more mental energy you’re expending. And I think that’s very fatiguing over the course of a day.” |
2.2.2. Sources of Fatigue Outside Work (Table 4)
Sources of Fatigue | Comments |
---|---|
Childcare Duties (9/17, 12) | “And some people, they have kids, right? So they get home at 7:00 or 8:00 AM, have to take their kid to school and don’t really fall asleep until later. That’s very tough for your sleep hygiene. That obviously affects your work in the ED.” “So that is tough, just having little kids, for sure. Especially because when you get off your shift, you are the primary caregiver. Even if you have other family members at home, the kids just tend to prefer mom to put them into bed and to do everything. Once I’m home, the kids want me to do it. So I don’t really get to rest after a shift. I just kind of start my second job being a mom.” |
Insufficient Sleep Quality or Quantity (9/17, 11) | “I think sometimes I ask myself, can you have physician wellness without feeling like you have slept well and that your sleep tank is full? I feel like that’s one of our baseline physiological needs is sleep. And I feel like you can’t even begin to talk about physician wellness until you’ve at least made sure everyone’s getting enough sleep.” “Things that contribute to fatigue, not sleeping well, which can also go along with scheduling, but at the same time, it goes along with being nine months pregnant. It’s harder to get really good sleep at night before shifts, and so I think that that can contribute to fatigue.” |
Other Home Duties (4/17, 5) | “And another is just outside of work, that’s just other life issues that need to be addressed, whether that is family or physically just having to address issues, or I should say physically have to be somewhere else, which then decreases your ability to sleep or prepare for your next clinical shift.” |
2.2.3. Consequences of Fatigue at Work (Table 5)
Consequences of Fatigue | Comments |
---|---|
Less Compassion Toward Patients and Colleagues (13/17, 22) | “Your compassion decreases the more tired you get. You just lose that empathy because, yeah, you’re just so tired, and it’s tough then to keep going with that.” “I’ve learned through the years, the first thing to go is my sunny disposition. And when I’m fatigued, I think I still make appropriate decisions and good medical management, but I’m not very nice and can be perceived as rude.” “There is more margin for compassion when rested. And a lot of people in the in-patient who come into the emergency department really need a grandmother. And there’s just a lot more space for that expression of caring that helps those people feel better and feel like they have a handle on what’s going on. Especially when it’s something minor at 3:00 or 4:00 AM when the body is just always tired.” |
Decision-Making Ability Suffers (10/17, 18) | “It affects decision-making as well. There’s a greater probability of errors when people are fatigued. And I actually think there’s some sort of a tendency towards just flat out being a little bit more rash and blowing off things that otherwise might be an obvious concern.” “I find that I can’t think as quickly, make decisions as decisively sometimes. I’ll find myself being a little more indecisive or taking longer to think through things. I feel like I can’t recall information maybe as quickly or I don’t trust that I’m recalling it.” |
Consequences Related to the Quality of Patient Care (7/17, 10) | “I would say, I’m much slower at my job. I see less patients per hour, much less efficient. And certainly, when you’re more tired, like at the end of a shift, you tend to work up patients differently. I’m more aware that I’m tired and then I might not be thinking right, so I’ll order more CAT scans, more blood work, things that may not be necessary for the patient, but to guide me, to make sure I’m not missing something.” |
2.2.4. Consequences of Fatigue Outside Work (Table 6)
Consequences of Fatigue | Comments |
---|---|
Sleep (10/17, 16) | “So more of the emotional shifts I think affect my ability to sleep. If I have a really difficult case or a death of a patient, I think that affects my ability to sleep more than the length of time that I’ve worked. Because usually if I work a long shift and I feel fatigued, I think that I can get to sleep pretty well when I get home, just usually not within the hour of coming home. I kind of have to decompress before my energy level has come down enough to allow me to sleep.” “I know a lot of my colleagues, they have trouble sleeping right when they get home. And that’s especially important after a later shift. If you have a 5:00 PM to 1:00 AM shift and you get home at like 2:00 AM, if you can’t fall asleep for an hour or two it’s 3:00 or 4:00, and then you’re waking up mid morning, and that’s very tough for your sleep-wake cycle. So in terms of sleep strategies, the best thing to do is fall asleep right when you get home. And if you can’t do that, it’s tough.” |
Childcare (5/17, 6) | “It also makes it then tough on family and kids life at home, which I think adds another different layer to fatigue. Because then it puts a strain on relationships at home because you’re already fatigued, and then it’s just a cascade effect.” “If I’m physically tired [from work], my patience is so much less for my kids and I’m much more excited to just get them in bed so I can actually recuperate physically.” |
2.3. Prevention and Mitigation of Fatigue (Table 7)
Prevention and Mitigation Strategies | Comments |
---|---|
Sleep (10/17, 14) | “… to have respect for the amount of sleep that you get. My husband and I were actually talking about that today, how we like that we respect each other’s sleep, that it’s not a luxury to get eight hours of sleep. It’s an absolute necessity for health. It’s like eating the right food every day and working out. Sleep is right up there for us. So I think that would be one thing.” “Definitely looking ahead at your sleep schedule, try and anchor some time. If I’m doing an overnight shift, I will take a nap before that shift. I have to transition then to meetings for the next day. I will definitely try and get back on a daylight circadian rhythm again so I will sleep, but not sleep all day, get myself up.” |
Caffeine (10/17, 12) | “There’s really not much I can do, except for try to force myself to take naps. And then I’m relying a little bit more on caffeine by the third and fourth [shift in a row]. So I guess I try to implement a sleep strategy, and increase my caffeine consumption.” “Caffeine, sugar. There’s not really time to walk away and take a break. Yeah. It’s those two things, I would say, mostly.” |
Pace (9/17, 12) | “There are times where if you don’t check yourself, you may have too much on your plate at one time, but you don’t have to, if you don’t want to. You can kind of scale it back so you have that flexibility to help reduce your own shift stress by limiting how much you have on your plate at one time.” “… at about 4:00 AM, I’m going to feel like I’m hitting the wall, and just being cognizant of that. And if I need to take more time to look at things or dig a little bit deeper, then I need to do that.” |
Exercise (10/17, 10) | “You have to try to go get a breath of fresh air, go get a drink of water, go get something to eat, and try to make time for it. That’s what I do sometimes. I’ll intentionally go for five minutes and just walk outside. I don’t even do anything. I just walk outside for a minute, just to clear my head a little better, get some fresh air.” “I try to get up and walk. If I notice I’m just feeling sluggish and not into it and I’m just almost wishing I was somewhere else because I’m so tired and I don’t feel like I can get through the shift, I can get up and walk or I go to the physician’s lounge …” |
Eating (9/10, 10) | “I get tired if I don’t get a chance to eat or hydrate. So if I’m on shift and I’m feeling funky then I’ll look and say, okay, how am I doing in terms of like basic body functions? Am I eating?” |
3. Discussion
Limitations
4. Materials and Methods
4.1. Participants
4.2. Procedures and Materials
4.3. Analysis
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Appendix A
- What contributes to your fatigue?
- How does fatigue affect your work performance?
- How does job-related fatigue affect your sleep?
- What do you do if you are fatigued?
- How do you know when you are or one of your coworkers is fatigued?
- What do you do to prevent fatigue?
- What is your perception of how your shift scheduling contributes to your fatigue?
- Do you think you have ever committed a medical error related to fatigue?
- What could the Department of Emergency Medicine do better regarding physicians and fatigue?
- Thank you for participating in this focus group/interview. Your responses will be used when developing a Fatigue Risk Management Program for the Emergency Department. You will receive an email from Starbucks within a few days of participating containing a virtual gift card that you can either print or use with their phone. If for some reason you do not receive the gift card within a few days, please contact Dr. Lauren Fowler at [email protected].
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Characteristic | Number of Participants (%) |
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Gender | |
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Race | |
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Characteristic | Mean (Median; Range) |
Age | 42.6 (40.5; 30–63) |
Years in Emergency Medicine | 11.4 (7.5; 2–31) |
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Share and Cite
Klinefelter, Z.; Hirsh, E.L.; Britt, T.W.; George, C.L.; Sulzbach, M.; Fowler, L.A. Shift Happens: Emergency Physician Perspectives on Fatigue and Shift Work. Clocks & Sleep 2023, 5, 234-248. https://doi.org/10.3390/clockssleep5020019
Klinefelter Z, Hirsh EL, Britt TW, George CL, Sulzbach M, Fowler LA. Shift Happens: Emergency Physician Perspectives on Fatigue and Shift Work. Clocks & Sleep. 2023; 5(2):234-248. https://doi.org/10.3390/clockssleep5020019
Chicago/Turabian StyleKlinefelter, Zachary, Emily L. Hirsh, Thomas W. Britt, Caroline L. George, Margaret Sulzbach, and Lauren A. Fowler. 2023. "Shift Happens: Emergency Physician Perspectives on Fatigue and Shift Work" Clocks & Sleep 5, no. 2: 234-248. https://doi.org/10.3390/clockssleep5020019