Paramedics working during night shift are faced with the problem of heavy workloads; from caring for patients under stress and having the ability to perform in dim lighting. Over time, this type of workloads can become tiring physically, mentally, and psychologically. Working on night shift tampers with paramedics’ sleep patterns, bringing about fatigue. This jeopardizes the safety of patients under the care of the paramedics as well as that of the paramedics.
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The purpose of this research is to study the various effects of fatigue on paramedics during nightshift. The paper shall critically look at the effects of fatigue on the safety of the paramedics and patients under the care of the paramedics during the night shift. It shall also look at the physiological and psychological effects on the health of the paramedics with fatigue. The paper will analyze the relationship between sleep and fatigue. Lastly, the study will look at the intrinsic relationship between ageing and fatigue.
A study on the effects of fatigue on paramedics during night shift is important and relevant to the field of medicine in a number of ways. Work on a night shift roster of 10-12hrs are able to use their knowledge to put measures in place, this ensure their safety as well as that of the patients they care for. They will also be able to find ways of reducing the amount of fatigue experienced (Kripke et al, 2005). The same knowledge will enable the paramedics to understand the roots of any problems they may be experiencing so as to seek the right interventions.
A sample of 100 paramedics was randomly selected from major hospitals in the country. They were served with self-reporting standardized questionnaires, which they were asked to fill as faithfully as they could. One of the components in the questionnaire was the Epworth Sleepiness Scale (ESS). There was also the Berlin Questionnaire (BQ), and the Pittsburgh Sleep Quality Index (PSQI). The last item was the Beck Depression Inventory (BDI). The questionnaires were filled under a strict observation of medical ethics by the paramedics participating in the study.
The ESS measures an individual’s level of sleepiness during daytime and his propensity to doze off during work. People who are sleepy during the day scored higher. A high score implies a high amount of sleepiness during the daytime. The Berlin Questionnaire contains three categories which relate to one’s snoring during sleep, sleepiness and fatigue during the time he is awake, and his state of hypertension and obesity. The PSQI measures the quality of sleep for an individual. The index measure contains seven items that measure the quality of sleep for an individual. Some of the things measured are the quality of one’s sleep and the rate at which they experience disturbance while asleep. Others are the efficiency and the latency of one’s sleep. The time that one spends while asleep and the impact of this sleeping pattern during the day are also measured. The BDI is used to measure the severity of depression in an individual. It assesses psychological and physiological symptoms of an individual using the indicators of mood, guilt, punishment, pessimism, insomnia, weight loss, and many others.
Paramedics have had to resort to a trial and error when dealing with interventions to prevent fatigue. This is due to the lack of research made thus far; possibly causing an imbalance in sleep and an overall health and well-being. With the Victorian population increasing, the rise in calls during night shift has forbidden Paramedics to be able to find time to rest throughout the night. As workload demand increases on pre-hospital professionals, a decrease in sleep, health, mental and physical sharpness decreases. Further research is necessary to determine the most appropriate management technique to either decrease workload or increase Paramedic health and safety.
In times past, sleep was regarded as an inactive process when the brain ceased its active operations (Kripke et al, 2005). During this time, the sensory input to the brain declined in amount, reducing the amount of activity the brain could engage in. This predisposition, however, changed in the 1960s when scholars discovered the notion of the Rapid Eye Movement (REM) (Hobson, 1994). Scientific studies revealed that the REM was a separate state from sleep, which was characterized by dreaming, active inhibition of motor activities, and activation of the cerebral functions (Kripke et al, 2005).
REM improves an individual’s attention during the times he is awake, boosting his intellectual capacity. Sleep which does not involve the rapid eye movements is also responsible for enhancing the functioning of the body’s immune system, thus boosting one’s health. Sleep, according to Folkland et al (2005), plays an important role in the body of an individual in the general functioning and health. It is through sleep that the body is able to rest and restore normal functioning in the physiological, psychological, and neurological capacities (Hobson, 1994). Disruption on one’s sleep hinders the individual’s well being (Kripke et al, 2005).
The body works under a natural pattern of sleep known as the Circadian Rhythm. This rhythm is intrinsically generated and adapted to the 24 hour day and is responsible for regulating physiological, biological, and metabolic functions of the body. Staying awake when the body should naturally be sleeping requires that the cycle is adjusted (Hobson, 1994). The adjustment process results in a number of negative effects. One is the suppression of the production of a substance known as melatonin and a disturbance on the levels of Cortisol and body temperature.
Melatonin is the substance responsible for inducing sleep among people, and any work at night inhibits the production of the substance (Tanguy et al, 2012). The suppression of the production of the hormone during night time also causes an individual to experience lack of sleep during the day (Kripke et al, 2005). Persons suffering from the Circadian Rhythm exhibit symptoms of fatigue, poor performance, and sleep disturbance when they finally sleep.
Lack of sufficient sleep makes individuals become less aware of the environment surrounding them and affects the REM sleep (Folkland et al, 2005). Night shift workers generally sleep 1-4 hours less than day shift workers. There is the possibility that these workers accumulate sleep debt with time, which can lead to errors and accidents in the work place out of fatigue. Psychological effects of sleep debt include mood swings, irritability, depression, and anxiety (Hobson, 1994).
One of the major effects of sleep debt, according to Dowson & Zee (2005), is fatigue. Working in shifts is another prominent cause of fatigue, as the individual’s Circadian Rhythm is interrupted by the shifts. Fatigue affects bodily functions of alertness, concentration, judgment, performance, and vigilance (Joyce et al, 2009). Individuals suffering from fatigue suffer from memory impairment, and their capabilities in decision making and solving problems can be affected.
A report by the Council of Ambulance Authorities (CAA) of 2006/2007 (Dowson & Zee, 2005) indicated that paramedics were highly subject to errors and accidents during night shifts because of high levels of fatigue (Hobson, 1994). Paramedics on shift rotations are more prone to fatigue compared to those on a strictly day or night duty. A study by Tanguy et al (2012) indicated that workers on the night shift were three times more prone to occupational accidents than those on day shifts.
Effects of Fatigue on Health.
One of the most prominent causes of fatigue is sleep deprivation and disturbance. Given that sleep is a physiologically generated function, fatigue also affects other physiological functions. The circadian rhythm synchronizes external time signals with the internal functions of the body (Hobson, 1994). This internal clock contains genes and protein substances, which regulate a number of physiological functions within the body and a disruption to this clock has the probability of impairing the normal functioning of an individual (Takeyama et al, 2009).
Night shift paramedics experience a lack of synchrony in their internal and external environment, leading to the impairing of cognitive functions, altering hormonal functions, and gastrointestinal disturbances (Yoon et al, 2003). Although the circadian timing for most animals occurs in full synchrony with the circadian timing, human beings have the unique ability to override the internal clock and operate in reverse of the clock dictation (Takeyama et al, 2009).
The circadian rhythm affects the individual’s body temperature, brain activity, regeneration of the cells, and other biological functions (Yoon et al, 2003). External stimuli such as electric light during the night have the ability to delay the production of the protein substance Melatonin, which is responsible for sleep (Hobson, 1994).
One of the effects of the disturbance of the circadian rhythm is the Seasonal Affective Disorder (SAD) (Tanguy et al, 2012). Persons with this disorder have difficult waking up in the morning, experience morning sickness, and tend to overeat. Besides these, these people lack sufficient concentration abilities, become withdrawn from friends and family, and experience a lower sex drive (Yoon et al, 2004). The paramedics spend longer times exposed to light as they stay awake in the nights under artificial light, and during the day under the natural light (Takeyama et al, 2009). Their bodies have to adjust to this and the circadian rhythm is affected and will need to adjust.
Another physiological effect is the Delayed Sleep Phase Disorder (DSPD) (Joyce et al, 2009). This disorder affects an individual’s timing of sleep, timing of alertness, and the rhythm of core body temperature. Individuals with this problem have an unusually long circadian cycle, such as the one developed by night-shift paramedics (Folkland et al, 2005). While the circadian cycle resets itself naturally in response to light and darkness, persons with this disorder take longer to respond to the changes in light and darkness (Yoon et al, 2003).
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A disturbance in the normal circadian cycle can have devastating effects on the Reticular Activating System (RAS) (Redecker et al, 2004). This is a part of the brain that is responsible for regulating functions that manage the transition between sleep and awakening. The RAS is tasked with ensuring that as an individual wakes up, the state of relaxation is transformed to that of high alertness and attention. Due to increased neural activity, the rate of blood flow in the brain increases to mark the increased activity (Yoon et al, 2004). If the RAS cycle is affected by changes in the circadian cycle, its ability to initiate the wave of alertness and increased attention is also affected. This usually is the case among paramedics who are not able to concentrate during specific times due to a dysfunction of the RAS (Takeyama et al, 2009).
A disturbance of the circadian rhythm can have devastating effects on the digestive system (Joyce et al, 2009). The stomach is at its peak level in the morning, needing high amounts of food to keep at par with the needs. Eating at this time helps to improve digestive functions as well as the production of the required energy levels (Hobson, 1994). This energy is lowest later in the evening, and the body does not need a lot of food at this time. What this means for the paramedics at night time shift is that rather than eat a heavy meal in the morning, they are likely to be asleep. They will eat their heavy meal in the evening as they set out to work. This trend has disastrous effects on one’s digestive system (Yoon et al, 2003).
A recent discovery on the effects of the night shift is the possibility that working on night shift could be a probable cause of cancer (Redecker et al, 2004). Substance melatonin is produced at night as darkness sets in. working at night requires the presence of light, which acts as an inhibitor to the production of the substance. The substance is thought to suppress cancer cells (Folkland et al, 2005).
Fatigue has a number of psychological effects for paramedics working on night shifts (Takeyama et al, 2009). One of the psychological effects is frustration. Paramedics working on night shifts operate on a reversed time schedule (Joyce et al, 2009). They spend most of their day sleeping and or resting and their night time at work. This way, they are left out of valuable family time and activities such as sporting activities and spending quality time with family members (Redecker et al, 2004). This state leaves the paramedic frustrated and depressed on his inability to maintain close family bonds. Retired night shift paramedic workers responded to a study that they experience higher levels of depression compared to day shift workers (Takeyama et al, 2009).
A US report on Emergency Medical Service providers indicated that paramedics were at higher risks of decreased mental and physical performance (Tanguy et al, 2012). A similar report on Japanese paramedics indicated that older paramedics exhibited higher levels of depression than the younger members. Similar studies in the UK and Scotland found that paramedics working on night shifts suffered poor mental health (Yoon et al, 2004). Besides social and family factors, depression among paramedics working in the night shift could emerge as a result of unfavorable working conditions at night (Hobson, 1994). External conditions such as lower temperatures than those of daytime, security matters, and insufficient lighting could be some of the factors that can lead the paramedics to depression (Joyce et al, 2009).
Ageing and Night Shifts.
Melatonin is a powerful anti-oxidant agent that blocks the movement of free radicals, which damage cells, therefore playing an anti-aging role. Working at night means that the production of the substance is suppressed due to the presence of artificial light and (Joyce et al, 2009).
One of the effects of ageing on the circadian rhythms is the impairing of the response of the light synchronizers to the changes in daylight and darkness (Folkland et al, 2005). As people age, they tend to get sleepy earlier and rise up earlier than younger persons. This pattern is referred to as the Advanced Sleep Syndrome.
This situation presents a problem for night-shift paramedics who may not be able to maintain alertness through the night. Persons of the age of 40 and higher exhibit a higher tendency to giving in to sleep at night than those younger (Joyce et al, 2009). This could explain the reason why paramedics in the UK who work the night shifts are mostly below 40 years of age, with the older ones seeking day-time positions of resigning from work (Hobson, 1994). It also explains why most occupational accidents and errors are committed by older persons. Besides, these persons tend to exhibit emotional instability at work, with signs of stress and distraction because of the negative impact of lack of the much needed sleep.
Effects of Fatigue on Paramedics’ Safety.
A fatigued paramedic is likely to behave in a manner similar to a drunken paramedic on twice the alcohol levels than the legal limit (Redecker et al, 2004). Paramedics have to take up complicated tasks in a timely manner given the emergence involved in a number of night calls. In their tired state, they need to act fast and decisively, perform clinical procedures on the patients, and drive with care to the patients and back (Joyce et al, 2009). It is commonly reported that some of the patients the paramedics deal with may be mentally unstable or drug users, with the ability to infer injury upon the paramedics. A paramedics’ report in Queensland Australia stated that 94.3%of paramedics reported to have been assaulted and verbally abused by persons under the influence of alcohol (Folkland et al, 2005).
All these factors put the safety of the paramedic in jeopardy. Fatigue is a major cause of the problem as the paramedics’ judgment ability is compromised at this hour; many of them get emotional easily out of the fatigue. Fatigue is responsible for 35% of road accidents by paramedics, while the same contributes to over 56% of self-injury during treatment of patients (Redecker et al, 2004).
Effects of Fatigue on the Safety of Patients.
While paramedics’ safety is compromised due to fatigue, that of the patients under their care is even at a higher risk. A clouted judgment is one of the major dangers paramedics subject their patients to (Folkland et al, 2005). In many occasions, the paramedics are not able to effectively determine the health state of their patients, leading to possible misdiagnosis. The paramedics in this state also endanger the lives of their patients as they drive through traffic at night and in dimly lit streets for possible accidents (Hobson, 1994).
According to the circadian rhythm, night time is a naturally inactive time for the body when the body is naturally slow to reactions and alert levels are lower (Redecker et al, 2004). The resultant effect on a paramedic working at night is that he/she is not able to respond effectively and in time to emergency, his judgment and assessment abilities are not as sharp as they should be (Joyce et al, 2009).
In spite of the voluminous evidence on the negative impact of fatigue on paramedics on night shifts, the amount of research performed on the topic is not enough to substantiate claims with proof. In spite of the insufficient research done on paramedics’ work, their contribution to the health of communities is invaluable and deserves detailed studies to explore their plight.
It is the responsibility of the employer and the employee to ensure that paramedics have good health. Labor organizations in the UK need to ensure these are looked into. In recent times, there have been efforts by employer organizations to institute changes into the working shifts of paramedics. Some interventions include scheduling few night shifts and having long breaks. Some of the measures of reducing fatigue that employees are taught include sleep hygiene, regular exercises, healthy food diet, and spending as much quality time with family and friends as possible. These help to make up for the time spent at work and reduce emotional fatigue.
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