Publications and Resources

Objective for CSSP-2018-CP-2366 Our objective is to develop a consensus-based, evidence-informed national Standard on First Responder Workplace Fatigue Risk Management that will provide an approach to systematically preventing and managing workplace fatigue by addressing it in a strategic, coordinated approach, and as part of a broad organizational management framework. How this milestone supports the objective for CSSP-2018-CP-2366 This milestone will contribute to the development of a Seed Document that will be used to develop a national Standard, in accordance with CSA Groups’ accredited standards development process. This report describes the “Research and Synthesis of Evidence” phase, specifically key informant interviews of first responder personnel of their lived experience with fatigue, its impact on their health and performance, organizational policies, practices, and programs, and both personal and organizational risk mitigation strategies. The objective of this scoping review was to broadly identify relevant research pertaining to fatigue risk management and synthesize the research to inform aspects of risk management model known as the RACE model (recognize hazards, assess risks, implement controls, and evaluate effectiveness of controls) that will be integrated into a broader management system framework using Plan-Do-Check-Act (PDCA). Background First responders are at high risk of suffering from decrements in neurocognitive and physical performance related to fatigue. Such performance decrements endanger not only the personal health and safety of these responders but also the health and safety of their fellow responders and the public they serve. Fatigue may also be a precursor to adverse longer-term outcomes, such as musculoskeletal disorders, cardiovascular disease, and mental health disorders. Appropriate management, policymaking, standards, guidance, and research activities can reduce the exposure to these fatigue-related risks and hazards before they pose significant problems during emergency response operations. Methods We conducted a needs assessment by interviewing key informants to discuss their perspectives on fatigue, workplace policies, and both personal and organizational practices to mitigate fatigue risk. Participants represented three first responder occupations across Canada: firefighting, police services, and paramedic services. Participants were frontline personnel or managers. Interviews were audio recorded, transcribed, and analyzed for overarching themes. General Findings The lived experiences of key informants were analyzed into themes that were organized into a broad management systems model using the Plan-Do-Check-Act framework. Participants attributed fatigue to sleep and mental exhaustion, physical fatigue during work, and burnout. Outcomes of fatigue included deficits in work performance, impacts on their health and wellness, and challenges in their personal and family life. Specific and comprehensive workplace written policies often do not exist; participants who have limited fatigue policies in their workplace expressed the need for improvements to address content and implementation deficiencies. All participants believed fatigue was worth addressing in their workplace and that fatigue risk management should be a shared responsibility between employees and employers. Identifying and education personnel and management on the potential impact or outcome of fatigue may help motivate the organization to support a fatigue risk management system. Participants identified three broad types of risk factors: shift duration and pattern, task and work environment, and staff level. Assessment tools were primarily informal, based on self-assessments and partner-observations of the signs and symptoms of fatigue, and formal incident investigations were common. Risk mitigation strategies ranged from administrative (provisions for napping, shift schedules, support programs), personal (regimented sleeping habits, improved sleep quality at home, short-term solutions), and employee recruitment and training. All key informants indicated that there is no follow-up of prevention activities nor are there any policies, programs, or practices of corrective and preventative activities after implementing a risk control action. Conclusion Obtaining key informant insight towards the extent, impact, and management of fatigue contribute to the development of a Canadian fatigue risk management standard for first responders. Although participants understood the potential consequences of fatigue and expressed the desire to reduce its effects, current workplace strategies for fatigue risk management are reactionary, risk assessment tools are informal, and control strategies are much to be desired. Recommendations ranged from providing space within a base to facilitate restful sleep, offering a range of shift patterns to match an individual’s chronotype, and improving the training for personnel during early education, support throughout employment, and training for managers. Participants recommended that training should be delivered by individuals who are credible (with similar lived experience) and knowledgeable.

Objective for CSSP-2018-CP-2366 Our objective is to develop a consensus-based, evidence-informed national Standard on First Responder Workplace Fatigue Risk Management that will provide an approach to systematically prevent and manage workplace fatigue by addressing it in a strategic, coordinated approach, and as part of a broad organizational management framework. How this milestone supports the objective for CSSP-2018-CP-2366 This milestone will contribute to the development of a Seeds Document that will be used to develop a national Standard, in accordance with CSA Groups’ accredited standards development process. This report describes the “Research and Synthesis of Evidence” phase, specifically a scoping review of peer-reviewed literature to provide current state-of-the-art scientific knowledge in first responder workplace fatigue risk management. The objective of this scoping review was to broadly identify relevant research pertaining to fatigue risk management and synthesize the research to inform aspects of risk management model known as the RACE model (recognize hazards, assess risks, implement controls, and evaluate effectiveness of controls) that will be integrated into a broader management system framework using Plan-Do-Check-Act (PDCA). Background First responders are at high risk of suffering from decrements in neurocognitive and physical performance related to fatigue. Such performance decrements endanger not only the personal health and safety of these responders but also the health and safety of their fellow responders and the public they serve. Fatigue may also be a precursor to adverse longer-term outcomes, such as musculoskeletal disorders, cardiovascular disease, and mental health disorders. Appropriate management, policymaking, standards, guidance, and research activities can reduce the exposure to these fatigue-related risks and hazards before they pose significant problems during emergency response operations. Methods We conducted a scoping review to examine the extent, range, and nature of research activity, allowing us to identify gaps in the current literature. A scoping review consists of five stages: 1) identifying the pertinent research question(s), 2) searching the relevant studies, 3) selecting studies, 4) charting the data, 5) summarizing and reporting the results. Due to the multifaceted nature of fatigue, we adopted an integrative approach focusing on cognitive fatigue (i.e., sleepiness, arousal, attention, cognitive overload/underload), physical fatigue (i.e., muscular fatigue, central/peripheral fatigue), perceptual fatigue (i.e., visual fatigue), emotional fatigue (i.e., compassion fatigue), and burnout. We were guided by the following questions: In EMS, Firefighting, and Law Enforcement, how are hazards of fatigue identified? In EMS, Firefighting, and Law Enforcement, how do organizations and personnel assess the risk of fatigue? In EMS, Firefighting and Law Enforcement, what control actions or interventions are available to reduce fatigue? In EMS, Firefighting and Law Enforcement, what are valid and reliable instruments for measuring or detecting fatigue among personnel? General Findings Our comprehensive literature search strategy resulted in a total of 403 relevant articles that met our inclusion criteria. We found that the focus on the type of fatigue differed between the three first responder occupations; the distribution of papers based on risk factor sub-categories and interventions also differed between occupations. 38.7% focused on firefighting, 33.3% on police, and 22.8% on EMS work, 5.2% of articles focused on a combination of the three occupations. Cognitive fatigue most represented in EMS research (45 articles) and Police research (88 articles). Physical fatigue most represented in firefighting research (116 articles). Personal/social/cultural (20 articles) and work organization (17 articles) fatigue risk factors were frequently cited in EMS research. Work organization (47 articles) and personal/social/cultural (36 articles) risk factors were common in police research. There was a consistent distribution of articles representing all four risk factor sub-categories in firefighting research. We identified potential fatigue-related outcomes into three outcome sub-categories. In both firefighting and police, physical health were most frequently identified. There was a consistent distribution of the number of articles among outcome sub-categories in EMS research. The primary type of intervention or risk control strategy in EMS research was engineered solutions (7 articles). In firefighting, 18 articles focused on PPE and 17 articles on engineered solutions. In police research, the most frequently cited intervention was training (12 articles). Fatigue Measurement & Risk Assessment Tools Tools ranged from self-reported instruments and surveys to objective measures. The Maslach Burnout Inventory was the primary tool of choice when measuring burnout; Schaufeli et al.’s (2001) study recommends using both the Maslach Burnout Inventory and the Malach-Pines Burnout Measure to balance both sensitivity and specificity. Surveys instruments were common to measure cognitive fatigue, including the Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, and Chalder Fatigue Questionnaire; however, there is a lack of information on the sensitivity and specificity of these instruments. Objective measures of cognitive fatigue including heart rate, critical flicker fusion frequency, psychomotor vigilance task, oculomotor behaviour, polysomnography, and actigraphy have all been employed. These measures remain elusive in large-scale studies due to cost, practicality, and efficiency. Physical fatigue measures include heart rate as an index of physiological strain and metabolic rate, Borg’s Rating of Perceived Exertion (RPE) as a psychophysical scale for physical strain, and observational risk assessment tools to assess musculoskeletal disorder risk. Further investigations are warranted to evaluate sensitivity and specificity of these tools. Fatigue & Outcome Relationships in First Responder Occupations We identified 22 papers that linked risk factors, fatigue type, and outcome. Cognitive fatigue was cited as the most acknowledged type of fatigue linked to health (injury, accident risk, musculoskeletal disorders, cardiovascular disease), wellness (depression, anxiety, dissatisfaction), and work performance. Increasing fatigue generally led to adverse outcomes, however 15 of the retained articles were cross-sectional studies, limiting our interpretation of causality. Fatigue Management Interventions Identified in First Responder Occupations We identified interventions and controls based on the Hierarchy of Controls (NIOSH, 2015). In all three occupations, training was the most common type of intervention to mitigate burnout. PPE and engineering controls were most common in combating physical fatigue. There was a stronger focus on administrative and training controls to reduce cognitive fatigue. No single intervention was supported by overwhelming evidence, but we found limited support for stretcher design, predictive capacity testing, self-contained breathing apparatus (SCBA) design (material and shape), and mindfulness-based resilience training. Articles indicate that changes to protective clothing, to reduce physical demands and fatigue, were not effective solutions in firefighting work. Conclusion The scoping review provides insight towards the extent, impact, and management of fatigue based on a broad range of fatigue types for first responder occupations. Categorizing by fatigue type might be useful in targeting appropriate controls and focus future research investigations. In all three occupations, burnout, cognitive fatigue, and physical fatigue were associated with adverse health and performance effects; these results highlight the importance of managing fatigue, of any type, to prevent longer term outcomes. Although a range of measurement tools have been identified in the peer-reviewed literature, future investigations are needed to identify tools specific to first responder occupations and information on the sensitivity and specificity of these instruments. No single interventions were supported by overwhelming evidence; high quality research, including randomized control trials, may help identify and inform effective risk mitigation strategies for first responders.