SA Ambulance Service. Fit for duty. Staff guidance booklet. Fatigue Risk Management System

Transcription

1 SA Ambulance Service Fit for duty Staff guidance booklet Fatigue Risk Management System

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3 Contents Fit for duty Message from the CEO...2 Introduction...3 What is a Fatigue Risk Management System?...4 What is fatigue?...5 What effect can fatigue have on a person?...5 What causes fatigue?...6 Fatigue management...6 Definitions...7 Roles and responsibilities...9 Responsibilities by role...9 Organisational policy and governance...9 Role of local (OHS) workgroups...10 If it is to be, it s up to me balancing employer and individual responsibility...11 Identifying and assessing fatigue...11 How to identify and assess fatigue?...11 Combating fatigue...13 Recovery sleep...13 Keeping on top of fatigue...14 The five levels of control...14 The SAAS Fatigue Assessment Card individual fatigue scoring...16 How to use side 1 of the card...17 Information regarding SAAS specific fatigue issues...20 General fatigue management/ mitigation strategies...23 Reporting fatigue...25 Duty of care...25 Unforeseen circumstances...25 Fatigue assessment...25 Reassignment of duties...25 Generating a fatigue report...26 What happens when the review of the fatigue report is complete?...26 Fatigue investigation...26 Performance management excessive levels of fatigue General information about sleep, fatigue and lifestyle...28 Body clock (circadian rhythm)...28 Fatigue is cured by sleep, but what is sleep?...29 Sleep stages...29 Tips for getting sleep...31 Eating healthy to combat fatigue...32 Staying hydrated...39 Caffeine...39 Alcohol in moderation...40 Physical activity...40 Education and training...41 Assessment...41 Conclusion...42 References...43

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5 Message from the CEO Fatigue has been identified by SA Ambulance Service (SAAS) as a significant risk to the health and welfare of our staff if it is not managed appropriately. SAAS is committed to raising awareness of fatigue, helping you know how to measure your own fatigue levels and providing you with skills and strategies to manage fatigue. The first step in addressing fatigue issues was the SAAS Fatigue Management Workshop held in December This was the first workshop of its kind held by an ambulance service in Australia. What emerged from this workshop was the need to develop a Fatigue Risk Management System (FRMS) for SAAS. The aim of the FRMS is to create awareness of the hazard of fatigue in the workplace, and educate and train all staff on ways to evaluate and manage fatigue. SAAS s FRMS includes a fatigue management policy, a fatigue management procedure and information on actions you can take to ensure you get sufficient rest and sleep between shifts/ work days, at night and on weekends so we all present fit for duty. The FRMS complements a number of measures, like shift swaps, dynamic deployment and annual leave, that SAAS already has in place to help support staff. This Fit for duty handbook explains what fatigue is, how to identify and assess it, what causes it and how to prevent and manage it. It also covers details on SAAS s FRMS which is a multi-layered system of education, self-evaluation, policy, reporting and investigations all designed to mitigate the risk associated with fatigue. The SAAS Fatigue Assessment card (in the back of this booklet) is a great self assessment tool for you to determine your own fatigue levels. I encourage you to keep it handy and use it regularly. Let s all take responsibility for our own health and those around us. Ray Creen Chief Executive Officer page 2

6 Introduction The Government of South Australia is committed to a zero harm vision for the South Australian Public Sector (i.e. it takes the approach that every injury is preventable). SAAS shares and supports this vision and fosters an organisation where: > > safety management is a core value > > safety performance is best practice > > every member of staff feels safe at work > > no one is asked, required or permitted to work without acceptable safety measures in place. Safety depends, among other things, on staff being fit for duty at all times whilst at work. Sleepiness and fatigue can be attributed to a range of factors including lack of recovery sleep, time on task and time of day. Sleepiness and fatigue can affect physical and mental capabilities to perform your duties at safe levels. Individuals may be affected by fatigue differently depending on their age and general wellbeing amongst other things. Fatigue impairs judgement, hand-eye coordination, reaction times, concentration, problem solving abilities, moods, motivation levels, morale, communication skills, health and relationships with family, friends and work colleagues. In some areas of SAAS, fatigue impaired performance may have a catastrophic affect on staff and public safety. SAAS actively manages the risks associated with fatigue through the utilisation of risk assessments and fatigue management strategies (sensible rosters, education etc). Risks are measured, monitored and mitigated to reduce the risk of endangering SAAS staff and the general public. SAAS has a range of mechanisms in place as part of day-to-day operations to help ensure staff are supported to keep safe at work and to reduce the likelihood of fatigue. These include: > > voluntary flexible workplace arrangements > > drug and alcohol management > > OHS and injury management > > drivers responsibilities and requirements > > health food and drink choices for staff in SA Health facilities > > compassionate transfer > > broken or late crib procedure > > overnight accommodation > > rest breaks between successive operational shifts > > RV points (country) > > meal breaks > > transport home after exceptionally fatiguing shift page 3

7 Fit for duty What is a Fatigue Risk Management System? The SAAS Fatigue Risk Management System (FRMS) is a multi-layered system of education, self-evaluation, policy, reporting and investigation all designed to mitigate the risks associated with fatigue. The FRMS is a method of systematically managing organisational and individual risk with respect to fatigue. SAAS has determined that fatigue risk is a hazard that will be managed via the OHS&W system. It is also the responsibility of each and every staff member to present to work fit for duty. To assist with this SAAS provides staff with tools to assess their own sleep opportunities and resultant fatigue risk levels this booklet being one of them. SAAS s fatigue management policy is an important part of SAAS s FRMS and all staff are encouraged to access this tool, as well as the fatigue management procedure. The policy articulates our commitment to proactively measure, mitigate and manage the risks associated with fatigue. It is up to every one of us to keep safe and to keep SAAS safe. The system will enable individual work groups/teams (both patient services and support services) to assess their own work area and to make some location-based determinations on fatigue. We recognise that some risks differ across work groups depending on role and location. This component of the FRMS aims to empower groups/teams. That is, to give work groups/teams the ability to put in place plans to mitigate fatigue. We acknowledge the expertise that lies across our organisation. It is the responsibility of local managers and their associated OHS representatives to monitor and ensure compliance with SAAS s FRMS via audit. The FRMS is both proactive and reactive, providing a means to anticipate and prevent or reduce the effect of fatigue related risk. page 4

8 What is fatigue? Fatigue is the physical and psychological condition that accumulates when an individual s optimal physical or mental limits are exceeded. It manifests as degradation in both physical and mental performance. Fatigue generally increases with time from an individual s last sleep and with physical or mental exertion (International Quality and Productivity Centre Fatigue Workshop, June 2008). The Australian Government Civil Aviation Authority (CASA) (2004) defines fatigue as exhaustion of the mind or body resulting from labour or exertion and/or a lack of sleep. WorkCover NSW (2006), in implementing regulations in 2006 on fatigue in long haul road transport, has described fatigue as the feeling of weariness from bodily or mental exertion and feeling tired, drained and exhausted. Fatigue influences an individual s physical, mental and emotional state, which may result in them being less alert, accompanied by poor judgment, slower reactions to events and decreased motor skills. What effect can fatigue have on a person? Fatigue inhibits the ability of an individual to function normally. The indicators of fatigue can include: > > desire to sleep > > involuntary napping > > micro-sleeps > > reduced vigilance > > delayed reaction times > > decreased alertness > > poor judgement > > decreased motor skill > > irritability > > poor hand-eye coordination > > reduced visual perception > > degradation in physical and mental performance. Fatigue can also have negative effects on health including: > > heart disease > > high blood pressure > > stomach ulcers > > gastrointestinal disorders > > depression > > lower fertility. page 5

9 Fit for duty What causes fatigue? Fatigue can be caused by either work or non-work factors. Maintaining concentration for extended periods, being exposed to temperature extremes, working in safety critical and high-risk situations may cause or increase work related fatigue. Non-work related fatigue may be associated with the following: > > an individual having a sleep disorder (e.g. sleep apnoea) > > family and social responsibilities/ commitments (e.g. financial difficulties, domestic responsibilities or sleep disruption due to ill or dependant family members) > > physical activity (e.g. renovation work on your home or participating in sporting activities) > > travelling long distances prior to commencing work > > emotional stressors. All these factors can contribute to increased fatigue. Unplanned overtime or irregular work hours can impact on both work related and non-work related fatigue. This occurs because of the reductions in the opportunity to achieve quality restorative sleep. Shift patterns and long working hours can reduce the opportunity for adequate restorative sleep by: > > reducing the total time available for sleeping > > working and sleeping at inappropriate biological times > > adversely affecting the quality and quantity of sleep > > increasing competition between sleep and other non-work activities. Fatigue management Traditionally fatigue has been managed in other industries solely through the prescriptive regulation of hours of work. This approach is based on the premise that fatigue is the result only of the amount of time spent working. It has for some time been widely recognised that there are many factors that contribute to fatigue and to the associated declines in performance and alertness. Generally these factors form three groups: > > work-related factors: includes the type of work being performed, workload and the duration of the duty period > > sleep-related factors: relates to the physiological requirement for an optimal daily amount of good quality sleep and the time since the last sleep occurred > > circadian (body clock) factors: refers to the underlying physiological processes that effectively programs individuals to be asleep during the night and awake during the day. page 6

10 Definitions Fit for duty SAAS staff have a responsibility to: > > report for duty and commence shift with a zero fatigue score risk > > use time off appropriately > > obtain sufficient sleep and prevent excessive wakefulness > > (where the above measures have not been possible) notify an appropriate individual to ensure that an appropriate risk mitigation process is implemented or remove themselves from duty. Fatigue The definition of fatigue is highly debated and is often defined through causes and not consequences. Fatigue is a subjective experience and cannot narrowly be defined but is related to a cumulated sleep/wake debt ratio and is reflected through performance decrements and psychological impairments such as decreased reaction times, poor communication, poor judgement and mood fluctuations. Recovery sleep Restorative sleep that reduces or removes the effects of fatigue and is required in different amounts by each individual. Fatigue score A value determined to objectively and quantitatively describe fatigue and one s ability to be fit for duty. Long distance driving The Commercial Motor Vehicle Act (1979) defines permissible hours of driving. The Act describes long distance driving as eight hours or more. SAAS defines long distance driving as any journey (either metropolitan or country) which takes two or more consecutive hours to complete. Driver fatigue A condition that affects the ability of a person to maintain control of a motor vehicle in any environment or condition. Some early warning signs of fatigue can include: > > yawning > > poor concentration > > tired eyes > > restlessness > > drowsiness > > slow reactions > > oversteering > > micro sleeps > > near hits/misses > > inability to maintain constant speed > > straying out of your lane. page 7

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12 Roles and responsibilities The SAAS FRMS applies to all staff (patient services, support services, career and volunteer, and management). Fatigue risk management is an integral part of safety management and as such every one at SAAS has a fatigue risk management accountability. Responsibilities by role > > Chief executive officer and executive directors are responsible for the development and continued improvement of the SAAS FRMS. > > General managers are responsible for the implementation of the FRMS in their respective areas and in ensuring that all staff are familiar with the FRMS. > > State duty managers, managers patient services, support services line managers, patient services team leaders, occupational health and safety representatives are responsible for the day-to-day management of the system, investigations and reporting of fatigue reports to senior management. > > Staff are responsible for using their time off work appropriately to obtain sufficient sleep and where this has not been possible to notify the state duty manager to discuss mitigation options. It is your responsibility to ensure that you are fit for duty prior to commencing duty. > > Rostering staff and patient services team leaders are responsible for ensuring that rosters/shift patterns allow for sufficient sleep opportunity between shifts. > > Educational Services is responsible for the induction of new staff to the FRMS and provision of supporting educational material. > > OHS staff have the responsibility of compiling the monthly reports from the state duty managers to present to the OHS Steering Committee for review/audit. > > Emergency Operations Centre staff have a responsibility to monitor patient services crews and to rotate staff to balance workloads with a view to minimising fatigue risks. > > Evaluation and review will occur annually by the Executive Management Team to ensure effective ongoing performance and implementation of improvement opportunities to the FRMS. Organisational policy and governance SAAS s policy on fatigue risk management is available for all staff on SAASnet and is an organisational wide policy. Fatigue risk is a hazard, managed via the OHS system. The goal of the fatigue management policy is to reduce fatigue related risk. page 9

13 Fit for duty SAAS will empower individual work groups/teams (both patient services and support services) to assess their own work area and to make some locationbased determinations on fatigue. Local governance is the first step to prevention. Managers of work groups and their associated OHS representatives will then monitor and ensure compliance via audit. The FRMS will be multi-layered. Modern theorists often describe errors or accidents occurring because of failures at different levels within a system, whether that is with the health and safety rules, human factors or monitoring systems. Therefore we need to have varying levels of controls to mitigate risks at these differing levels. This was described by Reason 1997 using the analogy of swiss cheese. When multiple layers of swiss cheese are put together, the holes (here synonymous with room for error) are reduced. Role of local (OHS) workgroups Each general manager in conjunction with the manager patient services or support services line manager must work with the OHS representatives within their local area to monitor issues of fatigue, investigate reports of fatigue and participate in system review and analysis. Potential risks Policies and procedures Education and training Management support and role modelling Personal responsibility Effective reporting system Control measures for reducing potential exposures page 10

14 If it is to be, it s up to me balancing employer and individual responsibility Fatigue levels are also dependent on the effectiveness of an individual s managing/ coping strategies, general health and wellbeing. Whilst SAAS monitors and continues to develop systems that ensure its day-today operations do not cause unacceptable levels of fatigue (e.g. sufficient time off between shifts/work days etc), each member of staff has a duty of care to actively manage their time away from work to ensure that they report for work fit for duty for the expected duration of the shift/work day. Identifying and assessing fatigue Staff can learn from experience, and from their training and education to recognise the physical and psychological indicators of fatigue. These indicators include: > > involuntary napping or micro-sleeps > > reduced vigilance > > delayed reaction times > > irritability > > poor hand-eye coordination. Both management and staff must ensure all risks associated with shift work and extended working hours are identified and reported. Hazard identification, mitigation and audits of incidents will form part of this process. How to identify and assess fatigue? At home A significant factor in the severity of fatigue symptoms is prior sleep loss. That is, individuals who are sleep deprived before a shift/day at work can experience more difficulty than those who are well rested. If an individual is not fully rested before work and commences duty with a sleep debit, then generally it should be expected that the sleep debit will only worsen during the shift/work day. The recommendation is to maximise the amount of sleep at least one and preferably two days before work. As affected individuals may not necessarily be cognisant of these indicators, all staff need to monitor each other for the emergence of any signs and symptoms of fatigue. page 11

15 Shift patterns and social/ family commitments Shift patterns/working hours affect a staff member s personal, domestic and social life. Without appropriate coping strategies, staff may find that various shift patterns/ working hours have an adverse effect on their relationships, domestic workloads and/or community commitments. Some shift workers find it difficult to maintain a satisfactory social and family life due to the negative effect shift work and/or fatigue can have on mood, motivations and common free time. This can also affect work performance, health and safety, morale, absenteeism and productivity. These issues are addressed and discussed within SAAS s training materials, which are available to all staff and their families to assist them in gaining an understanding of the effects and consequences of shiftwork and how to manage them. Commitment by management to support staff who undertake shift work is demon strated by managers and supervisors: > > ensuring all staff participate in fatigue management training > > ensuring scheduled rosters and roster changes do not result in unacceptable peak fatigue scores, both for the immediate shift and also as a compounding effect on subsequent shifts for all involved > > addressing work related fatigue issues > > consulting with and supporting staff who are suffering from non-work related fatigue > > addressing non-work related fatigue issues that are not being adequately addressed by individuals. Trust your own body and how you feel. page 12

16 Combating fatigue At the end of the day, the only way that you can reduce fatigue and ensure you are fit for duty is to ensure you get adequate sleep. Having said that, addressing fatigue requires a multilayered approach. The purpose of SAAS s Fatigue Risk Management System is to provide a supportive structure for you to ensure you are equipped with the knowledge to identify and manage fatigue appropriately. Recovery sleep Adequate recovery sleep reverses fatigue (Rogers, Dorrian & Dinges, 2003). The quantity and quality of the sleep is dependent on when and where the sleep is obtained during a 24-hour day. For example: > > Working longer hours and/or irregular hours reduces the opportunity for sleep. > > Sleep can be further reduced as workers attempt to manage competing demands for sleep. > > Sleep during the middle of the day is not as recuperative as that during the night since the latter aligns to the body s circadian rhythm. The most critical factor in managing fatigue is gaining adequate restorative sleep. In this regard both SAAS and staff have a shared responsibility. SAAS will ensure staff rosters allow for adequate breaks for necessary recovery between all periods of work. Individuals have a duty of care to ensure adequate recovery sleep is obtained between shifts/ work days so that they are fit for duty for the entire shift/work day. page 13

17 Keeping on top of fatigue Fit for duty The five levels of control There are a number of ways that we, as individuals, and SAAS as an employer can keep on top of fatigue. Level 1 controls relate to organisational structures/systems that support staff to be fit for duty. Level 2 controls relate specifically to individuals; levels 3, 4 and 5 are specific to employer/manager responsibility. Level 1 control Level 1 control measures are prescriptive health and safety rules or rules of rostering that aim to mitigate fatigue by providing adequate sleep opportunity between shifts/work days (e.g. a minimum number of hours between shifts/work days and allocation of overtime based on fatigue score). Level 2 control Level 2 controls are all about the individual being able to assess their own levels of fatigue and this is done by assessing prior sleep and wake time. Unlike other subjective measures, prior sleep and wake are objective and observable measures of fatigue. Prior sleep and wake provides the individual and the organisation with an integrated measure and allows the staff member a way to make a clear judgement of prior sleep and wakefulness. Prior sleep and wake measures can also be set or modified to the risk profile associated with a specific task or group of staff (e.g. SAAS may set a different measure for shift work staff as opposed to support services staff). In recent years there has been emerging scientific and regulatory consensus that many prescriptive shift work rules fail to provide an adequate control mechanism to prevent unsafe work practices by fatigued workers. This is primarily due to a failure to: > > distinguish between non-work and sleep time in determining the recovery value of time off > > take into account the time of day at which shifts or breaks occur. It is vital that we use more than just prescribed rules to manage fatigue. As such, SAAS will mitigate fatigue risk by: > > involving staff in the development and design of rosters and decisions regarding changes to roster systems > > utilising fatigue scoring methodology prior to introducing rosters > > monitoring fatigue levels associated with actual rosters. page 14

18 Level 3 control Receipt of fatigue reports and the instigation of organisational investigation and control procedures constitute level three controls. Staff will have the ability to make a fatigue report prior to commencing or during a shift. Upon receipt of a fatigue report from a member of staff, the state duty manager will take action to mitigate fatigue situations as reported by staff. Any leave granted as a result of a fatigue report will be deemed as sick/personal/ carers leave. Additionally, SAAS will provide screening of staff for sleep disorders as part of their pre-employment medicals and offer assistance to existing staff who identify or suspect they suffer from a sleep disorder. Sleep apnoea and other related sleep disorders are conditions that cause multiple wakening during sleep and, as a consequence, reduce the recuperative value of sleep and increase levels of fatigue. Level 4 control Level 4 controls constitute fatigue investigations and actions undertaken by senior managers and/or local OHS committees. These investigations and actions will be following the identification of fatigue related issues or errors during control levels 1 to 3. Level 5 control Level 5 controls are the subsequent root cause analysis and review of incidents that occur at levels one through four. That is, incidents that occur in regards to actual fatigue incidents conducted by the appropriate general manager and local OHS committees. It is important to note that a root cause analysis would only occur if there was an adverse event.

19 Fit for duty The SAAS Fatigue Assessment Card individual fatigue scoring The SAAS Fatigue Assessment Card (see example below) is designed to be carried by all SAAS staff so they can measure their own fatigue score. There is a wallet sized SAAS Fatigue Assessment Card for you in the back of this booklet. You are encouraged to keep it on your person at all times as a tool to check your fatigue level. The individual assessment card uses minimum sleep and maximum awake rules as a basic self assessment tool to determine fatigue levels. It is a tool to enable SAAS staff to self-determine their risk of fatigue and manage their risk of fatigue on their own or in conjunction with the state duty manager (or line manager for support services staff). The prior sleep wake model, is comprised of three simple calculations: > > X hours sleep in the prior 24 hours > > Y hours sleep in the prior 48 hours > > length of wake from awakening to end of work. Before commencing a shift every staff member should be able to calculate their prior wake threshold and when obtained sleep doesn t meet the criteria, the score will demonstrate an increased risk of a fatigue related error. Depending on the score a staff member will take a particular course of action. Either self monitoring, having a fellow member of staff monitor you or alteration to/removed from duty. SA Ambulance Service Fatigue Assessment Step 1: Determine the amount of sleep had in the last 24 hours. Sleep (hrs) < Points SCORE Step 2: Add this to the amount of sleep obtained in the preceding 24 hour period giving a total for the past 48 hours. Sleep (hrs) < Points Step 3: Assess how many hours you will have been awake since your last sleep at the end of your shift. If total sleep in step 2 is greater than hours awake at end of step 3, points = 0. If less, add 1 point per hour awake greater than sleep in step 2. Step 4: Total your points to determine your score page 16

20 SAAS Fatigue Assessment Card side 1 How to use side 1 of the card Step 1: Sleep in prior 24 hours This section allocates points based on the accumulated number of hours sleep achieved in the past 24 hours. Step 2: Sleep in prior 48 hours This section allocates points based on the total number of hours sleep achieved in the past 48 hours. Step 3: Hours awake since last sleep (at end of shift) This section allocates points based on the number of hours awake since last sleep at the end of your shift minus the number of hours sleep achieved in the past 48 hours (refer to step 2). If sleep in the past 48 hours is greater than the hours awake, score = 0. SA Ambulance Service Fatigue Assessment Step 1: Determine the amount of sleep had in the last 24 hours. Sleep (hrs) < Points SCORE Step 2: Add this to the amount of sleep obtained in the preceding 24 hour period giving a total for the past 48 hours. Sleep (hrs) < Points Step 3: Assess how many hours you will have been awake since your last sleep at the end of your shift. If total sleep in step 2 is greater than hours awake at end of step 3, points = 0. If less, add 1 point per hour 1 awake greater than sleep in step 2. Step 4: Total your points to determine your score 8 15 Step 4: Calculate score Add together the points from steps 1, 2 and 3 to generate your score. Example (see above): 1. You slept 3 hours in the past Your total sleep in the past 48 hours = 9 hours. 3. You woke at 0600 this morning and your shift ends at 1600 hours; hours awake at end of shift (10) minus hours sleep in past 48 hours (9) = = 15 points. page 17

21 Fit for duty SAAS Fatigue Assessment Card side 2 How to use side 2 the card (once the assessment is complete) Level 1 (score of 1 4) Keep an eye on yourself Controls and mitigations strategies available to the individual at this level include: > > increase you self supervision and monitoring of alertness > > look for indicators of fatigue > > watch your food intake and keep hydrated > > ask your colleagues to monitor you > > strategically use caffeine (particularly during hours when a staff member would normally be asleep) > > use strategic napping. Level 2 (score of 5 8) Look out for each other Staff with an elevated level of fatigue risk should report this immediately to the state duty manager both prior to commencing shift or if fatigue is identified during a shift. This is relevant to both patient services and support services staff. This one stop reporting line is to ensure we are able to capture the OHS data effectively and accurately. What action do I take? SCORE CONTROL LEVEL 1 4 Keep an eye on yourself 5 8 Look out for each other 9 + Notify state duty manager to discuss actions Further information can be obtained from Fit for duty staff guidance booklet. The state duty manager will discuss the fatigue score with the staff member and ensure that safety critical tasks are minimised (e.g. driving) and that all reasonable efforts are made to mitigate the effects of fatigue. It is then the responsibility of the state duty manager to notify the appropriate line manager. page 18

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23 Fit for duty Controls and mitigations strategies available at this level include: > > reporting score to state duty manager > > strategic napping (i.e. two hours) > > reallocating positions (driver and attendant); may need to split crews > > restructuring of work tasks and/or breaks > > relocating to lower demand area (own or other region) > > monitoring by a colleague > > submission of a fatigue report. Level 3 (score of 9+) Notify state duty manager to discuss actions Staff with a fatigue likelihood score in this range are to be considered unfit for duty. This level of impairment is broadly comparable to drug or alcohol intoxication. Controls and mitigations strategies available at this level include: > > advise the state duty manager as soon as possible > > do not commence shift > > staff will be given the opportunity to obtain sufficient sleep in order to be fit for duty > > submit a fatigue report. Information regarding SAAS specific fatigue issues These issues are all level 1 controls which mean that SAAS, as an employer, has put measures in place to ensure SAAS staff are safe and fit for duty. Mutual shift swaps Rosters are dynamic and subject to continual change to meet service and staff needs. When mutual shift swaps are requested, staff will calculate their fatigue score and team leaders/managers will evaluate the score before authorising the shift swap. Rostering staff will not process a shift swap unless it is authorised by the appropriate team leader/manager. Team leaders/managers will not approve a shift swap if the score enters or is already at level 2 (score 5 8) or above, either on the shift of the swap or on a subsequent shift. It is the responsibility of the individual to ensure they are fit for duty at the time of the swap and secondly to ensure a potential estimate for future fatigue levels has been calculated. This secondary (future date) calculation is completed by the authorising officer (team leader or line manager) by calculating sleep opportunity in-between actual shifts/work days (e.g. to ensure minimum break requirements are met). page 20

24 Overtime When overtime is required the staff member will assess their fatigue score and advise the team leader/manager or rostering officer allocating the overtime. The team leader/manager or rostering officer will consider the staff member s fatigue risk before allocating overtime. Additional information from the PROMIS rostering system can be accessed to assess duration between a staff member s shifts. Overtime should be allocated to the officer with the lowest fatigue risk. Overtime will not normally be considered if the determined fatigue score enters or is already at level 2 (score of 5 8), or if it will be above this either on the overtime shift or on subsequent shifts. If no suitable staff are available, the approval for overtime must be referred to the manager patient services or line manager (for support services staff). In these circumstances the manager may approve overtime for staff whose fatigue score enters or is already at level 2 (score of 5 8) or above on either the overtime shift or on subsequent shifts. In these circumstances the approval for overtime is to be for the minimum extent of time necessary provided that additional mitigating strategies are adopted (e.g. strategic napping and appropriate monitoring. At the end of the overtime shift, it is the responsibility of the individual staff member to monitor their fatigue level using their fatigue assessment card. On call and volunteer staff SAAS attempts to minimise staff exposure to on call and is working towards eliminating on call from patient services areas. Given the unpredictable nature of on call, it is very difficult to plan workloads or breaks. For this reason we can only rely on the individual s vigilance in monitoring their own fatigue levels using the SAAS Fatigue Assessment Card and liaising with the appropriate manager should a fatigue risk present itself. Volunteer staff across the state have similar vagaries in their workload and also have a responsibility to be fit for duty and monitor their fatigue levels. It is important that volunteers know they can avail themselves to wage reimburse ment to ensure sleep opportunity is obtained. This is particularly relevant for night ambulance responses. It is important that volunteers discuss this with the state duty manager should their fatigue score impede their ability to function safely at their regular employment. page 21

25 Fit for duty Driver fatigue SAAS has a responsibility under the OHS Act (1986) to ensure that all staff at work are, as far as reasonably practicable, safe from the risks of injury resulting from driver fatigue. By virtue of the nature of a 24/7 emergency service, there will be unexpected events that require long distance driving. However, a planned working/ driving schedule should be prepared in conjunction with and approved by the state duty manager prior to undertaking the journey. Hazards associated with the proposed journey and driving schedule will be identified and assessed. Appropriate control mechanisms will be developed in consultation between the driver and the ACTL, CTL, MPS or state duty manager to address the risks. We want you to think about what you are doing; if you are driving for more than two hours please swap drivers or take an appropriate break (e.g. 15 minutes). Maximum driving times and breaks Driving schedules which include a driving time of two consecutive hours (behind the wheel) will be accompanied by a minimum 15 minute break (from driving). The maximum total driving time (excluding breaks) will not exceed eight hours in any one day. With regard to operational ambulance driving, the driver and attendant should rotate their duties to ensure no more than two consecutive hours of driving is completed by any SAAS member. Driving immediately after awakening SAAS, as an employer, has a duty of care to its staff. Each individual staff member also has a duty of care to look after their own welfare and the welfare of their fellow workmates. There is sufficient researched evidence to suggest that safety critical tasks should not be undertaken for approximately 15 minutes after being woken suddenly. This period after waking is known as sleep inertia. Sleep inertia is particularly relevant within SAAS s patient services areas. To reduce the risk of a staff member being woken up suddenly to respond to a triple zero (000) call and being immediately expected to undertake the safety critical task of driving, it is recommended that both crew members should not sleep simultaneously. The crew member remaining awake and alert will undertake the driving task allowing time for their colleague to regain full wakefulness enroute to the job. page 22

26 It is not SAAS s intention to deny staff sleep in order to avoid sleep inertia. Rather, it is SAAS s intention to educate staff about the potential impact that sleep inertia may have on their performance and encourage them take actions to mitigate these effects. Sleep inertia defined Wyatt & Bootzin, 1994, cited in the Australian Government, Australian Transport Safety Bureau (2002), defined sleep inertia as periods of poorer task performance that results immediately after awakening. It is commonly reported as a feeling of mental dullness or sluggishness immediately after awakening, or the poor performance related to the process of arousal from sleep. Tassi et al (2008) define sleep inertia as the period immediately after awakening characterised by decreased performance and/or disorientation. During a period of sleep inertia, people demonstrate all the outward physical signs of being awake, but are not cognitively awake, individuals affected by sleep inertia typically report feeling sleepy, disorientated, confused and sluggish. (Australian Government, Australian Transport Safety Bureau, 2002) Ferrara, De Gennaro & Bertini (2000), found that during sleep inertia, cognitive performance reached a normal level about 30 minutes after awakening; however, they found that motor performance was still below the normal levels for 75 minutes. Further, that cognitive and motor performance ability is affected if woken from a specific stage of sleep, specifically REM sleep. Even though you may be awake your body may not be functioning properly. page 23

27 Fit for duty General fatigue management/mitigation strategies The following list, whilst not exhaustive, outlines SAAS endorsed fatigue mitigation initiatives (some initiatives relate to patient services only): > > increased supervision and monitoring of alertness > > food intake and hydration > > increased supervision by colleagues > > strategic use of caffeine (particularly during hours when a staff member would normally be asleep) > > strategic napping (two hours protected and undisturbed) > > reallocation of positions (driver and attendant) > > relocation to lower demand area for recuperative sleep and rest (EOC staff to develop a monitoring system which highlights crews that may need rotation and advise the state duty manager) > > crews who have achieved two hours recuperative sleep should be swapped with crews who have not had an opportunity to rest > > If a staff member reports a high fatigue score from home prior to commencement of duty, allow for return to bed for two hours recuperative sleep, before attending for work. (The intent here is, first and foremost to ensure staff are safe; secondly, it is better to have a staff member for eight hours out of a ten hour shift, than not at all.these reports will be monitored and reviewed by management and OHS representatives). > > If a staff member reports a high fatigue score from home prior to commencement of duty and is unable to guarantee two hours undisturbed recuperative sleep. A taxi can be arranged to transport staff member to station where two hours undisturbed recuperative sleep may be obtained. In these circumstances a taxi will be arranged to return the staff member home at the end of the shift. > > If at the end of a shift or if extended unforeseen overtime results in a high fatigue score for a staff member, they should not be permitted to drive home. A taxi or suitable conveyance can be arranged for the trip home and for return to work to collect the staff members own transport when safe to do so. > > Staff will be given the opportunity to obtain sufficient sleep in order to be fit for duty. page 24

28 Reporting fatigue The SAAS fatigue management policy and procedure is available to all staff on SAASnet. The easy-to-follow procedure takes you through the steps you are required to follow to report fatigue and how to use the card. Duty of care All staff have a duty of care to report fit for work. This responsibility includes taking measures to: > > ensure that adequate recovery sleep is obtained between shifts/work days > > out-of-hours activities do not result in fatigue that impairs workplace performance at anytime during the rostered shift (i.e. you must arrive refreshed enough to not be likely to be fatigued before the end of the shift/work day). Unforeseen circumstances On occasions, circumstances outside an individual s control (e.g. a sick child, relationship problems, bereavement etc) will result in inadequate recovery sleep that may contribute to fatigue. Fatigue assessment The state duty manager must discuss the situation with the staff member concerned and assess their suitability for continued duties. When making this assessment the state duty manager should consider the psychological, physiological and social effects of insufficient sleep. As a guide, an individual who has had less than five hours recovery sleep in the last 24 hours or less than 12 hours recovery sleep during the last 48 hours should be deemed unfit for operational duties. Reassignment of duties The state duty manager may consider the following options: > > In consultation with your ACTL, CTL, RTL, MPS or support services, line manager, reassign staff member to temporary non-operational duties. > > Allow staff member to obtain at least two hours undisturbed sleep before resuming/commencing the shift. When these circumstances arise and an individual recognises, or a colleague advises, that the individual is exhibiting signs of fatigue, they should report to the state duty manager rather than put themselves or others at risk. page 25

29 Fit for duty Generating a fatigue report Maintaining and enhancing a positive safety culture requires a willingness to address and remedy all shortcomings as soon as they become evident. This in turn relies on comprehensive reporting of all incidents and risk exposures, whether large or small, that may pose a threat to our patients, clients, staff or general operations. SAAS is committed to openness and frankness in reporting. A fatigue report will be generated when the staff member contacts the state duty manager. The report must include: > > all occurrences where a staff member is unfit for duty due to fatigue > > all instances of on duty staff entering an unacceptable (level 2 or above) fatigue risk score > > any concerns by staff regarding fatigue issues. The state duty manager is the first point of contact for fatigue reports and initial management of a fatigue issue 1. All reports will, however, be forwarded to the applicable general manager and local OHS workgroup for review/audit and ongoing mitigation. 1 It is important to note that the state duty manager must be notified of all fatigue reports. Sometimes it may be more appropriate for support services staff to liaise directly with their line manager to report fatigue. However, please ensure the state duty manager is aware of this report for OHS reporting requirements. It is important to note that every fatigue report will be reviewed. What happens when the review of the fatigue report is complete? Once the review into a fatigue report is complete, the general manager or their nominated deputy will contact the reporting staff member (unless anomalously reported) to discuss and to provide an update on the outcome of the review. Recommendations from these investigations will be presented to the Patient Services Management Team for consideration. Fatigue investigation In the event of a fatigue related error/ incident, the investigator (local manager in consultation with the local OHS committee or OHS representative) will examine or ascertain a fatigue score for the staff member. Rostering data leading up to the occurrence will also be obtained, if appropriate, to determine if work related fatigue may have been a contributing factor. This information will form part of the error/incident investigation process thereby ensuring any work related contributing fatigue issues are identified and, if necessary, addressed. page 26

30 Performance management excessive levels of fatigue If an individual accumulates unacceptable levels of non-work related fatigue SAAS management will adopt a performance management approach to address the situation. This approach will offer appropriate support and assistance to the staff member with difficulties in gaining recovery sleep. Factors to be considered When considering fatigue related issues line managers must consider: Non-work related factors may also be assessed and action taken, as necessary, using a supportive performance management framework. This forms level 4 and 5 controls and will be managed by the general manager/ manager patient services in conjunction with the local OHS workgroup. It is important to note that these investigations are not designed to be punitive. Protecting the health and wellbeing of SAAS staff is paramount. > > personal circumstances such as sick household or family members, relationship difficulties, family tragedy or bereavement (friend or relative) > > non-work related activities (e.g. excessive social activities, non-work commitments that limit sufficient rest prior to work) > > behavioural inconsistencies demonstrating signs of fatigue (such as delayed response time, irritability, reduced concentration) > > recent sleep/wake history. Having said that, staff who take advantage of or abuse SAAS s fatigue management reporting system will be subject to performance management. page 27

31 General information about sleep, fatigue and lifestyle Fit for duty Body clock (circadian rhythm) All humans have a natural hour body clock which is designed to make us sleepy at night and alert during the day. Most aspects of physical and mental performance are at their peak during the late afternoon and at their worst between 3.00 and 5.00 am. Many physiological functions such as body temperature, blood pressure and hormone levels follow similar cycles. Shift work involves trying to work at times when performance is poor because of these cycles Performance 37.6 Performance Body temp :00 06:00 12:00 18:00 00:00 06:00 Circadian rhythm performance over the 24-hour cycle Note that performance is at a maximum at approximately 2.00 pm and a minimum at approximately 3.00 am. 00:00 06:00 12:00 18:00 00:00 06:00 Circadian rhythm performance and body temperature over the 24-hour cycle Note that body temperature rises and falls with circadian rhythm. Sleep latency Performance Body temp Sleep time :00 06:00 12:00 18:00 00:00 06:00 Circadian rhythm sleep latency (time it takes to get to sleep) and sleep time over the 24-hour cycle page 28

32 Fatigue is cured by sleep, but what is sleep? Sleep is a reversible behavioural state of perceptual disengagement from, and unresponsiveness to, the environment. Sleep drive is a desire to go to sleep; sleep drive is determined by the amount of time we have been continuously awake and is influenced by the quantity and quality of time spent asleep. Sleep latency is the interval of time between settling in to go to sleep and the onset of sleep. It varies throughout the 24-hour cycle. Sleep stages The average person needs eight hours of sleep per day. There are five stages of sleep stages 1 to 4 and rapid eye movement (REM). Stage 1 Drowsiness The eyes are closed during stage 1 sleep, but if aroused from it, a person may not feel as if they have slept. Stage 1 may last for 5 to 10 minutes. Stage 2 Light sleep The heart rate slows and body temperature decreases as the body prepares to enter deep sleep. Stages 3 and 4 Deep sleep The point when our brain waves are least like waking. Consequently, it is the most difficult stage in which to wake sleepers, and when they are awakened they are usually sleepy and disoriented. Stage 4 is more intense than stage 3. Non-rapid eye movement (REM) sleep The period of non-rem sleep (NREM) is comprised of stages 1 to 4 and lasts from 90 to 120 minutes, each stage lasting anywhere from 5 to 15 minutes. Surprisingly, however, stages 2 and 3 repeat backwards before REM sleep is attained. This means that a normal sleep cycle has the following pattern: waking, stage 1, 2, 3, 4, 3, 2, REM Usually REM sleep occurs 90 minutes after the onset of sleep. Stage 5 rapid eye movement (REM) REM sleep is distinguishable from NREM sleep by changes in physiological states, including its characteristic rapid eye movements. Heart rate and respiration speed up and become erratic, while the face, fingers, and legs may twitch. Intense dreaming occurs during REM sleep as a result of heightened cerebral activity, but paralysis occurs simultaneously in the major voluntary muscle groups, including muscles of the chin and neck. page 29