There is a link between working shifts and physical and poor psychological health and wellbeing (Harrington, 2001; Vogel et al, 2012). Between September 2010 and September 2012, United Kingdom (UK) ambulance staff had the highest aggregated sickness rates by National Health Service (NHS) staff group at a level of 6.2%. All NHS staff groups saw their sickness levels rise during the same period (Health and Social Care Information Centre, 2013).
NHS leaders have committed to improving workplace culture and ensuring staff health and wellbeing is part of performance measurement. Leaders support the challenge to promote healthy lifestyles and prevent ill health among the NHS workforce and recognise that staff health is linked to productivity and performance (NHS Employers, 2013). The Boorman Report (2009) set out recommendations to improve NHS staff health and wellbeing and recognise the link to organisational performance. The state pension age for paramedics is increasing to 68 years in 2046 following government changes in 2011 (Unison, 2016).
A focused literature search was completed during October 2013 using the keywords of ‘paramedic’, ‘shift work’ and ‘impact’ and their synonyms and MeSH headings. The databases BNI, CINAHL, Embase, AMED and Medline were searched individually, as was Google Scholar. The search identified nine relevant papers, five of which were empirical research. Only one of these papers comprised research carried out in the UK and was a small study of six participants with variable working roles and included one paramedic (Crew, 2006). Eight of the papers were international and focused on different aspects of shift work, such as effects on sleep (Elliot and Kuehl, 2007; Nugent, 2010; Cotter, 2011; Archer et al, 2012; Sofianopoulos et al, 2012), human error (Cotter, 2011), off-duty preparation for night shifts (Frakes et al, 2005), and health specifically (Wong et al, 2012). Access to one paper was unachievable.
The main effects of shift work on paramedics were found to be sleep deprivation, negative effects on physical wellbeing, psychological wellbeing, and an increased risk of human error. Wider reading on the effects of working shifts found that shift work was associated with adverse effects on health, safety and performance outcomes, circadian rhythm misalignment, poor sleep quality and sleep disorders, a heightened risk of occupational accidents and an increase in cardiometabolic disease and mood disturbances (Rajaatnam et al, (2013).
Research in the UK is deficient in this area, and this project therefore aimed to identify the perceived impacts of shift work, and provide a rationale for further research into occupational factors affecting the paramedic profession.
Aims
Objectives
Methods
The ontological influence on the research design was relativist in nature, whereby reality is believed to be constructed through meanings and understandings developed socially and experientially (Robert Wood Johnson Foundation (RWJF), 2008). The most prominent paradigm was interpretavist in the knowledge that we cannot be separated from what we already know and believe. The researcher and the participant are linked, and the knowledge that exists already and the researcher's values are inherent in all aspects of the research process (RJWF, 2008). This exploratory study utilised a qualitative research design to explore the impact of shift work on UK paramedics.
Two focus groups were formed within one sector of an ambulance service in the South West of England using convenience sampling. Within the participating ambulance service the usual shift length is either 10 or 12-hour shifts. Health and Care Professions Council-registered paramedics employed within the local ambulance service were recruited to the research. The research was advertised locally and within the ambulance service's internal bulletin. The aim was to recruit eight participants to each focus group.
A moderator (JP) and an assistant researcher (SM) conducted the focus groups. The focus group was audio recorded and notes were taken throughout. A third researcher (KK) transcribed and analysed the data using thematic analysis. The transcriptions and initial data analysis were corroborated by the three researchers to provide the final data analysis.
Results
The first focus group contained eight participants, unfortunately only three participants were recruited to the second group. Study participants are described in Table 1.
| Nationality | 100% British |
| Age | Mean 44 years (range 21–60 years) |
| % married or co-habiting | 100% |
| Gender | 36% female; 64% male |
| % with dependent children | 64% |
| Mean length service | 16 years (range 2.5–35 years) |
Results of thematic analysis
Eight major themes emerged from the thematic analysis of the transcribed focus groups. Each theme will be discussed individually.
Physical health
Participants described an overall negative effect of working shifts as a paramedic on their physical health and made a link to opportunities to exercise regularly.
Participants described not being able to commit to regular exercise and some participants described having to give up team sports due to an inability to commit to training. During a run of shifts participants found it difficult to fit in any exercise and described exercising sporadically to fit in with shifts.
‘You gradually lose your place in the team and I ended up having to give that up and now I just do like lone going up to the gym as and when I can, but even that's difficult’ Participant 3, FG1.
When on shift, paramedics reported that they find it extremely difficult to eat regularly and healthily. They described not being able to take their breaks at ‘normal’ meal times and difficulty in storing food on shift leading to a poorer diet and increased snacking on unhealthy foods.
‘Whether it was a contributory factor towards my type 2 diabetes…so I've been in the ambulance service 10 years doing shift work. Is that a factor that because of poor diet etc. that I've ended up with diabetes… especially as there's no family history of diabetes at all in my family’ Participant 4, FG1.
This participant in particular described difficulties keeping to a ‘normal’ meal routine to manage having type two diabetes and felt the shift work further impacted negatively on their health.
Participants described feeling ‘generally below par’ most of the time and particularly unwell after working night shifts. Paramedics felt it takes a week of annual leave to feel well again after working a pattern of shifts.
Paramedics described the unique working environment in pre-hospital care and the lack of facilities available to take care of your own health. One participant described having had recurrent urinary tract infections, which they attributed to a lack of toilet facilities on shift. Also described was a dehydrating effect of working night shifts.
Psychological health
Paramedics described stress as the main impact of shift work on their psychological health. There were many factors that contributed to increased levels of stress. One of the main factors mentioned was dealing with stressful incidents at work. ‘Stressful incidents’ were not necessarily a traumatic incident, but could come in a variety of forms and were very individual to the paramedic.
‘It's the perception of what's a nasty job, you know the nasty job, you say you have a TRIM (trauma risk management), but there's other jobs that completely fall under the radar that's really affected you’ Participant 10, FG 2.
Other stress-inducing factors mentioned were high-pressured decision-making, the unpredictable nature of the work and the lack of control paramedics had over events. Paramedics mentioned the accumulation of stress over time and the need to find mechanisms to cope with this.
There were many other stress-causing factors that paramedics mentioned and these included obtaining annual leave and ‘juggling’ family life.
‘I have two young children, they're both in primary school, it's a constant effort to juggle, my wife's a technician as well in the ambulance service, you've got to call on grandparents, close neighbours, yeah, it is a constant juggling act and very unsupported’ Participant 8, FG 1.
Shift work was described as having a negative effect on mood. Participants described fluctuations in their mood and depression.
‘My moods were going up and down, up and down, up and down and went to him (doctor) for some sort of answer, and twice I went to him and both times he said you need to get plenty of sleep, you need to eat regularly and all these things he was saying, I wanted to scream at him I can't do that’ Participant 10, FG 2.
Fatigue
Participants described an accumulated sleep debt, which was especially apparent on night shifts, and particularly where a paramedic worked over two nights in a row.
‘No matter how busy my nights are I only sleep about two to two and a half hours when I get home’ Participant 1, FG 1.
Paramedics described a constant battle with ‘normal’ sleep routines—both against them and to get back into them, and a constant disruption in sleeping patterns. Paramedics also described forgoing sleep to try and get back into a normal sleep routine. In particular, paramedics described swapping between night and day shifts with insufficient recovery time as ‘exhausting’. One paramedic who worked a set shift time felt that this was preferable to working a constantly changing shift pattern.
‘Paramedics described stress as the main impact of shift work on their psychological health’
Other factors described as contributing to fatigue were the increasing amount of shift overruns, long commutes to work, the impact of long distance driving and demands from outside of work.
Some paramedics described suffering with insomnia. Insomnia was caused on early shifts by a fear of over sleeping and also by reflecting on incidents on previous shifts, whether it was felt they had gone well, or not so well. Older paramedics described this kind of reflection persisting despite a higher level of experience.
‘Even when you've been doing it as long as ****…you still go home and you still…if you screwed up in some way, or you think you've made a a bad decision then you just lie there and think about it’ Participant 9, FG 2.
Paramedics who had worked shift work in previous occupations felt that ambulance shift work was for some reason much more exhausting. The unpredictable nature of the work was seen as particularly exhausting and ‘stressful’ incidents left paramedics feeling drained.
Social
Paramedics commonly described social isolation. When working shifts the paramedics described the difficulties in committing to team sports, clubs and social activities. Working nights, weekends and public holidays often makes it difficult for paramedics to commit to social events. Some paramedics described swapping to sports that were described as being more ‘loner’ sports.
‘Our social life is affected because you can't arrange to do anything after work, the amount of functions that you don't end up going to…club activities, any interests, you can't regularly pay a subscription to anything because invariably you can say oh well, I'm on an early I'm off at 6 that day you will be off at 8, so there's a huge impact and I think when we all come into shift work we're all very naïve as to how over a period of years that will effect you, in many ways’ Participant 3, FG 1.
On a more positive note paramedics described having more days off to do things and to see people because of working less days due to the longer hours of shift work. They also enjoyed being able to do things when there were less people around.
‘Participants described an accumulated sleep debt, which was especially apparent on night shifts, and particularly where a paramedic worked over two nights in a row’
Family
Paramedic shift work was described as putting strain on family relationships. Often paramedics described being severely fatigued and not being on their best form.
‘But it does put strain on relationships…no matter what people say it does put strain on them because you don't spend quality time with your spouse, your children’ Participant 6, FG1.
Fluctuations in mood were felt by other family members, and family leisure time could be difficult to plan and was often impacted by the demands of the paramedic role.
When on a ‘run’ of 12-hour shifts, paramedics described having a block of time where they didn't see their families and described family life as ‘all or nothing’.
‘I think one of the biggest problems I've got is I can go four days really without seeing my two little ones’ Participant 7, FG 1.
Other paramedics viewed blocks of time off as a real positive, as it gave them a block of quality time with their families.
‘I mean this week I done last Saturday and Sunday night and finished Monday morning…I've taken two days leave. I'm not back to work now till Monday night. So I've got seven days off for two days leave. That's the pros’ Participant 9, FG 2.
Paramedics cannot rely on ‘formal’ childcare due to unpredictable finish times and early starts and late finishes. Families often rely on ‘informal’ childcare which can put pressure on extended family. A positive of this is the lack of childcare costs. Where both parents work in the ambulance service paramedics described it as particularly stressful to ‘juggle’ family life.
One paramedic described the effect of the shifts on his wife's ability to commit to social activities and courses because of childcare. Often paramedics miss family events. Paramedics who worked 10-hour shifts found it better for family life, but the knock-on effect was spending more days at work.
Age
Paramedics felt that their resistance to the negative effects of shift work became less with age and were concerned about the difficulties of coping with paramedic shift work with increasing age. The paramedic role was described as being more acceptable at a younger age and when individuals had fewer commitments. Older paramedics described age-related conditions and how these make it harder to work as a paramedic. Paramedics described it taking longer to adjust to changing shift times with age. Paramedics were especially concerned about the expected retirement age for paramedics. They did not view working to retirement age as achievable and felt they would have to find something else to do before retirement age.
‘But there's no remuneration, there's no consideration with the fact that your life may be shortened because they're still expecting us to do this job at 67, we'll be dead before then’ Participant 3, FG 1.
Safety and performance
Paramedics were especially concerned about driver fatigue and the increased risk of road accidents, particularly on nights.
‘You think professional drivers, like HGV drivers, they've got to take breaks, again, it seems to be a jack of all trades and you sort of think you do it, you get on with it, there doesn't seem to be much sort of staff protection’ Participant 7, FG1.
There was also an expressed fear of making clinical errors due to high fatigue levels and of fatigue affecting decision-making skills. Paramedics felt that high fatigue levels have a detrimental affect on clinical effectiveness.
Organisational
Paramedics perceived that there was a lack of organisational acknowledgement and concern about the negative effects of shift work on paramedics. There was a lack of organisational guidance on how to best manage shift work in the ambulance service.
Paramedics felt generally unsupported and disempowered. Factors mentioned were opportunities to take breaks, support following stressful incidents, flexible working, increasing late finishes, sickness management and long-distance transfers and the general increase in demand.
Paramedics felt there was room for more innovative ways of working, that 12-hour shifts were not suitable for all staff and that some staff may choose to work a permanent day or night pattern.
‘But it does make a huge difference not having the swaps and changes of times and shift times, like doing earlies onto nights and then the quick turn arounds’ Participant 2, FG 1.
Paramedics were anxious about some organisational changes and perceived there to be a centralisation of resourcing, with staff rostering being managed centrally with a lack of awareness of individual circumstances at a local level. Participating paramedics felt this would impact negatively on paramedics’ working lives. Paramedics recognised the organisational pressure of a 24-hour, 7-day-a-week ‘emergency’ service and the difficulties for the organisation of maintaining staff welfare.
Interestingly, the vast majority of the participants felt they would rather continue with paramedic shift work than change to a 9–5 job. They described job satisfaction and in the main they enjoyed their role as a paramedic.
Discussion
This exploratory research has given an insight into the occupational environment of paramedics and the work-based challenges paramedics face. These two groups of paramedics described factors associated with working shifts that mirror research already completed within different occupations: effects on physical health, fatigue, family life, safety and performance; but additionally described factors that are more limited to working in the paramedic profession such as a broader range of psychological stressors and organisational factors. The theme of psychological health was a wider theme that went beyond shift work and encompassed the overall paramedic role and the unique and stressful nature of the work. The authors recognised that shift work may not be exclusive as a causative factor in the outcomes discussed and that the effects of the physical and psychological demands facing paramedics were difficult to separate from the effects of shift work. The results expanded on the findings of the limited literature that informed this study and added further depth to the impacts of working shifts as experienced by UK paramedics.
There are some limitations to this study which should be taken into consideration. The main thematic analysis was undertaken by one researcher (KK) and then subsequently checked and agreed with the researchers (JP, SM) who ran the focus groups. The researchers recognise that reflexivity must be addressed and that the researcher's own opinions and attitudes are likely to have influenced the direction of the focus groups and the results of the analysis.
A criticism of the use of focus groups is that the sample may not be representative of the whole, and generalisable to the paramedic population. Participants are self-selecting which may have led to bias in the results. An additional factor to consider is that the second focus group consisted of only three participants, which would have had implications for group dynamics and the general flow of the focus group.
Conclusions
This research has allowed an insight into the perceived effects of shift work on UK paramedics and exposes the challenges paramedics face in their working environment. This study added further depth to the limited literature that informed the background to the study. This was an exploratory study, and has highlighted a number of areas where further research could be beneficial. There is a suggested link between the comparably high rates of sickness among UK paramedics and the effects of shift work and paramedics’ overall working environment. Further exploration and recognition of the effects of shift work on UK paramedics and implementation of strategies to reduce the negative effects of shift work on UK paramedics may reduce occupational sickness levels, increase productivity and allow for a healthier and more satisfied paramedic workforce.
Key Points
This research was funded by a College of Paramedics small grant scheme
Conflict of interest: none declared