Title: Fighting fatigue in the NHS ambulance workforce: development, acceptability and feasibility testing of a comprehensive fatigue risk management system to improve staff and patient safety
Funder: Department of Health and Social Care

Abstract: The consequences for patients of being attended to by ambulance crews suffering the effects of poor sleep and fatigue can be tragic, yet exhaustion through poor sleep quality is recognised by the NHS. Insufficient and disturbed sleep carry implications for resource management due to staff sickness and absenteeism, and for the quality of the service provided. There are many actions that staff and ambulance services can take to prevent fatigue, and to minimise its impact. Ambulance services are trying out different ways of working to help staff feel less tired at work and safer on scene, including improving rostering, but these actions are often piecemeal and we don’t know how they compare against international best practice or whether they are making care and working environments safer._x000D_ _x000D_ What we have done so far:_x000D_ Through a review of all available evidence, we found no published research studies of sleep in UK ambulance staff and only one small study on fatigue. In 2019 we conducted the first such study in the UK, collecting data from 689 staff in one Trust. We showed that: 60% of staff reported clinically important levels of mental and physical fatigue, 75% of staff reported poor sleep quality, and fatigued staff were more likely to report being injured and to feeling unsafe at scene. Looking nationally, we found that no NHS ambulance trust in England had a fatigue management policy for their staff and only four Trusts mentioned support for better sleep in staff wellbeing policies. When we presented these findings to all the Chief Executive Officers and Chair Boards of NHS ambulance services in the UK there was strong support for evaluating what ambulance services could do differently to reduce staff fatigue, improve sleep, and support patient safety. _x000D_ _x000D_ We have brought together a team of patients, staff with lived experience, fatigue experts, ambulance service researchers and managers, international expertise, and companies currently working with ambulance services on fatigue management. We aim to develop a new approach to fatigue management for the UK ambulance sector that meets the needs of staff and operations and is most likely to improve patient and staff safety. Our recommendations will include learnings from the current COVID-19 pandemic._x000D_ _x000D_ To do this we will:_x000D_ • Define the actions ambulance services should be taking to monitor and respond to tired crews, and help staff sleep better. We will do this by learning from what happens in other countries, and in high-risk industries in the UK_x000D_ • Talk to senior managers, local managers, front-line staff and patients to understand their experiences of current fatigue management actions and how they might impact on safety outcomes_x000D_ • Produce and test a guide for ambulance services on how to implement best practice in their setting that matches their needs and risks. _x000D_ _x000D_ We anticipate the following outcomes:_x000D_ • New knowledge on the best strategies that ambulance trusts can use to help staff sleep better and to reduce the risk of being dangerously fatigued at work_x000D_ • An understanding of how patient and staff safety might be improved with a system-wide approach to preventing and managing fatigue _x000D_ • A plan that can be put into practice that can be flexible enough to meet the different needs of each ambulance trust, giving a means by which we can monitor how much the new plan is costing the services, and how effective it is at reducing fatigue.

Lay abstract: Background: Poor sleep and fatigue are common in acute and emergency health care staff and increase risk for adverse staff and patient safety outcomes. These risks can be reduced through development and implementation of a fatigue risk management system (FRMS), as is done in other safety-critical industries like aviation and transport. The evidence suggests individual components of a FRMS which may be effective, but we do not yet know about the optimal packaging of these interventions. FRMS adoption in the NHS needs local tailoring and understanding of barriers and facilitators._x000D_ _x000D_ Aims and objectives: The aim is to develop a comprehensive fatigue risk management system for the UK ambulance sector that is underpinned by a theory of change and is acceptable, feasible, and likely to improve patient and staff outcomes. _x000D_ _x000D_ Objectives:_x000D_ 1. Co-produce an agreed set of evidence-based and emerging components of a FRMS for the UK NHS ambulance sector that are considered feasible and acceptable._x000D_ 2. Identify which components of a comprehensive FRMS are in use and why (promotors/inhibitors)._x000D_ 3. Investigate how front-line staff and patients experience current fatigue actions and potential to improve safety culture and reporting._x000D_ 4. Development and usability testing of the FRMS and its implementation guide that allows tailoring to organisational and local context and is underpinned by a new theory of change and logic model._x000D_ _x000D_ Design and Methods: We will conduct a multi-site, multi-method study with four linked Work Packages (WPs). The project will run for 30 months with co-design and current practice capture occurring across all NHS Ambulance Trusts, with in-depth inquiry in four purposively selected Trusts. _x000D_ WP1: collates a list of candidate actions for inclusion in the FRMS, which are iteratively refined through a survey and co-design event over 1.5 days. A draft FRMS with development report will be produced._x000D_ WP2: will identify which components of a comprehensive FRMS are currently in use and why, through interviews with senior leadership in Trusts_x000D_ WP3: will investigate how front-line staff and patients experience current fatigue actions and potential to improve safety culture and reporting._x000D_ WP4: will produce implementation guidance for the FRMS, which will then be usability tested in four Trusts to produce the final FRMS and implementation guidance._x000D_ _x000D_ Anticipated impact and dissemination: With all outputs co-produced with research end-users, our focus on linking to patient and system outcomes, and producing tailorable implementation guidance, our approach will help maximise sustainable uptake and longer-term impact on patient- and system-prioritised outcomes. Short-term impacts include access to practical guidance for staff, managers, and senior leaders to reform fatigue and sleep health practices. Patients and the general public will have a greater understanding of the fatigue pressures affecting ambulance staff and the need for accommodations on shift such as meal breaks and short naps. Smart rostering has the potential to increase staff engagement and reduce absence. An improved safety culture can reduce costs over the longer-term due to reduced incident numbers and efficient incident investigation.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE