Effect of Fatigue Training on Safety, Fatigue, and Sleep in Emergency Medical Services Personnel and Other Shift Workers: A Systematic Review and Meta-Analysis

Figures & data

Figure 1. PRISMA 2009 Flow Diagram for PICO#5 PROSPERO 2016:CRD42016040110.

Table 1. Description of the sleep health and/or fatigue-related education/training intervention/program

Author, Year	Refid PMID#	Description
Scott, 2010	RefID-2995 PMID-20467338	A one-hour in-person education including information about fatigue, sleep and circadian rhythms, neurobehavioral and health effects associated with sleep loss or deprivation and misconceptions about sleepiness. Strategies for managing alertness, minimizing fatigue and maximizing sleep duration and quality were highlighted with an emphasis on naps and caffeine.
Rosekind, 2006	RefID-2872 PMID-17183922	A comprehensive alertness management program involved education, a 3.5-hour interactive multimedia CD-ROM including alertness strategies and information on healthy sleep. Innovative schedules were also developed and implemented.
Poulsen, 2015	RefID-2728 PMID-26094782	A one-day workshop on recovery self-care practices with written educational material, including a focus on sleep quality.
Chen, 2010	RefID-924 PMID-21139448	A 5-week education program including topics: arranging good sleep environment and habits; reducing emotional stress; controlling diet, alcohol consumption and tobacco use, exercising regularly and introducing alternative therapies.
Carter, 2013	RefID-872 PMID-23989029	Cognitive-behavioral therapy for insomnia.
Atlantis, 2006	RefID-538 PMID-17059294	Supervised exercise prescription and health education seminars on wide-ranging topics such as disease, nutrition, ergonomics and occupational jet lag. One-on-one, 1-hour counseling sessions available mostly focused on nutrition. Sleep hygiene strategies were promoted for preventing occupational jet lag and included: 1) adjusting sleep schedule; 2) adjust meal times; 3) avoid large meals and caffeine towards end of shift; 4) bright light exposure during breaks; 5) wear sunglasses during travel home; 6) reduce noise/light at home for sleep preparation; 7) use of naps before night shift; 8) exercise therapy.
Holbrook, 1994	RefID-1682 PMID-7808891	One-hour sleep hygiene training as part of a three-hour in-service educational forum on health and nutrition.
Kuehl, 2016	RefID-1997 PMID-27158956	The SHIELD program included twelve 30-minute, team-based, scripted, peer-led sessions over six months. Focused on improving diet, physical activity, body weight, and sleep and reducing unhealthy stress and behaviors such as tobacco and substance abuse. The program targeted multiple sleep disorders and evaluated the impact of the multi-component program on sleep quality.
Hardaway, 2005	RefID-1597 PMID-n/a	Extensive briefings on sleep physiology and fatigue countermeasures, guide of suggested nap and sleep periods and suggested light exposure and avoidance times to facilitate circadian alignment, additional time between flights (42 hours off versus 18 hours off on a layover).
Smith, 2016	RefID-3093 PMID-n/a	Email-based sleep wellness program consisting of eight weekly modules highlighting different aspect of sleep health.
Sullivan, 2016	RefID-n/a PMID- 27692049	In-person sleep health educational seminar with sleep disorders screening; facilitating further evaluation, diagnosis, and treatment for those found at high risk of a sleep disorder.
Fabreau, 2013	RefID-1272 PMID-23987729	A “bundle” that included a night-float system, educational sessions on sleep hygiene, an electronic handover tool, and a simulation-based medical education curriculum.
Christopher, 2015	RefID-946 PMID-n/a	A mindfulness training program with an eight-week curriculum and 2+ hour classes each week. The program was described as being grounded in practices shown previously to enhance / address fatigue and poor sleep.
Lee, 2014	RefID-2074 PMID-24229383	A four-week home-based cognitive behavioral therapy including cognitive restructuring, sleep hygiene, sleep restriction, stimulus control, and relaxation training.
Arora, 2007	RefID-529 PMID-17846392	A 60–90 minute SAFER program lecture. The Sleep, Alertness, and Fatigue Education in Residency (SAFER) program was developed by the American Academy of Sleep Medicine. Elements of the program are available on the academy's website at: (http://www.aasmnet.org/store/product.aspx?pid = 1224. Last Accessed 2/14/17).
Steffen, 2015	RefID-n/a PMID- 25563534	Eight weekly, live participatory group sessions including sleep hygiene, stimulus control, guided imagery, cognitive restructuring, meditation, and relaxation techniques.
Smith-Coggins, 1997	RefID-n/a PMID-9332626	A multi-component intervention that included a 2-hour educational session. The first hour included education on sleep physiology and circadian rhythms. Participants also received information about diet manipulation (active placebo group/control group). Other components of the main intervention included schedule modification and promotion of multiple fatigue countermeasure strategies.
Arboleda, 2003	RefID-517 PMID-12737958	Driver fatigue training. Details of the program's components were not provided in the manuscript.

Table 2. Synthesis of findings on the impact of fatigue/sleep education and/or training programs on critical and important outcomes

Experimental Studies
			Important Outcomes
Author, Year	Refid PMID^*	Study Design	Personnel Safety	Patient Safety^*	Personnel Performance^†	Acute Fatigue^‡	Sleep and Sleep Quality^§	Long-Term Health^║	Burnout / Stress
Scott, 2010	RefID-2995 PMID-20467338	Quasi-experimental	Mixed/ Inconclusive	Favorable		Favorable	Favorable	—	—
Rosekind, 2006	RefID-2872 PMID-17183922	Quasi-experimental	—	—	Favorable	—	Favorable	—	—
Poulsen, 2015	RefID-2728 PMID-26094782	Quasi-experimental	—	—	—	—	Favorable	—	Favorable
Chen, 2010	RefID-924 PMID-21139448	Quasi-experimental	—	—	—	—	Favorable	—	—
Carter, 2013	RefID-872 PMID-23989029	Quasi-experimental	—	—	—	—	Mixed/ Inconclusive	—	—
Atlantis, 2006	RefID-538 PMID-17059294	Randomized controlled trial	—	—	—	—	Favorable	—	—
Holbrook, 1994	RefID-1682 PMID-7808891	Quasi-experimental	—	—	—	—	No impact	—	—
Kuehl, 2016	RefID-1997 PMID-27158956	Randomized, longitudinal cohort	—	—	—	—	Mixed/ Inconclusive	Mixed/ Inconclusive	Favorable
Hardaway, 2005	RefID-1597 PMID-n/a	Quasi-experimental	—	—	—	Favorable	Favorable	—	—
Smith, 2016	RefID-3093 PMID-n/a	Quasi-experimental	—	—	—	—	No Impact	—	—
Sullivan, 2016	RefID-n/a PMID- 27692049	Randomized controlled trial	Favorable	—	—	No impact	No impact	Favorable	—
Fabreau, 2013	RefID-1272 PMID-23987729	Quasi-experimental	—	Favorable	—	—	—	Favorable	—
Christopher, 2015	RefID-946 PMID-n/a	Quasi-experimental	—	—	—	Favorable	Favorable	Favorable	Favorable
Lee, 2014	RefID-2074 PMID-24229383	Quasi-experimental	—	—	—	—	Favorable	Favorable	—
Arora, 2007	RefID-529 PMID-17846392	Prospective cohort followed by quasi-experimental	—	—	—	—	No impact	—	—
Steffen, 2015	RefID-n/a PMID- 25563534	Quasi-experimental	—	—	Favorable	Favorable	Favorable	Favorable	Favorable
Smith-Coggins, 1997	RefID-n/a PMID-9332626	Randomized cross-over design	—	—	Mixed/ Inconclusive	Mixed/ Inconclusive	Mixed/ Inconclusive	—	—
Arboleda, 2003	RefID-517 PMID-12737958	Observational, survey	Favorable	—	—	—	—	—	—

Findings are classified as favorable in support of program implementation, unfavorable, mixed/inconclusive, or no impact.

^* Includes quality of care.

^† Includes external subjective ratings of the study subject's performance including perceived satisfaction with the subject's performance.

^‡ Includes acute states of fatigue, sleepiness, and alertness.

^§ includes sleep latency, total sleep time, recovery, and related measures.

^║ General wellness or well-being measures included.

Figure 2. a) Forest Plot (outcome: sleep quality 4–8 weeks post-intervention follow-up fixed effects model. b) Forest Plot (outcome: sleep quality 4–8 weeks post-intervention follow-up random effects model) The figure reports the standardized mean difference (SMD) for sleep quality as measured by the within-group change in the Pittsburgh Sleep Quality Index (PSQI) during the post-intervention follow-up in five studies occurring between 4 and 8 weeks relative to baseline. The SMDs for these studies are the estimated change from baseline relative to the variability in the study and also known as Cohen's d measurement of effect size. The effect size is not tied to a specific scale or scales used in the pooled analysis. An SMD of zero implies there was no change from baseline. An SMD less than zero indicates the outcome at follow up was less than at baseline. Common delineations or cut-points for interpretation include: 0.2 = small; 0.5 = medium/moderate; 0.8 or greater as large. The SMD is non-significant if the corresponding 95% confidence interval is wide and overlaps 0. For the Carter et al. study we used the PSQI measurements at baseline and 5 weeks follow-up (40). For the Chen et al. study, we used the PSQI measurements at baseline and 5 weeks follow-up (11). For the Scott et al. study, we used the PSQI measurements at baseline and 4 weeks follow-up (32). For the Smith et al. study, we used the PSQI measurements at baseline and 8 weeks follow-up (35). For the Lee et al. study, we used the PSQI measurements at baseline (T1) and (T3) 4 weeks after intervention phase follow-up (39). The standard deviations were estimated using the standard deviations from the baseline and follow up measure assuming a positive, moderate correlation between measurements within the same individual: SD for the change = √(SD² _baseline + SD² _follow-up −2^*0.5^*SD_baseline^*SD_{follow up}).

Scott LD, Hofmeister N, Rogness N, Rogers AE. An interventional approach for patient and nurse safety: a fatigue countermeasures feasibility study. Nurs Res. 2010;59(4):250–8.

 PubMed Web of Science ®Google Scholar

Rosekind MR, Gregory KB, Mallis MM. Alertness management in aviation operations: enhancing performance and sleep. Aviat Space Environ Med. 2006;77(12):1256–65.

 PubMedGoogle Scholar

Poulsen AA, Sharpley CF, Baumann KC, Henderson J, Poulsen MG. Evaluation of the effect of a 1-day interventional workshop on recovery from job stress for radiation therapists and oncology nurses: a randomised trial. J Med Imag Radiat Oncol. 2015;59(4):491–8.

 PubMed Web of Science ®Google Scholar

Chen PH, Kuo HY, Chueh KH. Sleep hygiene education: efficacy on sleep quality in working women. J Nurs Res. 2010;18(4):283–89.

 PubMedGoogle Scholar

Carter PA, Dyer KA, Mikan SQ. Sleep disturbance, chronic stress, and depression in hospice nurses: testing the feasibility of an intervention. Oncol Nurs Forum. 2013;40(5):E368–73.

 PubMedGoogle Scholar

Atlantis E, Chow C-M, Kirby A, Singh MA. Worksite intervention effects on sleep quality: a randomized controlled trial. J Occup Health Psych. 2006;11(4):291–304.

 PubMed Web of Science ®Google Scholar

Holbrook MI, White MH, Hutt MJ. Increasing awareness of sleep hygiene in rotating shift workers: arming law-enforcement officers against impaired performance. Percept Mot Skills. 1994 Aug;79(1 pt 2):520–22.

 PubMed Web of Science ®Google Scholar

Kuehl KS, Elliot DL, MacKinnon DP, et al. The SHIELD (safety & health improvement: enhancing law enforcement departments) study mixed methods longitudinal findings. J Occup Environ Med. 2016;58(5):492–98.

 PubMed Web of Science ®Google Scholar

Hardaway CA, Gregory KB. Fatigue and sleep debt in an operational navy squadron. Int J Aviat Psychol. 2005;15(2):157–71.

 Web of Science ®Google Scholar

Smith KC, Wallace DP. Improving the Sleep of children's hospital employees through an email-based sleep wellness program. Clin Pract Pediatr Psychol. 2016;4(3):291–305.

 Google Scholar

Sullivan JP, O'Brien CS, Barger LK, Rajaratnam SM, Czeisler CA, Lockley SW. Randomized, prospective study of the impact of a sleep health program on firefighter injury and disability. Sleep. 2017;40(1):zsw001.

 Web of Science ®Google Scholar

Fabreau G, Elliott M, Khanna S, et al. Shifting perceptions: a pre-post study to assess the impact of a senior resident rotation bundle. BMC Med Educ. 2013;13:115.

 PubMed Web of Science ®Google Scholar

Christopher MS, Goerling RJ, Rogers BS, Hunsinger M, Baron G, Bergman AL, Zava DT. A pilot study evaluating the effectiveness of a mindfulness-based intervention on cortisol awakening response and health outcomes among law enforcement officers. J Police Crim Psych. 2016;31(1):15–28.

 Web of Science ®Google Scholar

Lee KA, Gay CL, Alsten CR. Home-based behavioral sleep training for shift workers: a pilot study. Behav Sleep Med. 2014;12(6):455–68.

 PubMed Web of Science ®Google Scholar

Arora VM, Georgitis E, Woodruff JN, Humphrey HJ, Meltzer D. Improving sleep hygiene of medical interns: can the sleep, alertness, and fatigue education in residency program help? Arch Intern Med. 2007;167(16):1738–44.

 PubMedGoogle Scholar

Steffen MW, Hazelton AC, Moore WR, Jenkins SM, Clark MM, Hagen PT. Improving sleep: outcomes from a worksite healthy sleep program. J Occup Environ Med. 2015;57(1):1–5.

 PubMed Web of Science ®Google Scholar

Smith-Coggins R, Rosekind MR, Buccino KR, Dinges DF, Moser RP. Rotating shiftwork schedules: can we enhance physician adaptation to night shifts? Acad Emerg Med. 1997;4(10):951–61.

 PubMed Web of Science ®Google Scholar

Arboleda A, Morrow PC, Crum MR, Shelley MC, 2nd. Management practices as antecedents of safety culture within the trucking industry: similarities and differences by hierarchical level. J Safety Res. 2003;34(2):189–97.

 PubMed Web of Science ®Google Scholar