The Impact of On-call Scheduling on the Health of Technologists in Cardiac Catheterization Labs A Literature Review By Jon Daniel Holly Powell A thesis submitted to the School of Radiologic Sciences in collaboration with a research agenda team In partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN RADIOLOGIC SCIENCES (MSRS) WEBER STATE UNIVERSITY Ogden, Utah December 15, 2021 1 THE WEBER STATE UNIVERSITY GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Jon Daniel Holly Powell This thesis has been read by each member of the following supervisory committee and by majority vote found to be satisfactory. ______________________________ Dr. Robert Walker, PhD Chair, School of Radiologic Sciences ______________________________ Dr. Laurie Coburn, EdD Director of MSRS RA ______________________________ Dr. Tanya Nolan, EdD Director of MSRS ______________________________________________________________________ Christopher Steelman, MS Director of MSRS Cardiac Specialist 2 THE WEBER STATE UNIVERSITY GRADUATE SCHOOL RESEARCH AGENDA STUDENT APPROVAL of a thesis submitted by Jon Daniel Holly Powell This thesis has been read by each member of the student research agenda committee and by majority vote found to be satisfactory. Date December 15, 2021 ____________________________________ Jon Daniel December 15, 2021 ____________________________________ Holly Powell 3 Abstract On-call scheduling is used in healthcare and other professions as a normal job component due to the need for employees to be available in emergency situations 24/7. The cardiac catheterization lab (CCL) employs on-call scheduling to ensure effective patient care in emergent medical situations. Employees working on-call are required to report to work at any time during their scheduled on-call shift, often with limited warning. Physicians, nurses, and technologists in the healthcare industry often have little choice but to become accustomed to the on-call work pattern. On-call work is often not an option, but rather a component of the job.12 Despite that, the on-call staffing schedule has received substantially less attention than other staffing strategies to study its impact on workers. There is also a paucity of research related specifically to the health and well-being of CCL technologists who work on-call shifts. This paper presents the results of a systematic assessment of published studies examining the health effects of on-call workers, including physicians, nurses and technologists in catheterization labs. A literature review was utilized to generate inference and draw conclusions regarding the health consequences of on-call shifts of technologists working in CCLs. The health impacts in this review focused on fatigue, sleep disturbances, stress, and mental health risks. We also found these negative health problems can lead to poor health habits workers develop in order to cope, further impacting health. In addition, orthopedic impairment and radiation exposure specific to cardiac cath lab technologists and staff were explored to see if there might be a cumulative health effect from the strain of working on-call in cath labs. 4 Our literature review indicates that on-call scheduling of CCL technologists may have a significant impact on their health. Health risks unique to CCL technologists may also have a cumulative effect. 5 Background Occupational work patterns and their effect on the health of personnel in a variety of staffing models including shift work and overtime work have been studied extensively. Research in these areas suggests that shift work, especially night shifts, has the potential to disrupt sleep patterns, impact certain illnesses and increase the risk of cardiovascular, gastrointestinal, and reproductive disorders.1 On-call shifts refer to scheduling that is performed on an “as-needed basis.” On-call scheduling, sometimes referred to as on-call shifts, is a work pattern used in the healthcare industry as well as other industries where the employee work schedule is intentionally unpredictable. Healthcare workers who work an on-call schedule must be available any time during their shift, often with short notice, to carry out their job responsibilities. 16 In addition to healthcare workers, a variety of occupations employ on-call shifts, including airline personnel, public utilities employees and others who supply goods/services that are considered essential. For many of these professions, being on-call is not a choice, but is a condition of employment. In the CCL timely response to emergencies are particularly significant as reduced patient treatment time is significantly associated with survival.62 CCL workers who are on-call are often required to immediately respond and arrive at the cath lab within 30 minutes of contact. Because technologists in a CCL assist with sophisticated invasive procedures, effectively performing these tasks any time of the day or night is vital to a patient’s health outcome. 6 Introduction/Statement of the Problem Many industries face similar issues when using on-call shifts to stay adequately staffed. The healthcare and aviation industries, for instance, have some comparable challenges. Life and death decisions must sometimes be made in seconds. “Both involve hours of boredom punctuated by moments of sheer terror,” said Dr. David M. Gaba, associate dean of immersive and simulation-based learning at the Stanford University School of Medicine in Palo Alto, Calif. 2 A key difference, however, is how work scheduling is regulated to avoid accidents and errors. In the aviation industry, accidents, and the reasons behind them, are meticulously investigated through an independent inquiry to understand what went wrong. On the other hand, hospitals and laboratories may under report and may fail to fully investigate medical errors.3 Like airplane crashes, human error is sometimes to blame for adverse events in health care. A 1999 report by the Institute of Medicine estimated as many as 98,000 patients die annually from preventable medical errors.4 The Federal Aviation Association (FAA) recognizes the effect of fatigue on its workers and the possibility that errors may occur as a result. The FAA has regulations in place restricting pilot time in the cockpit and allowing for mandatory rest time between shifts. Specifically, pilots are required to have a minimum of 10 hours of rest between each shift, and eight of those hours must be uninterrupted sleep. The reason these regulations passed were due to concerns about fatigue and pilot error that could put passenger safety at risk.5 There are also drive time restrictions and weekly limits for truck drivers in the trucking industry. The Federal Motor Carrier Safety Association revised its hours of service regulatory policy in 2013 to reduce accidents related to truck driver fatigue.6 7 In the healthcare industry medical residents have been given work-hour limitations by the Accreditation Council for Graduate Medical Education.7 Due to patient safety and health concerns, they are no longer allowed to work more than 16 hours in a day, or 80 hours in a week.8 No such regulations exist for staff in a CCL. In CCLs, round-the-clock qualified staffing is essential to patient care. Mandating that staff must have a required amount of rest between shifts is challenging. 63 But the impairment in safety attributable to fatigue has been found to be similar to the impairment associated with moderate levels of alcohol consumption and fatigue does not discriminate. It can diminish alertness, perception, and reasoning in pilots, truck drivers, and CCL technologists alike. Purpose of the Study The purpose of this literature review was to determine if technologists working on-call shifts in CCLs face health impacts as a result of that work pattern. Because of the narrow scope of literature available pertaining to health and on-call work, our objective was to investigate literature that could be linked to the on-call health experiences of healthcare workers as well as workers in other industries to draw conclusions about the health and well-being of CCL technologists who work on-call shifts in CCLs. Gaining an understanding of the adverse health impacts CCL technologists experience, and the possible significance and consequences of those impacts, may serve to influence management and staffing strategies in order to better support the well-being of these essential workers. The goal of this thesis was to demonstrate that the health effects of the working on-call schedules can be presumed to exist in CCL technologists as it does in other healthcare 8 workers and other industries. We found there was no on-point published literature addressing the health impact of on-call shifts on the CCL technologist population. There was, however, relevant data that was used to infer what the possible health effects and significance of those effects are on a CCL technologist’s physical and mental health. Population The population of our literature review includes studies of allied healthcare professionals, multidisciplinary staff, including physicians, nurses, and technologists, who experience negative health effects associated with working on-call shifts. Where available, we have sought out information on technologists and staff who work specifically in CCLs. In addition, we reviewed studies regarding on-call scheduling in the airline and trucking industry as a comparison on the health effects of working on-call across different industries. Assumptions The assumption of this review is that there are many adverse health effects for medical professionals working additional on-call hours. We assume CCL technologists experience similar health effects as a result of working on-call shifts as other healthcare workers. We also assume that literature pertaining to other industries has a correlation to the adverse health effects experienced by medical professionals working additional on-call hours. Research Methods and Design/ Nature of the Study This study utilized multiple literature databases, peer reviewed articles, scientific journals, and literature reviews to create inferences concerning the health impacts of on-call shifts among CCL technologists. 9 The research method incorporated a systematic literature review using a directed approach, which is where the analysis starts with a theory as guidance for our initial research.64 We then determined the presence of certain themes within the different studies reviewed, focusing on the health effects of workers employed in on-call shifts. The medium of choice for the study was scientific journals and peer reviewed publications staying within a publication date parameter within 10 years, however we did use a few outliers containing relevant literature. After an accumulation of relevant publications was conducted, an analysis of the meanings and relationships of different themes or concepts were conducted. Relevant peer-reviewed published research studies were used for this literature review. A set of key words and terms were utilized for finding relevant articles. We used a variety of key search terms that included: on-call fatigue, cardiac cath lab fatigue, cardiovascular technologist burn-out, effects of on-call staffing with emergent healthcare workers, on-call sleep disturbances, cath lab tech health, on-call health impacts, etc. Inclusion criteria for selection included literature in the English language, and the studies had related relevant information regarding the health effects of working on-call shifts. Studies were excluded if they did not relate to our topic, did not include enough information, or ideas were outdated. Articles were selected based on relevance to the CCL and on-call induced health effects. The literature reviewed was collected from the following databases: Google Scholar, One Search, PubMed, Science Direct, and Medline. We also reviewed grey literature, which is literature produced in print and electronic formats by academics, business and industries, but which is not controlled by traditional commercial publishers. 65 This included Cath Lab Digest, newspaper articles, and government reports. The resulting literature was then organized by category to assess for similarities and differences. The literature was also reviewed for gaps in 10 the research to develop further questions to be looked at with our literature reviews. This literature review will look at the angles of research and findings in studies contributing to health effects that are not directly related to on call staffing. We will look for supporting studies of our findings. Definition of Key Terms ● Cardiovascular Technologists A cardiovascular technologist works in a CCL and performs complex procedures, including stent implants, cardiac pacemakers and defibrillators and other tests to diagnose heart disease. They take emergency calls and participate in saving the lives of those who are having a heart attack 69. ● Directed Approach Analysis starts with a theory or relevant research findings as guidance for initial research. 64 ● Fatigue Fatigue is physical and/or mental exhaustion that can be triggered by stress, medication, overwork, or mental and physical illness or disease 68. ● Mental Health An important part of overall health and well-being. Includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make healthy choices 67. 11 ● On-Call Staffing/Scheduling Workers leave their place of employment and are placed "on-call" on evenings and weekends, which means they can be called back to work during these periods if necessary 11. ● Systematic Literature Review A systematic review aims to identify all empirical evidence that fits the pre-specified inclusion criteria to answer a particular research question or hypothesis. By using explicit and systematic methods when reviewing articles and all available evidence, bias can be minimized, thus providing reliable findings from which conclusions can be drawn and decisions made 66. Research Questions ● Q1. What are the health impacts CCL technologists face when working on-call shifts? ● Q2. Can we apply what we have learned from the challenges other industries have faced with CCL technologists? ● Q3. If workers do have health issues as a result of working on-call, are there circumstances or actions that make the health problems better or worse? ● Q4. Are there specific health concerns directly related to those who work on-call shifts in the CCL? Literature Review There is limited published literature exploring the health risks and the consequences of healthcare personnel working on-call shifts. Within this narrow scope of articles even less 12 attention has been given to technologists working on-call shifts in CCLs. However, patterns and similarities within the literature highlight the possible impact of on-call scheduling for CCL technologists. For this review, the specific areas focused on were health risks, the need for recovery, turnover, and coping strategies. In some instances, empirical evidence was used to make inferences. From these papers we can infer that CCL workers who work on-call have similar challenges as other healthcare professionals who work on-call. Fatigue and Sleep Risks It has been documented that fatigue and sleep disturbances are associated with the strenuous demands of on-call shifts. A national survey of 325 Certified Registered Nurse Anesthetists (CRNAs) established that on-call shift fatigue is a prevalent problem and may be linked to medical errors and other negative health consequences.9 In addition, the judgment of on-call nurses has been shown to be significantly altered throughout 12-hour day shifts, raising concerns about fatigue after working a full shift then having to return to work while on call.10 Many on-call healthcare workers are expected to work their regular shift the following day. Yet decreased quality and quantity of sleep can leave workers feeling fatigued for periods during and after their on-call work11 with multiple negative effects on the worker and patients under their care.14 A meta-analysis review of healthcare workers determined that shift work increased sleep disturbances and impacted circadian rhythms,12 and another study on circadian rhythms found that shift work disrupted the 24 sleep-wake cycles that are essential to effectively carry out functions and processes.13 Findings of a cross-sectional study of a population of Dutch workers and the connection between their on-call work and fatigue suggested the uncertainty and lack of control not knowing if a call would come was related to fatigue and other 13 difficulties.15 A Finland study found that physicians had sleep problems and work-interference-with-family (WIF) associated with their on-call duties. They also had high distress, lower job satisfaction, and their performance at work was impacted.16 Overall sleep quality and sleep patterns are affected in relation to working on-call shifts. Lack of adequate breaks between shifts may lead to emotional distress and further overall fatigue.17 Like other healthcare workers, we can infer that CCL workers also experience fatigue and sleep risks while working on-call due to similar strenuous demands of the job as other health professionals. Stress and Mental Health Risks On-call scheduling is linked to stress and mental health problems. Studies have long been known to show that job-related volatility can cause stress.18 Research has found that unpredictability associated with on-call shifts can lead to stress, 19 and these type shifts have been found to trigger more stress than regular shifts.20 A literature review investigating on-call scheduling and health concluded that on-call work scheduling posed a health risk. The restrictions and randomness associated with waiting to be called into work make it challenging for on-call workers to arrange their time and lives around their work schedules, causing stress.21 In addition, women (doctors and nondoctors) described more stress from being on-call than men. This could be because women often have greater responsibility for household and childcare duties which could lead to more stress in trying to balance it all. This may indicate the need to explore the role of gender in on-call experiences.22 14 A survey using the Hospital Anxiety and Depression Scale to assess the mental health of general practitioners determined that anxiety and depression were associated with on-call duties, increasing with the frequency of time spent on-call per month,23 and on-call duties were rated to be among the most stressful aspects of physicians' work.24 On-call workers are also typically only called into work in cases of emergency. As such, the procedures performed are often exhausting and difficult, which in turn may lead to stress.25 The unpredictability, stress and anxiety other healthcare employees working on-call shifts are confronted with are no different than what CCL workers also experience. Widespread Health Risks Associated with On-Call Shifts Research clearly indicates that on-call scheduling is not just isolated to fatigue and stress. These shifts may lead to a litany of health risks. A United Kingdom study identified fatigue and sleep difficulties as the main effects of on-call work and an occasional reduction in performance. But meal irregularity and reduced quality of on-call time off were also reported, emphasizing the risk for compromised overall health.26 A study performed in Poland regarding emergency medical personnel found that with increased on-call shifts staff reported a decrease in work-life balance, a lack of satisfaction with the work, and an increased impact on overall health.27 Additional adverse health risks were noted in a study conducted in 2017 of medical residents who work 24-hour on-call shifts. 40 medical residents who worked a 24-hour on-call shift, were compared to a control group of 18 residents who only covered regular shift hours. The study showed deterioration in the physiological condition, mood, and cognitive performance of doctors after a 24h on-call shift.28 15 Another study found shift work increased the risk for obesity, injuries, and a wide range of chronic diseases. There was also decreased time for family and personal activities.29 A survey addressing gender experiences of being on-call determined female respondents were more likely to be responsible for managing their households and reported that being on-call significantly disrupted their leisure, social, and family activities.30 Respondents from a nursing study revealed that there is an increased risk of sleep disturbances, family stressors, and mood changes due to working unpredictable rotating shifts. Participants stated their concerns about fatigue and fatigue-related illnesses were ignored and a disruption in the circadian rhythm caused them to opt-out of exercising.31 In a Kennesaw State University qualitative study on the consequences of fatigue due to on-call scheduling, participants indicated that on-call scheduling led to weight gain and unhealthy eating habits. The long and changing hours led to fatigue and forced family and life adjustments that had to be made. Nurses newer to working on-call shifts expressed greater stress and anxiety than those with more than five years’ experience.32 Poor coping mechanisms associated with mandatory on-call shifts are linked to anxiety, depression, and stress. Increased alcohol intake, sleep disturbances, and overeating are also prevalent in those who participate in on-call regularly.33 One study found a relationship between shift work and accidents, type 2 diabetes, weight gain, coronary heart disease, stroke, and cancer.34 In a recent Canadian study, the frequency of burnout and distress in cardiovascular center nurses was examined. The survey included the Well-Being Index (WBI), which measured fatigue, depression, burnout, anxiety or stress, mental and physical quality of life, and work-life integration. Of the 242 respondents, 188 (77.7%) reported burnout in the 16 previous month; 189 (78.1%) had a WBI score of 2 or higher, and 132 (54.5%) had a score of 4 or higher (indicative of severe distress).35 Nurses working shifts ten hours or longer were up to two and a half times more likely than those working shorter shifts to leave their jobs due to burnout. The research showed extended shifts undermine nurses' well-being and may result in increased job turnovers and patient dissatisfaction.36 CCL workers, like other healthcare workers, face comparable situations while working on-call. It is reasonable to assume, then, that their health challenges are the same. Lack of Recovery from On-Call Scheduling Impacts Health In order to mitigate risk to a worker’s health, there is a convincing argument to be made for detachment and recovery when working on-call schedules. Rest in between on-call shifts is significant to the well-being of healthcare workers. During on-call shifts, hospital staff are faced with emergent and emotional situations and have very little recovery time before returning to regularly scheduled shift work, which can lead to fatigue and stress.37 The unpredictability and constraints from working these shifts may also interfere with a worker’s capacity to relax, which in turn is important for mental detachment and recovery. Without some detachment and recovery, a worker’s mental health can be at risk.38 A study determined on-work hours during which employees are required to remain available for work cannot be considered leisure time because employees’ control over their activities is constrained and their recovery from work is restricted.39 It is reasonable to assume that on-call scheduling of CCL technologists can create situations where rest and recovery time is disrupted, and leading to negative health impacts. 17 Unique Health Issues in the CCL may have a Cumulative Effect Within cardiac catheterization laboratories, cardiovascular technologists have similar experiences while working on-call shifts that nurses and physicians have, but there has yet to be a study concentrating specifically on cardiovascular technologists and the effects of on-call scheduling. While searching for information on cardiac technologists and the health effects related to their on-call experience, unique health risks these workers face became apparent, which widened the scope of this review. According to a 2016 study published in the journal Circulation: Cardiovascular Interventions, working in a cardiac cath lab is associated with increased health risks not experienced in other healthcare specialties. Cardiac catheterization laboratory doctors and staff have three times the likelihood of cancer and seven times the likelihood of orthopedic-related problems due to heavy protective attire that must frequently be worn. They have higher incidences of skin lesions, cataracts, and other ailments compared to health care personnel not subject to radiation exposure. Cath lab staff also reported greater mental distress with notably higher rates of anxiety and depression compared with other healthcare workers in other areas.40 Orthopedic problems and radiation exposure are risk factors in cath lab staff performing certain cardiovascular technology procedures, an Italian study disclosed. Health problems are more recurring in workers performing fluoroscopically guided cardiovascular procedures. Cath lab workers are also at a higher risk of having hypertension, hypercholesterolemia, anxiety, and depression. The more time personnel worked in the cath lab, the higher the risks, the investigation found.41 18 These workers face distinct health risks other disciplines in the medical profession do not. Risks related to radiation exposure and orthopedic problems because of necessary protective attire could lead to career terminating orthopedic injuries, cataract formation, or life-altering cancers.42 Turnover Consequences Due to Health Impact On-call duty may decrease a healthcare worker’s physical and mental well-being and increase their intentions to leave their job. A study focusing on physicians found an association between on-call work and turnover rates. The highest levels of turnover were among workers who had on-call duties and reported job-related stress.61 Some hospitals are actively addressing the health effect of on-call job strain to limit turnover rates. William Beaumont Hospital Administrative Nurse Manager Sara May credits high cath lab staff retention to proactive management. After complaints from technologists about the health impact of on-call scheduling, the administration responded by adding a midnight shift to reduce night calls.46 Burnout, however, is high and may be reaching a tipping point for technologists. A quantitative study in 2017 analyzed the frenzied and intense workload that is often present within a cardiac catheterization laboratory. Researchers found that on-call requirements negatively influenced how nurses in cath labs rated their caring ability. Working on-call shifts in addition to scheduled shifts negatively impacted not only staff health but also patients in the cardiac catheterization laboratory.49 19 On-Call Health Impact Repercussions While certain types of individuals may be better suited to cope with the health stressors of on-call scheduling, this review did not seek to address specific traits linked with the ability to physically and mentally better manage on-call work.53 However, the literature shows that workers who have negative health effects due to on-call shifts may develop unfavorable health habits in order to cope with those shifts that worsens their health problems. There is a convincing association between chronic on-call work-related fatigue as a contributing factor to acquiring additional negative health behaviors including unhealthy eating habits, lack of physical activity, as well as alcohol, tobacco, and other drug use.54 Some report eating sugary snacks to stay awake while on-call, and because they lack time and energy, they choose fast foods for meals. On the other hand, some state good habits that they have developed as a result of working on-call such as using exercise to help recover from stressful shifts.56 A randomized controlled trial found that designing health interventions to address coping and resilience among on-call workers including physical and mental relaxation and cognitive behavioral therapy to reduce stress can be effective. Reducing work hours may also mitigate burnout for working on-call.59 It is unrealistic for all work-related fatigue and stress to be removed from CCL technologists. But an individual’s ability to positively cope with the negative health effects of working on-call rather than further aggravating the effects can significantly impact well-being.60 20 Study Limitations Despite a comprehensive analysis of the published literature in this study, there is a lack of available research regarding the health of CCL technologists working on-call schedules. The majority of the studies reviewed were related to the health effects of physicians and nurses and were not related specifically to CCLs. More study is needed due to the critical gaps of available research in the current published literature. Conclusions/Summary There exists very little published literature addressing the health effects of cardiac technologists working on-call in CCLs. Based on published research studying the health problems of on-call healthcare workers, this review suggests that on-call scheduling in CCLs plays a significant role in the health risks of technologists and other staff. On-call shifts reduce the quality and quantity of sleep, leaving workers feeling fatigued. In addition, the strain of being on-call, forced to limit activities, and being unable to detach creates stress whether or not workers are actually called in to work or not. Technologists in CCLs also face unique risks other healthcare workers do not have that are associated with musculoskeletal problems and radiation exposure. These negative health influences on technologists, along with on-call scheduling, may have a cumulative effect on health. The critical need for more on-call research focused specifically on cardiac technologists is warranted. This study stresses the dire need for further research and for practical solutions to improve the health of cardiac technologists within CCLs. The CCL is not just another laboratory. It is a highly specialized area in a hospital equipped with imaging technology where a team of doctors, nurses, and technologists work together to perform intricate tests and procedures to diagnose and treat cardiovascular disease. 21 On-call CCL technologists must often work when they are at their worst and in the worst circumstances. A delicate emergency heart procedure necessary to save a life in the middle of the night deserves the best possible technologist. This research suggests that on-call workers in CCLs may not be at their best in these emergency situations. A co-pilot or an air traffic controller who is sleep-deprived, fatigued, and stressed would not be the top choice in an emergency. But in short-staffed CCLs where technologists must work on-call, there is little choice. What emerges from this review are the substantial gaps in research regarding CCL technologists and the toll of on-call scheduling for these workers. In addition to the health impact of on-call shifts, along with orthopedic strain and radiation exposure, there may be a cumulative impact of harm done to these workers due to combinations of stressors. The on-call work pattern is firmly entrenched in CCLs. More time to rest and detach between shifts is unlikely. Labor shortages are at an all-time high. Invasive and interventional cardiology in CCLs is most often focused on quality care and patient outcomes. The health risks to technologists working in CCLs have received little to no attention as to health implications associated with working on-call in addition to other stressors. CCL technologists assist in providing vital interventions to help improve the lives of their patients. Intervention to improve the health and well-being of these essential healthcare workers is necessary. Further research is needed to study this population more in-depth and also to gain insight into what cardiac technologists do to cope with grueling schedules on a day-to-day basis. There may be a limit as to what a technologist in a CCL can endure before their health and the health of their patients are severely compromised. 22 CCLs are required to provide 24-hour service. As a result, on-call shift work for cardiac technologists is typically unavoidable. Because the need for qualified technologists is growing, this study provides a dire warning for the need to further investigate the health impacts and consequences of on-call scheduling for CCL technologists. 23 References 1. Kuhn G. Circadian rhythm, shift work, and emergency medicine. Annals of Emergency Medicine. 2001;37(1):88-98. doi:10.1067/mem.2001.111571 2. Murphy K. What pilots can teach hospitals about patient safety. The New York Times. https://www.nytimes.com/2006/10/31/health/31safe.html. Published October 31, 2006. 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