Barriers to Implementing Evidence-Based Guidance for Fatigue Risk Mitigation in the Prehospital Setting

The primary aim of this research study was to capture knowledge and awareness, beliefs and behaviors related to, and perceived barriers to adopting, implementing, and maintaining evidence-based guidance as outlined in the 2018 emergency medical services (EMS) evidence-based guidelines (EBG) for fatigue risk management (FRM) and the American Academy of Sleep Medicine/Sleep Research Society's (AASM/SRS) Guiding Principles for determining shift duration.

We used a mixed methods study design with in-depth interviews based on the Theoretical Domains Framework (TDF) for behavior change. Sampling was nationwide and stratified by rural/urban status with goal enrollment of 40 EMS agency administrators (employers) and 100 frontline EMS clinicians (employees). We used deductive coding to assign participant statements to established domains and constructs of the TDF.

Thirty-six employer and 100 employee in-depth interviews were completed. Most employers represented a fire-based or third-service agency (64%), employed all-paid personnel (58%), and provided mostly ground-based services (92%). Most employees were paramedic, firefighter-paramedic, or firefighter emergency medical technician (EMT) certified (85%) with 3.8 median years of experience (IQR 2, 7). Most employers (61%) and employees (85%) reported no awareness of the existence of EBGs focused on fatigue. Once informed of the guidance, most employers (78%) and most employees (65%) responded that they "very much want to" or "somewhat want to" adopt some or all the guidance and recommendations. Most employers (67%) and employees (61%) reported they "very much needed to" or "somewhat needed to" adopt and implement the existing guidance. Participants identified common barriers to adoption as: lack of awareness and knowledge, a perceived misalignment of some recommendations with expectations, fear of negative emotional reactions in response to changing shift schedules, costs associated with adoption, and fear of disrupting the status quo.

While most EMS employers and employees reported the need to adopt EBGs for fatigue mitigation, barriers identified in this study impede adoption and implementation. Overcoming these impediments should include increasing awareness of fatigue EBGs and related guidance, however, increasing awareness alone may not result in a meaningful increase in adoption and implementation. Novel strategies targeting barriers identified in this study are needed.