Fatigue is an educational topic for first responders such as police, fire, emergency medical services (EMS), and healthcare workers and often a constant companion in these professions. Fatigue can be defined as “a feeling of weariness, tiredness, or a lack of energy.” More than 43% of workers report being sleep-deprived, which rises to more than 60% for those working the night shift. The Brigham and Women’s Hospital Sleep Matters Initiative and the National Safety Council estimate the cost of fatigue in the workplace at $136 billion in lost productivity. However, the cost goes well beyond the financial impact. There are also impacts on mental health, job performance, injuries, and accidents that are exacerbated by fatigue, issues that can rise in importance and affect first responders.
Manifestations of Fatigue
A 2023 meta-analysis of 43 studies on fatigue in emergency responders (paramedics, firefighters, and dispatchers) found fatigue is a prevalent issue both on- and off-duty. The study found this fatigue led to elevated depression and anxiety, along with a decrease in cognitive reaction speed. Fatigue was also commonly associated with negative outcomes for responders, including violating safety protocols, injuries, near-miss incidents, and medication errors. A previous 2017 study notes that organizations and personnel share the responsibility for managing fatigue risks, which traditionally focused on managing the hours of service or shift length and implementing fatigue mitigation strategies. These strategies, while well-intentioned, can face a range of challenges, including buy-in, implementation, and staffing challenges, among others.
A 2022 meta-analysis including law enforcement and correctional officers found that more than half of responding officers reported poor sleep quality. Officers with a sleep disorder had a higher probability of safety violations, falling asleep at the wheel, administrative errors, negative interactions with citizens, and increased citizen complaints. With transportation incidents as a leading cause of law enforcement fatalities, the degradation of alertness and reaction speeds associated with fatigue represents a danger to officers and the public. The challenges of shift work exacerbate these risks, with officers on duty for 10 hours being 90% more likely to be involved in an accident and 110% more likely after 12 hours.
Between the demands of the job, changes in shifts, overtime, work-life balance, and the current operating environment, responders are familiar with the concept and potential impacts of traditional fatigue. Agencies invest significant time and resources in educating personnel on the benefits of getting sufficient rest, degradation of performance, and safety considerations. It is critical, however, that agencies and leaders recognize that a lack of sleep is only one aspect of fatigue first responders deal with on any given day. Responders must also manage compassion, disaster, vigilance, and alert fatigue alongside the stresses and everyday pressures of their roles.
Compassion Fatigue – Caring Too Much
Compassion fatigue is a long-standing issue outlined by traumatology expert Charles R. Figley that describes the challenges responders face dealing with traumatic events and people in need. Even though research shows those traumatized desire a compassionate professional to assist them, that level of empathy can have an impact on the responder as well as the victim. The more engaged the responder becomes with each individual and situation, the higher the chance they share the victim’s feelings, which can lead to mental and physical exhaustion. To preserve themselves and meet the demands of the job, responders can become emotionally detached from events. This type of burnout is similar to disaster fatigue, where the increasing pace of major events places increasing demands on emergency management personnel, responders, and government agencies.
In the 1960s, FEMA responded to approximately 18 disasters per year. FEMA averaged 148 disasters in 2019-2023, with 315 in 2020 alone. The dramatic increase in response requirements led to burnout across the agency, which reported a 35% staffing gap in 2022. This gap and ongoing agency funding challenges add pressure on the remaining staff to complete their missions with fewer resources. The 2024 shortage of funds, which FEMA notes could reach $7 billion by the end of this hurricane season, would be the tenth time since 2001 that the agency had to triage its response due to funding shortages. These factors, coupled with the COVID-19 pandemic, humanitarian service requests at the southern border, and extreme weather events, strain emergency managers and agencies nationwide.
Vigilance Fatigue – Information Overload
Vigilance fatigue is an issue that can impact first responders and is increasingly affecting responders in today’s complex operating environment. Vigilance fatigue manifests as mistakes in identifying potential threats because of information overload, extended periods working under ambiguous threats, pressure to avoid errors, and poor or missing education on making decisions under stress. These working conditions accurately represent the basic working conditions for many first responders, particularly in the wake of the September 11, 2001, terror attacks.
Over the past 20-plus years, the threat of terror attacks, the use of social media, protests, and other persistent threats across the country have raised the stakes for every shift worked. Responders must constantly scan their environment for threats and updated information to perform their tasks safely and efficiently. Like the others described, this type of fatigue is exacerbated by lack of sleep, further complicating addressing the issue. Available resources and feedback on the effectiveness of efforts and awareness also impact continued vigilance. If personnel believe they are making the best decisions and already know some vectors are safe or how a situation will play out, they may get complacent or stop fully evaluating threats.
Alert Fatigue – Desensitization
Alert or alarm fatigue is also a persistent and growing problem for responders. Alert fatigue occurs when the number of alerts or alarms desensitizes an individual responsible for response, leading to delays or ignored events. This type of fatigue takes different forms but is an area of concern in healthcare, cybersecurity, emergency management, and traditional first responder roles. The pressures and concerns noted in the previous sections outline some of the limitations and challenges responders manage in their daily work. These may exacerbate the alert fatigue issue as responders strive to maximize the use of resources and effectiveness to meet increased service demands, budget limitations, and staffing shortages.
For cybersecurity responders working to secure businesses, agencies, and critical infrastructure, alert fatigue is also a persistent threat. On average, security operations center teams see 4,484 alerts daily, and two-thirds of those alerts are ignored. The same report noted that 97% of respondents were concerned they have or will miss a security threat buried among the noise of routine alerts. Analysts also reported that 83% of the alerts they received were false positives, reinforcing the disconnect between the alerts and the severity of the threats. The manual triage performed in most security operations centers costs over $3 billion annually in the United States.
Research in healthcare shows that 72-99% of clinical alarms are false. With such a preponderance of false alarms, the systems in place train clinical staff that the audible warnings are not an immediate threat or are most likely not important. This desensitization was on display in a 2013 case, where a pediatric patient at the University of California, San Francisco Medical Center (consistently one of the top ten hospitals in the United States) was administered almost 39 times the required dose of an antibiotic and suffered a grand mal seizure. The resident ordered the medication for the patient through a series of steps, entered the wrong conversion into the system, and then ignored the alert message on the screen. An investigation into the incident revealed that hospital pharmacists received alerts on nearly 175,000 orders per month, and about half entered the system. The burden on physicians was significantly less, but doctors still received 17,000 monthly alerts. Like the constant audible alerts in the clinical space, the continuous stream of pop-ups desensitizes users to potential dangers, particularly when alerts are overridden based on proper procedures and medical needs.
An investigation by the Boston Globe in 2011 found more than 200 deaths in 2006-2011 were attributed to issues with patient alarms. A Clinical Alarms Summit in 2011 also addressed this phenomenon and published ten actions to take immediately and a plan to prevent alarm fatigue-related deaths by 2017. The American Association of Critical Care Nurses then published best practices in 2013, with updated protocols in 2018. A review in 2020 of Intensive Care Unit nurses found that 95% of respondents felt the burden of alarms, and 93% thought excessive alarms could be ignored or muted, mainly due to repeated false alarms.
Combating Worker Fatigue
An evaluation of alerts is a priority. Reviewing the thresholds of alerts can provide insight into the current operating environment and reveal potential changes:
- Are alerts set too high or low?
- Do alerts need to be addressed immediately when the alarm sounds?
- Is there another method to provide notice if the alarm is informative or not an immediate concern?
As noted in the previous overdose example, all alerts in that system were provided in the same manner. Providing a variety of alarm types, based on preferred factors for the organization, could better engage with the responder. Consolidating “like” alerts and ensuring the alerts signify an actionable event to correct the deficient area can increase engagement and reduce wasted energy and effort.
In the technical environment, organizations can assist personnel by using automation to detect common threats and take corrective action when appropriate. By leveraging technology to correct these low-stakes, routine issues, security personnel can focus on concerns that need their attention while avoiding repetitive alarms and mundane corrections.
Evaluating the safety and operations of first response agencies requires consideration of not only standard metrics and traditional concerns like sufficient sleep but also complications that can impact personnel’s mental health and awareness. The concepts of fatigue discussed here are not new, but factors in today’s operating environment complicate them. The increasing rate of disasters, limited resources, and continuous access to information streams can be overwhelming to citizens, but much more so for those responding to emergencies. The constant in society with endless notifications at work and home forces people to choose which important messages to read, engage with, or ignore. This fatigue and behavior can follow into the workplace. Reviewing policies and procedures and helping emergency responders manage that workload with alerts triaged for importance and immediacy can reduce fatigue and improve overall outcomes.
Dan Scherr
Dan Scherr holds a Ph.D. in Public Policy Administration with a terrorism, mediation, and peace focus. He is an assistant professor in Criminal Justice and Homeland Security at the University of Tennessee Southern and program coordinator for the Cybersecurity Program. He is also a co-director of the Honors College. He is a Certified Fraud Examiner and Army veteran who served stateside during the September 11th attacks and has over two decades of experience in homeland security and operations.
Tanya M. Scherr
Tanya Scherr holds a Ph.D. in Public Policy Administration with a healthcare and emergency preparedness focus. She is an associate professor in Healthcare Administration for the University of Arizona and has three decades of healthcare experience. Along with being a Certified Fraud Examiner since 2011, she is also a former firefighter-emergency medical technician (EMT), previously licensed in several states, and held national certification. She has held several executive and board of director positions for community nonprofits that focus on women’s equality, domestic violence, and sexual assault.
