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CATNAPS: Co-producing an Ambulance Trust National fatigue risk management system for improved Staff And Patient Safety.
Hello, and welcome to this episode of the Catnaps podcast with me, Jeremy, a public member of the team, and Christy Sanderson, the principal investigator of the CATNAPS study. Over the weeks, Christy and I will be interviewing each member of the team to share what it is each member brings to the study, a closer understanding of their specialist expertise, and updates on the progress of the research. Poor sleep and fatigue are common in acute and emergency health care staff, and the COVID 19 pandemic has left many staff stressed and exhausted, and this project would explore how fatigue can be managed in the NHS Ambulance workforce and the best ways staff can be helped to sleep better. CAPNAPS is an n I NIHR funded study looking to produce an Ambulance Trust national fatigue risk Management System that is acceptable and feasible to improve safety for patients and staff. First of all, I would like to ask Christie, when and how did you identify fatigue in ambulance staff as being a research topic that you wanted to pursue?
Speaker 2:So thanks, Jeremy. It would have been about 4 to 5 years ago when I first started a conversation with our local ambulance service actually. They were really interested in how they could develop a research strategy that included work looking at how to support staff well-being and the experience of their staff. So we're talking sort of back 218 22,018, 2019 now. And in kind of talking about what sort of research we might kind of do with them to sort of help their staff well-being agenda, sleep and fatigue came up.
Speaker 2:So this was not an area that I'd really worked in before, but I got intrigued by listening to the shift patterns they work and the demands of the roles of people working in the ambulance service. So we sort of kept the conversation going. We ended up getting a bit of seed funding, from NIHR actually to do a study just in this one trust to ask staff how they were sleeping, how tired were they were when they turned up on shift, what was their trust kind of already doing to support their sort of sleep health and sort of manage fatigue on shift. And it was very eye opening, this study, and we decided we needed to know more and we needed to do it on a larger scale.
Speaker 1:That's interesting. Though not least because it's hard to get seed funding out of the NIHR. To to tell me a bit more about that because it's really difficult to get money for for for for initial projects.
Speaker 2:Absolutely. So we were really lucky that here at University of East Anglia, we are part of the NIHR Applied Research Collaboration East of England. So NIHR Arc East of England. And back then, they were still offering seed funding to help get some preliminary data to support kind of larger grants. So we applied for one of those and were successful.
Speaker 2:So we're talking really small seed funding. It was just under £10,000. But with that, we got survey data from just under 700 staff. We ran some focus groups. We interviewed paramedics kind of a rain from a range of experience from new graduates to more experienced.
Speaker 2:And that gave us the data to sort of know where to go next for our for our large bid.
Speaker 1:How long did did that particular study last?
Speaker 2:It was only 6 months. Really? Really quick little study. Yeah.
Speaker 1:Gosh. You do. That's very impressive. So when you decided to do this, what did people say when you started to talk about this? Did they was there interest sparked or did you have to nurture interest?
Speaker 2:So again, I think our our timing was was right. So we started these conversations pre COVID, but COVID had happened by the time we had kind of got our ideas together for our bid. So as we can kind of think back and all remember NHS staff across the board were, of course, hit really hard by COVID. And one of the things that were impacted was sleep, and staff were feeling extremely fatigued. So we had already started the conversation, but it became hugely salient with ambulance services.
Speaker 2:So we actually didn't have to do any great convincing. The main, I guess, area of concern from the people we were talking about in the ambulance services was, I guess, shaping a narrative around what could be done once we sort of identify the state of kind of fatigue in their staff for the potential risks to themselves and to patients and the public, and having sort of realistic expectations about the how the system can start to evolve to work more safely through a sort of fatigue lens. So it was kind of more managing concerns about, okay, we'll get this new information, help us think through what we'll then do about it. So actually when we wrote the grant, we had a huge focus on implementing evidence. So there's a lot out there that could be done, but the key question is how do we help ambulance services work with the evidence to make it real for their staff?
Speaker 1:Really, by the standard, this couldn't have happened at a better time. This is the absolute opportune time for the study to have come along.
Speaker 2:Yes. We we do, you know, try and look for positives in something like a pandemic and actually it was one of the ones I think people could see that the the potential for this study as a case study, in the NHS because, a study like this hadn't been done before, so we were really gonna be like a test case for how can the NHS think about fatigue in a new way.
Speaker 1:So what would you say would be the biggest challenges to getting the funding?
Speaker 2:I think from targeting this grant at NIHR funding, for me the biggest initial challenge was they had never funded a study like this. They do fund studies of the importantly around sort of staff experience and well-being, but really on the scheme of things not that many, although that's changed in the past couple of years, but they've never done a study on fatigue. They've never done anything around systems approaches to fatigue. So sort of thinking about how people do their jobs, how work is organized. So NIHR were really kind of taking a little bit of a step out of their comfort zone as well.
Speaker 2:So we were forever grateful for the selection committee that saw the work we'd done to say there's a coalition of the willing that wants this work done. Please give us the money and we'll do it. And thankfully, we were successful on our first go which also, you
Speaker 1:know, doesn't happen that often. No. It doesn't. It's it's another it's another big achievement. So I'd like to ask now about the teams.
Speaker 1:Studies need a variety of skills, but not all studies need the same skills. So how did you go about identifying what skills you needed to bring on to the team? And, also, how did you find the right people?
Speaker 2:Yeah. So this evolved probably over about a year. So our sort of initial team building work for the grant was obviously thinking about who do we need to make sure we ask the right questions. So obviously, our our first conversations were with our expert experts in paramedic science research. So obviously, Julia Williams, at University of Hertfordshire was our go to person.
Speaker 2:We'd already kind of done a little bit with Julia, but because she's just absolutely expert in everything to do with ambulance service research and also in mixed methods research, which we were we were interested in. Julia was on board because, you know, she could see this was a study at scale. We were gonna try and work with all of the ambulance services across the UK, and she had some incredible relevant experience. And also I think was really important in helping the individual ambulance services understand that we were working with the right people as well. Because I'm I'm not a paramedic.
Speaker 2:I've never worked in an ambulance service. So we absolutely needed somebody like Julia to say, you know, these guys are okay. They they won't do anything silly. So that was really important. The next conversations were around fatigue and human factors.
Speaker 2:So we were really lucky to be put in touch with an incredible expert, Colleen Butler, who at the time was at the health and safety executive. The absolute senior experience go to person around fatigue and fatigue investigation. And she was really interested and hugely influential in shaping the project because she had done all of this work in other sectors, but not so much in the NHS, but knew that it needed to be done. So we could draw on her huge expertise in what aviation does, what rail does, what transport does to ask the question, will this work in the NHS? So she was hugely influential.
Speaker 2:And then I guess our third stream was because at its heart for me, this is a health study. Sleep is a fundamental part of our health and hugely impacts on our health. So I wanted to get perspective of somebody who could think at a systems level about health and public health. And I had been working with Sandra James, who's now a public health consultant on another, ambulance services study looking at how to promote the mental health of ambulance personnel, across the country. And she'd been doing some amazing work pulling together the evidence around sort of mental health promotion and prevention and sleep had come up in that work.
Speaker 2:So we started a conversation around would you be interested in helping us take a public health approach to this study. So, it was, you know, a great team and absolutely would never have got the funding without their input.
Speaker 1:I'm looking forward very much to interviewing all those people. Going back to something you said a few moments ago, you used the technical term mixed methods. Now for the people who are listening who don't understand the various different ways of conducting research, can you talk us through what mixed methods actually means?
Speaker 2:Yeah. So if we think about the types of data we can collect, one type is quantitative data or numerical. So that's where we might use existing survey questionnaires or scales or quantitative biological data from a person, so that's all quantitative data. Then we have what's called qualitative data, which is information that reflects someone's experiences or perceptions of an event or their life or their health condition. And we collect that through all sorts of ranges of different means.
Speaker 2:It can also be through interviews, through observing someone, from doing an analysis of policy or written documents or materials, from analyzing videos. So it brings really really in-depth rich data. So we have these two types of data and a mixed method study brings both of these together. So we'll have some data that is quantitative, some data that is qualitative, and we'll have a way of bringing that data together to get a richer feel and experience for what's going on of whatever it is you're studying.
Speaker 1:Thank you for explaining that. The study I know has spoke with a number of ambulance and hospital staff and managers. So how is that going? How how do you approach people and what challenges did you face to get them to talk to?
Speaker 2:Yeah. So often one of the hardest things is to convince people to give up their time and that your study is worthwhile. Certainly for the senior people we were interested in interviewing, so people at director level in ambulance services, chief executives. Because we had done a year of groundwork to write this grant, I had already been very lucky and had an opportunity to speak to the chief executives of the ambulance trust, the, chairs of board, the various directors groups, so whether it's director of people and culture or human resources, operations, safety and governance. So I'd already had a chance to build some of those relationships.
Speaker 2:So they knew who I was. They had an input into the study design. They knew what we were trying to do. So when we formally started the study and then went back to these groups, we already had an open door. The main challenge it came down to was fitting things into their extraordinarily busy diaries.
Speaker 2:So, very very grateful, to our members of the team particularly Kiara Lombardo and Suzanne Adele who did an extraordinary job, chasing down these interviewees. Because we'd get a lot of interest but then it was just how do we fit ourselves into their diaries. So, so yeah, it was kind of time. It's not a it's not a novel research challenge but, yeah, particularly for senior people. You just have to be politely persistent and, flexible.
Speaker 1:I'm looking forward to hearing from Susanna and Guillermo from their insights as to those those interviews. So looking back, what lessons have you learned from this? What would you have done or would you have done anything different or in a different order? The reason I ask is that there could be people listening who want to learn from your experience. I'm keen to take the opportunity to encourage early career researchers to learn from the experienced ones.
Speaker 2:That's an interesting question about order. The order in which we have posed our questions and collected our data. In hindsight, I'd probably do things in the same order. So just to recap, we started with the big picture. So we did a huge evidence review of what is done to manage fatigue in health or other industries.
Speaker 2:So that's where we look to rail aviation transport to see what sort of interventions they've done. So that actually turned out to be a much bigger piece of work than I'd anticipated. So I was gonna do it again. I would give myself 3 times the amount of time allocation to that project cause we ended up finding lots and lots of things that could be done in the NHS. So we asked that question and then we took it to people in ambulance services who would have the job of, you know, implementing these innovations.
Speaker 2:And that I think worked really well because we had all the evidence and we said, how do we make this work for you? And we got some really specific and detailed feedback about what it what could be implementable and what couldn't. So I think that order felt right. The next bit of work which we're about to start is where we are going out on the front line literally. So we'll have, a couple of the paramedic members of our team going out with ambulance crews on a sequential run of shifts to see what is it like working 12, 13, 14 hour shifts, what's it like moving from day shifts to night shifts, What happens when people are taking breaks?
Speaker 2:So we'll get that, qualitative, really in-depth experiential data about how does all this play out on the ground in the real world. And then our final piece of work, is where we bring all of this together kind of backwards sort of our initial stakeholders to think, okay, we know what to do, we know what the challenges are, how do we now help ambulance services take steps down the path of actually making this change in their services? So we'll be working with them to sort of develop some guidance step by step help, to help them implement this in their sort of day to day strategies.
Speaker 1:Thank you very much. Now can I share with us, please, when you started on this odyssey, when you got funded, and how long has the study yet to run?
Speaker 2:Yeah. So as I mentioned, so the conversations around sleep and fatigue did start 4 or 5 years ago. But this study we submitted the application in I need to check my memory because this was in the the COVID dark times. So we submitted the application in September 2020, and we got funded the following summer and then started in October 2021, and we're running for 33 months. So we'll finish June next year.
Speaker 1:Got me.
Speaker 2:So it it's always a sobering reminder of how long the lead in time is. Like, it might take you a year to sort of build your coalition and write your grant. You then submit it, then you have to see if you get through the first wave of scrutiny, and then you write a much longer application, and then you find out to see if you've been successful. So it's, it's kind of one of those kind of paradoxes of research funding. You have to make the case that this is now now now research that has to be done right now, and then if you're lucky maybe you'll starting in 2 years time.
Speaker 1:So you mentioned next year, is that when the study will finish or when the data gathering will stop?
Speaker 2:So it'll happen both over the course of next year. So we'll complete that out of collection and then the write up, will be due, summer 2024.
Speaker 1:Looking for they look you were looking for another recess question.
Speaker 2:Yes. We already started on that, Jeremy. Yeah. We've already got another couple of ideas brewing. So
Speaker 1:Do you wanna tell me anything about that now? Oh, please do.
Speaker 2:I'll I'll tell you okay. What what I will tell you is what conversations with people in the ambulance services are telling us about the study they would like to see next. Because when we originally started talking about sleep and fatigue, we could have done a trial of an individual sleep health intervention, for example. But what we were hearing was they wanted that sort of systems view about tell us all the things we could do, how we would make a change. So we've done the really big picture, but they're still saying to make change on the ground, to make the business case for these change, to bring in more resources, we need effectively a demonstration trial.
Speaker 2:So the highest quality of evidence we could get, which would be something like a randomized controlled trial of one of these interventions that we've been looking at. And interestingly, we did actually previously try for funding a few years ago for a specific sleep health intervention. And one of the things the panel said was, but we don't know whether this is the right thing you should be doing. We know nothing about all the things you could be doing for sleep health with ambulance staff. So we've actually answered that question now.
Speaker 2:What we're working at now is which of these sort of individual interventions will be most compelling for a trial, because a big part of it will be an economic evaluation to say what impact does this have on service efficiency, on patient care and quality, on staff safety, on staff experience. And I think once we've got that kind of demonstration evidence from sort of an exemplar intervention,
Speaker 1:talk with me about this. Now I could be mistaken, and I often am. I am, after all, a married man, so I'm used to being mistaken. But I think I might have detected an antipodean nuance to your answer. So how does an Australian end up in Norfolk working at the UEA, and have you ever used the term bonza?
Speaker 2:I can hand on heart say I have never used the term bonza. I do use mate probably a little bit too often, but not bonza. So yeah, it it was just a happy sort of sequence of events I think. Look, just to be clear, I moved here from Tasmania, which is not very different to Norfolk. There's a lot of coastline.
Speaker 2:It's not on the road to anywhere. So I feel quite at home transiting transitioning from Tasmania to Norfolk. But yeah. No. UEA, asked me to apply for a job here, and I could see a lot of potential.
Speaker 2:They were interested in the staff or being work I was doing. They could see the application to thinking about NHS and social care workforces. So it was a happy meeting of mine, I think, and and here I am 7 years later.
Speaker 1:How wonderful. So what what what were you doing before this study, Chrissie?
Speaker 2:So I was working in a medical research institute in Tasmania, but actually doing very similar work around looking at the health and well-being of public sector workforces. So before I moved here, I had just finished a large 5 year evaluation looking at how to promote good health and well-being in a broad range of public sector workers. So it was looking at everyone from teachers to nurses to police to fire and rescue, to people who work in sort of traditional public service jobs, to the parks and wildlife people, because they all come under the sort of same employer, in Australian state government. So I had a great opportunity to look very broadly across different types of jobs. And I did learn a lot about health and well-being of health and emergency service workers actually as a particular interest group, and I've been very lucky that that's what I've been able to specialize on here.
Speaker 2:Great.
Speaker 1:Now I've asked a lot of questions. And is there a question that I haven't asked that you wish I had?
Speaker 2:Always a good question at the end of an interview. I suppose you could've you could've asked me what do I think will be different after this study.
Speaker 1:So, Christy, before we finish, what what do you think is gonna be different at the end of the study?
Speaker 2:So a single study doesn't usually transform health, but helps us get a step closer to the changes we might want to see. So I think from the feedback we've had, the invitations to speak, I've had the opportunities to kind of talk to lots of different people involved in sleep and fatigue in in the NHS. I think we are very much going to be producing new data that will be relevant across the health care sector and possibly to some elements of social care work as well. So for me, it will be successful if we've changed the conversation around staff fatigue in the NHS, and we already have some early indications that we have started to do that, which is all you can hope for for a study, which is really running over a relatively short time frame if we think about the the lifetimes and the time frames that the NHS operates under. So so for us, I think we are changing the conversation and we're gonna give some really hard evidence and clear clues about what work should be prioritized next.
Speaker 1:I one last thought that's just crossed my mind is that we've spoken about clinicians, we've spoken about academics, we've spoken about managers. Another component in the mix are the unions, and we haven't spoken about them. But I'm conscious that they would have a great deal of investment into into this. Can you tell us anything about the unions and your conversations with them?
Speaker 2:Absolutely. So when we were doing all of our initial year of consultations with I mentioned sort of the directors groups and the the chief executive groups, We also went to the staff facing staff side groups, which were thankfully, there was already a national group that held regular meetings that was, all of the representative unions that represent staff in the ambulance services that met regularly with staff well-being leads from trusts and also people from human resources and people and culture. So we had a natural group. So we went and consulted with them. We pitched the study to them.
Speaker 2:They gave input to the design, and we had subsequent follow-up conversations, with union groups as well. Because they, of course, one of their priorities is staff safety and staff well-being, and they had a lot of fantastic ideas about how we could kind of shape this study to sort of maximize its potential utility for all different users, all our different stakeholders. So absolutely, they were they were integral to its design.
Speaker 1:This is really exciting stuff. Well, it's been very interesting, Chrissy. Thank you for this. But as the crusty pizza of time loses its stuffing and the eternal kebab of destiny tastes a bit off, I noticed our time is now up. So next podcast, we will be interviewing another team member and learning how the study is making progress.
Speaker 1:And if anyone listening wishes to know more about this study, details can be found on the NIH our applied research collaboration website and on the UEA website. But if you just Google CATLABS study, Christy Sanderson, you will find it. Thank you for listening, and goodbye.