Implementation of a Knowledge System to Address the Need for a Fatigue Management and Wellness Programme for All New Zealand Doctors

• Abstract
• Introduction
• Worker Fatigue and Stress
• Fatigue and Stress in Doctors
• Implications of Good Staff Management
• Benefits of a National FMWP
• The Role of Health Knowledge Management in FMWP
• Scope and Aim of CETUs FMWP
• CETU FMWP development
• Identification of Key Stakeholders
• Literature Review
• Technology Development
• Programme Content Development, Pilot and National Rollout
• Challenges Faced in CETU FMWP Development
• Conclusion
• References

Abstract
The very nature of provision of 24-hour medical services is at times stressful, difficult and fatigue-inducing. Research has shown that fatigue and stress and their negative consequences occur frequently amongst doctors and that this is modifiable. There is an increasing body of literature on the management of shift work and caring for staff, the findings from which should be utilised by healthcare providers in New Zealand. In New Zealand there is no national specialty-wide teaching on non-clinical issues relevant to all doctors. Online continuing medical education on topics including personal development has the potential to increasingly fill the need for portable, practical, succinct, self-directed, literature-based education.

Through better knowledge management, utilising literature from health care and other industries, New Zealand doctors can be taught how to increase their capacity to best handle their working conditions and can be provided with support and healthcare when necessary.

This paper presents the case for establishing nationwide teaching for doctors on personal health, touches on the multidisciplinary requirements for success and explores the implementation of a supporting knowledge system as the best portal for achieving this goal.

Introduction
Many countries have ongoing issues with doctor recruitment and retention, particularly with Resident Medical Officers (RMO). In New Zealand, driving improvements through contract negotiations has proved difficult as District Health Boards (DHBs) have tried to balance human resources budgets with the real needs of doctors as represented by their unions. These negotiations have heightened awareness of staff dissatisfaction on a number of issues including working conditions and professional and personal support.

There is increasing scientific evidence of the "detrimental effects of sleep restriction on cognitive and psychomotor performance, and on physical and mental health" and "declining public tolerance of medical errors that cause harm to patients".^[1] In the last two years, two reports have looked directly at the issue of New Zealand RMO working patterns, health and clinical concerns.^[1,2] These reports have led to the recommendation by the Auckland District Health Board (ADHB) Clinical Education Training Unit (CETU) that fatigue be better managed and a Fatigue Management and Wellness Programme (FMWP) be initiated to answer this need. This initiative has been sponsored by District Health Boards New Zealand (DHBNZ). As a result, the CETU FMWP pilot programme has been developed and is scheduled to be launched online in January 2007 initially for ADHB staff followed by national rollout by mid-2007.

This paper uses the framework of this project to present the case for establishing nationwide teaching for doctors on personal health, touches on the multidisciplinary requirements for success and explores the implementation of a supporting knowledge system as the best portal for achieving this goal.

Worker Fatigue and Stress
Fatigue is "physical or mental exhaustion"^[3] "characterised by a lessened capacity for work… [that] dissipates with rest".^[4] Prolonged or severe physical, emotional or mental fatigue may result in a worker becoming unsafe.^[5-8] Occupational or workplace stress is "the result of the interaction between a person and their work environment... [where] the awareness of not being able to cope... [occurs] with an associated negative emotional response".^[8]

As detailed in table 1, fatigue and stress may arise due to the nature or content of the work, job context, such as structure and organisation, and/or due to personal factors including resilience, culture, health status and social factors. Changes in the nature of work, employment arrangements, new technologies, demographics, workforce expectations, worker responsibilities for ageing relatives, healthcare restructuring and global competition affect the medical workforce and can contribute to stress and fatigue.^{[2, 5, 9-12]} Events that are ordinarily acceptable may become stress-inducing when an individual is not rested, is isolated, has other health issues, is drained by conflict or excessive demands at work or elsewhere, or is dissatisfied at work. This is because long-term psychological and physiological health and survival depends on a balance between stimulation and rest.

Table 1: Potential Occupational Stressors ^{[1, 2, 5, 8, 13-14]}

Fatigue and Stress in Doctors
Research has shown that fatigue, stress and their negative consequences occur frequently amongst doctors with negative flow-on effects on productivity, safety and health.^{[1, 2, 6-7, 11, 15-17]} Therefore, it is vital to reduce fatigue and stress to prevent these health outcomes and to improve treatment of the consequences when they are unavoidable. Clearly the list of potential stressors (see table 1) is vast and it is not possible to prevent all of these from affecting doctors. However, it is possible to give doctors tools to deal with stressors, including education on identifying and coping with stressors and their consequences, and to provide easy access to support services.

Currently there is inconsistent teaching on non-clinical issues across medical specialties in New Zealand even though "personal development" is an obligation of most continuing medical education (CME) plans. Undergraduate and postgraduate education focuses on clinical knowledge rather than personal development and coping strategies. This balance is being redressed around the world with initiatives similar to the CETU FMWP.^{[6, 15, 18]}

Implications of Good Staff Management
Good management of staff is recognised as an essential component of running a productive, contented and loyal company whether in health care or not. Occupational stressors have always existed but the cost to business and wider society is increasing; supporting staff wellness is an investment in human capital.^{[8, 11, 12]}

By the very nature of the job, medical practice is stressful. New Zealand Health and Safety legislation (HSE) requires employers to take all practicable steps to provide as healthy and safe a working environment as possible.^[8] The Ministry of Health has published population health objectives that clearly identify occupational fatigue and stress as targets.^[19]

Benefits of a National FMWP
Table 2 outlines the potential benefits of a FMWP, including financial and community benefits. Self-abusive behaviours such as poor sleep, physical inactivity, smoking, excess alcohol and poor diet may be exacerbated by poor workplace design, job requirements and personal dissatisfaction.^{[2, 5, 8]} Employers can contribute to workforce health, productivity and satisfaction by consideration of rosters, personal health and family needs in light of the changing workforce, their unique environment and national and international literature. These philosophies are cultural enablers for FMWP.

Table 2: Potential Benefits of FMWP

Benefits for the medical community of a national FMWP include improved national DHB co-ordination and increased co-operation and understanding between training colleges and agencies seeking to care for health professionals. Once this module is established, nationwide teaching over a range of topics relating to doctor wellness, currently insufficiently covered, may be launched. Benefits for individual doctors include improved morale and health, reduced turnover and burnout and increased productivity. These benefits have potential flow-on effects for the general public through improved quality of care from healthier, motivated and non-fatigued doctors.

Finally, this programme could be expanded to other healthcare workers as it proves both relevant and beneficial.

In light of these points, DHBNZ and CETU have undertaken to support the national project organisationally and financially.

The Role of Health Knowledge Management in FMWP
For the understanding and management of fatigue to improve among New Zealand doctors, an education and support programme needs to be developed with in consultation with key stakeholders. Knowledge management (KM) frameworks have much to offer in the efficient and effective collation, distribution and feedback of FMWP education and support processes. KM encourages deliberate development of programmes using frameworks and organisational collaboration.^[20]

Through better KM we can teach our doctors how to increase their capacity to best handle their working conditions and can provide support and healthcare when necessary. KM allows tacit knowledge to be transformed into explicit knowledge, providing tools to recognise and manage fatigue and its contributors before negative consequences for the doctor, the workplace and the patient occur. In order for nationwide CME to be successful it needs to be portable, practical, succinct, informative, literature-based, current and supported. Fragmentation and lack of focus during planning and micromanaging and poor communication during development lead to increased risk of failure of CME.^[20-22]

Successful health strategies require commitment from the government and its agencies both through dedicated finances and in policy development. It is vital for key stakeholders including educationalists and information technologists to be identified and included in the planning and implementation phases of this project. Knowledge sharing between key stakeholders is required to effectively utilise existing knowledge silos that function as rivals rather than collaboratively, encouraging collaboration at the organisational level.

The KM framework of knowledge alignment, processes and foundations is of direct relevance to the development of an FMWP system and its day-to-day application:

1. Ensuring knowledge alignment:
   • Establishing FMWP context nationally and internationally
   • Identifying and recruiting key stakeholders in healthcare organisations, education providers, unions, Medical Council, specialist colleges, fatigue and wellness field, information technology
   • Determining DHBNZ and other stakeholder organisational aims and ensuring FMWP meets those
   • Developing a business case to ensure financial support of DHBNZ.
2. The knowledge processes will be utilised:
   • Acquire: Incorporating local and international literature and expertise on fatigue and wellness programmes, provision of education to doctors and health information technology projects in the development phase
   • Acquire: Ensure ongoing gathering of data through the questionnaire
   • Acquire/Create: Developing programme content for maximum outcomes with stakeholders
   • Share: Codification by developing an online module, facilitating learning
   • Share: Increasing communication and support between communities of practice, training colleges, current educators and support agencies
   • Create: Gathering data on self-assessments
   • Create: Nurturing bonds within the medical community
   • Create: Pilot followed by improvement, promotion and national rollout, auditing the module and making changes where necessary, updating the information as new literature becomes available.
3. Knowledge foundations ensure sustainability:
   • Identifying and developing with stakeholders the culture, technologies and organisational systems required to support FMWP to allow maximum accessibility for doctors.

Scope and Aim of the CETU FMWP
The ideal solution to wellness management is a comprehensive local programme that includes personalised education and individual tailored support for each doctor in New Zealand. However this is not feasible. In order to address the primary concerns regarding the lack of education on fatigue and general stress management, the aim of the DHBNZ-sponsored project is to develop a self-explanatory online module that can be accessed and used by New Zealand doctors. Relevant literature will be identified and summarised and presented in FMWP in a practical and relevant form. It will be individualised by the completion of validated questionnaires on sleep, anxiety and depression with immediate personalised feedback. Support services will be identified with links to their websites. Finally, CME certificates will be provided for completing the module.

For this module to be successful it needs to be:

• Portable: Internet based, remotely accessible, password protected.
• Practical: Relevant for clinicians in their daily lives including self-assessment measures and data capture.
• Succinct: Information presented clearly and concisely. 
• Informative: Covering necessary topics including identification of contributors, skills for self-recognition, explanation of prevention and management strategies, and documentation of professional and personal support with links to services and sources. 
• Literature-based: Providing evidence for data and recommended behaviours
• Current: Addressing topical issues with ongoing updates to the literature included within the module 
• Supported: Stakeholder buy-in. Ideally earning CME points, preferably to become mandatory; linked to DHB and specialist College websites.

Tools for measurement of current levels of fatigue, stress and other factors including ill-health, levels of physical activity, diet and smoking status can all be incorporated into the initial online assessment using validated questionnaires such as the Epworth Sleepiness Scale. Baseline understanding of ideal behaviours to cope with shift-work and stress can be determined prior to any knowledge sharing. Follow-up questionnaires of fatigue levels and behaviour plus organisational analysis of staff turnover and morale can be measured and evaluated over time to determine whether the intended key performance indicators have been achieved.

By focusing on assessing current knowledge compared with current behaviour and establishing a culture in which honesty and self-care are valued, we can increase this knowledge and create wisdom to facilitate behaviour change. FMWP will alter how doctors behave in their work and personal lives with a resultant decrease in fatigue and stress. Ideally, this programme would be considered a mandatory requirement for doctors, as this would reduce the development cost to utilisation ratio.

Modules, additional to the FMWP module, may be added to broaden personal wellness education in the future.

CETU FMWP Development
Developing FMWP involves five main steps:

1. Identifying and recruiting key stakeholders in health care organisations, education providers, unions, Medical Council, specialist colleges, fatigue and wellness field, information technology
2. International and national literature review on fatigue and wellness programmes, provision of education to doctors and health information technology projects
3. Identifying and developing with stakeholders the appropriate technology to allow maximum accessibility for doctors
4. Developing programme content for maximum outcomes with stakeholders
5. Pilot followed by improvement, promotion and national rollout.

Identification of Key Stakeholders
Initially the FMWP Project Manager (PM) wrote to all DHB Occupational Health, Human Resource and Resident Medical Officer departments and specialist Colleges advising them of the potential development of FMWP. Other stakeholders including the Medical Council and agencies currently providing support were also contacted. They were asked to provide information regarding relevant current programmes and to register their interest and support. They were also asked to identify any additional individuals or organisations that they felt should be included as stakeholders. The response was unanimously positive in support of FMWP and identified that although organisational policies supported worker wellness, there were very few practical programmes operating. A core group of stakeholders was identified to help with FMWP development.

Literature Review
A Medline search was performed using combinations of the keywords *Education, Medical/; *Education, Medical, Continuing/; *Physicians/ or *Physician, Impairment/ or doctor’s health or *Health/; *faculty, medical/ or *medical staff/ or exp *physicians/ or doctor.mp; clinician fatigue.mp; *Occupational Health/ or "Quality of Life"/ or *Occupational Health Services/ or *Workplace/ or *Health Promotion/ or wellness programmes.mp; *Health Promotion/; fatigue management.mp or exp *Fatigue/; *Stress/ or occupational stress.mp; *Internet/ or *Information Management/ or "knowledge management".mp. A Google and Google Scholar search was performed using similar terms.

Further literature was obtained directly from key stakeholders, ADHB and the New Zealand Ministry of Health website.

Technology Development
Implementing the FMWP nationally requires supportive technology.

Provision of FMWP for doctors from all specialties, at different stages in their training, around New Zealand requires online delivery.

An online delivery solution was identified as the most appropriate approach to support provision of FMWP for doctors from all specialties, at different stages in their training, around New Zealand. The Internet provides the ability to locate such resources easily and has the potential to help doctors identify and rectify weaknesses.^[22-25] New Zealand doctors almost universally have access to a computer with an Internet connection at work and are increasingly utilising websites as pharmaceutical, diagnostic and referral aids. The key to success is providing trustworthy, practical and succinct information in an easily accessible and memorable site with links to further information for those clinicians interested in delving deeper.

The process for technology development to date has been to approach educationalists and technologists through the ADHB eLearning Manager, Chief Information Officer, Information Services Web Manager, Computer Operations Manager and other key stakeholders. The eLearning Courseware Development documentation, based on KM frameworks, has been used to identify key courseware criteria and curriculum priorities (see table 3). This has enabled the development process of identifying key learning objectives and mapping core content and questions to these.

Table 3: ADHB eLearning Courseware ^[26]

It became evident that ADHB Information Services supported FMWP but did not have resources to allocate personnel to its development. Thus, an external IT advisor was contracted and worked with the PM to determine the online support required.

Programme Content Development, Pilot and National Rollout
The scope of this project is to provide a nationwide FMWP. From the outset, the PM has ensured that stakeholders nationwide have been identified and included in the development of FMWP to increase buy-in.

The online component has been written so that it is compatible with ADHB systems. In order to produce a high quality programme with as few rollout issues as possible, a didactic teaching programme for House Officers was run in November 2006 to assess the programme content.

The intention is to launch the online pilot programme internally at ADHB in early 2007 and troubleshoot the online content at that point. This will be followed by national rollout from mid-2007.

Challenges Faced in CETU FMWP Development
Two major issues that have been considered as part of the FMWP development are security and privacy.

It is essential that internally-based confidential ADHB medical and support information remains safe during external access to the FMWP module. As of December 2006, ADHB did not have the necessary firewalls allowing extensive safe external access to the internal system. This became a major issue for FMWP as the system requires nationwide accessibility for several thousand people. Plans are in progress for ADHB to have security in this area by January 2007, but, at this stage, the programme is being written in a format that will be compatible for launch on either the ADHB site or an external site.

Privacy for clinicians is essential if they are to access the module with trust and complete the assessment questionnaires honestly. Responses to questionnaires determine current level of work risk and screen for sleep and psychiatric disorders, and this information could potentially have medicolegal implications. Thus, the questionnaire database must be secure and anonymity must be maintained. Demographic questions have been made broad enough so that clinicians in rarer specialties particularly in small centres will not be identifiable. The need for providing personal details for CME certification has been considered in light of these privacy concerns, and the plan is to allow doctors to voluntarily submit personal information in a field unconnected to the questionnaire in order to protect their privacy. This approach will be explained at the start of the module.

Conclusion
Medicine is at times a stressful and fatigue-inducing profession. There is currently poor stress and fatigue recognition and management by New Zealand doctors despite evidence that good management of shift work and staff health improves financial and staffing outcomes. There has been a remarkable lack of published literature on personal development programmes for doctors to date, particularly in the sphere of wellness and fatigue management.

It is encouraging that publications confirm the Internet as a valid and effective tool to support the education and behaviour changes critical to achieving improvements in this area. With the rapid explosion of data online plus ongoing worldwide legislation reducing doctor hours and the introduction of rotating shifts, ensuring comprehensive and current doctor training is challenging. The potential for online CME to be extended to encompass personal development with portable, practical, succinct, self-directed, literature-based education is exciting and the applicability of the programmes to other healthcare workers makes the costs more feasible.

KM frameworks have provided the tools to develop an appropriate and supported nationwide FMWP that will allow fatigue and its contributors to be recognised and managed before negative consequences for the doctor, the workplace and the patient occur. Involvement of a wide range of key stakeholders from many disciplines has enabled the relevant content to be presented in a memorable manner in an online and therefore readily accessible format. Security, privacy and scoping issues have been investigated and resolutions proposed.

We have already applied these learnings, have specified the requirements for an online FMWP support system and begun its development. We proposed to evaluate and report the impact of the system once implemented.

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