Fatigue in the 21st century healthcare workforce – New understandings and solutions for personnel

April 4, 2022July 4, 2022 Danielle Norton

Written by Dr Dale Whelehan, Behaviour Scientist

“It’s precisely those who are busiest who most need to give themselves a break.” — Pico Iyer, The Art of Stillness.

The quote above is one that resonates a lot with me – and should to most healthcare workers. The past two years (and many years before that) have been challenging, and the above and beyond has been expected on a daily basis. It can often seem like the system is broken and beyond repair – leaving many feeling helpless. I hope my insights can share a small bit of light into helping you with your health and wellbeing over the coming months.

Introduction

I’m delighted to be joining as a regular contributor to discuss all things related to fatigue, burnout, sleep and rest. My background is in physiotherapy and I recently completed my PhD in the behavioural sciences exploring how issues related to fatigue can manifest themselves in healthcare workers. I also explored how we can begin to resolve some of those modifiable aspects of our day-today lives, as well as the systems we work in to make ourselves feel better and perform better.

In this introductory article I am going to briefly discuss the science behind how we experience fatigue and why we experience it. I hope by the end of it you will leave with a fresh understanding. Academic theories can often seem impenetrable and difficult to apply in the real-world. In this piece, I will outline some of the main theories around fatigue management in the workplace and offer a practical set of strategies for you to use.

In subsequent articles I’ll be talking more in-depth about the complexity of these issues and hope to get your input, and input from other experts in the field, in designing solutions to make healthcare the people-centred sector it should be.

Historical views of fatigue management

When we talk about fatigue, cognitive load theory 1 is often referenced. This theory suggests that as individuals we have a finite amount of information we can store in what is termed our ‘working memory’ at any given time. Working memory is the conscious experience of knowledge as experienced in real time. When individuals are overburdened with too much information, they experience what is known as a ‘cognitive overload’ and they experience a subjective experience of fatigue.

Emerging thoughts on fatigue management

While cognitive load is useful as a concept for thinking about fatigue, more recent research looks at issues around self-determination, motivation, and how the individual has a more influential role in the prevention and management of the fatigued state. Popularised in the 2010’s by a book called ‘The Psychology of Fatigue’ 2 , motivation can be said to play a pivotal role in determining how an individual reacts to a work task. Let us take a work task like charting a patient’s medications as an example. This new theory suggests we can optimise our work in a more nuanced way.

Using Figure 1, let us imagine we are ten minutes into designing the task and suddenly we begin to feel a small ‘urge’ of discomfort. This is the first emotional signal of the fatigue state. It tells you that your current task is not aligning with your desired goals, whether they be personal goals (e.g., you would rather be working on practicing an inservice you’re presenting at in the evening) or somatic goals (e.g., a need to sleep or eat). We typically push through the urge, employing a series of strategies to ‘concentrate’ on the task. In doing so, we continue to increase the level of fatigue we experience until eventually we enter a phase known as the ‘strain’ phase.

In this instance, fatigue is high. Should we decide to pursue further, we will enter the ‘disengaged’ phase whereby there will be significant fatigue and after-effects, and associated decrement in performance.

What does this mean for our performance in work?

So, what does that relationship tell us? First, it tells us how ‘goals’ can shape our experience of fatigue – so if we can make the tasks we are completing somewhat more goal-oriented, then we may not experience that downward trajectory of higher fatigue levels. Secondly, it tells us the importance of addressing any other goals which are in conflict with our current task, even if it means taking a small amount of time away from the task at hand to address these goals.

Third, it offers us a ‘signal’ that we can begin to use to raise levels of self-awareness and therefore avoid states of experiencing high fatigue on a regular basis. Finally, the theory provides us with an insight into the relationship between work and non-work activities. Should individuals enter the ‘strain’ or ‘disengaged’ phases of fatigue, they risk impacting their non-work time and activities, thus creating a cycle of insufficient opportunity to engage in desired activities and non-recovery.

When considering how we can better manage fatigue in our lives, the framework of basic psychological needs can be a good cognitive reminder for us to use. These have been defined as competency (I.e., a perception that you feel you are achieving something), autonomy (I.e., a feeling of volition over your own actions and your behaviours), and relatedness (I.e., a sense of closeness to those around you) 4 . Fulfilling these needs in the workplace, through appropriate workload modelling (Figure 2) is important to maintain motivation in the workplace.

Similarly, engaging in fulfilling and nourishing these needs in non-work settings is important in the prevention of longer-term fatigue related issues (e.g., burnout). Individuals can identify activities which promote a perceived sense of competency (I.e., learning a new skill), a sense of autonomy (I.e., having an hour every evening, void of family or friend influences to engage in a desired behaviour), and relatedness (I.e., keeping in regular touch with those who you connect with most).

Key lessons and insights

Fatigue is not necessarily a ‘good’ or ‘bad’ feeling. It simply is an emotional signal that tells us that current tasks are in contravention to desired goals. With that in mind, we should focus our efforts on making work-related tasks more goal-oriented and enjoyable; while also taking the time to pause when we experience fatigue and see if alternative activities need to be employed for longer term performance sustainability and optimal wellbeing. With that in mind, why not try and lean into recognising the onset of fatigue signals in your day-to-day life for the next few days. Identify the triggers that seem to exacerbate those signals and see if you can modify your workday to prevent the fatigue from increasing.

References

1 Chandler and Sweller (1991), Cognitive Load Theory

2 Hockey (2013), The Psychology of Fatigue

3 Whelehan (2021), To survive or to thrive: An investigation into fatigue and associated factors on surgical performance

4 Deci and Ryan (2004), Self-determination theory

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