Clinical Features

Fatigue in Healthcare – Employee Blame or System Reclaim?

In this article we provide a holistic understanding of fatigue in healthcare systems, including the interventions that are required to tackle long-standing issues of burnout in healthcare workers. Dale has previously described how fatigue occurs in individuals in our previous issue and is this time joined by fellow expert Naomi Algeo.

Dr Naomi Algeo is a Senior Occupational Therapist (Oncology/ Haematology), St. James’s Hospital. Her PhD research focused on the development of a workfocused programme to support women with breast cancer in returning to work. Naomi sits on the Development Group for Cancer Rehabilitation for the World Health Organisation and has presented widely internationally and nationally on the area of cancer survivorship and employment. She regularly presents on understanding and managing fatigue.


The COVID-19 pandemic is the biggest challenge the healthcare system has faced in living memory and placed significant demands on individuals to change behaviours. At the forefront of these challenges was the expectation that healthcare workers (HCWs) defend through the front-facing role of virus management and mitigation. The ramifications for such personal sacrifices has been well documented by The World Health Organisation (WHO), who have previously identified HCWs as particularly vulnerable and susceptible to the effects of pandemics (Koh et al., 2003) for both physical and mental health. In addition to the personal sacrifices, the pandemic placed severe strain on global healthcare services.

The health and well-being of HCWs, including minimising absenteeism is imperative to deliver, maintain and increase essential health and care services. However, the healthcare workforce have been exposed to higher risks of contracting COVID-19 (Nguyen et al., 2020), and therefore living with the long term consequences of COVID-19 (Ladds et al., 2020). Coupled with this, HCWs have a higher risk of experiencing high levels of occupational fatigue or “burnout” (Shanafelt et al., 2015). Fatigue is a common symptom experienced with both conditions (Ladds et al., 2020; van Dijk and Swaen, 2003), yet presents with different aetiologies and management strategies. While such issues are long standing in healthcare, the opportunity for change is more possible now than ever.

There is an imperative to provide innovative perspectives in changing culture towards fatigue in healthcare, by establishing systems which reduce fatigue risk, and enabling individuals to self manage their own fatigue levels. In this practical commentary we discuss the existing and emerging issues of fatigue in healthcare and the associated leadership considerations. We argue for the development of a systematic programme for fatigue identification, education, and mitigation to be designed by healthcare staff, implemented with good faith, and embedded through applying evidence-based behaviour change principles.

Worsening burnout since COVID-19

While ordinary levels of day-to-day fatigue are a normal emotional state resulting from time-ontask demands, chronic levels of occupational fatigue characterised in this instance as “burnout” is not. Defined by WHO in ICD-11 as a syndrome, this chronic fatigue is conceptualised as resulting from chronic workplace stress that is not successfully managed resulting in emotional exhaustion, mental distance from one’s job, and reduced professional efficacy (WHO, 2018). This is unsurprising given that this pandemic saw HCWs working increased hours, requiring additional PPE and most detrimentally greater disruption to sleep quality (Magnavita et al., 2020). Consistent levels of increased stress have also been associated with cognitive dysfunction such as impairment to the learning and memory regions of the brain (Kirschkaum et al., 1996) which can have impacts on work performance and ability. Neglecting occupational-based stressors may also lead to higher levels of clinical depression and anxiety (Teng et al., 2020). These psychological symptoms often go unnoticed within complex and busy systems, and particularly ones which are process and not human driven.

Emerging levels of Long-COVID Fatigue

The long-term consequences of COVID-19, also known as ‘Long- COVID’ (Perego et al., 2020), can onset after any severity of acute illness, with multi-dimensional clusters of often episodic symptoms. As per the WHO, Long-COVID “occurs in individuals with a history of probable or confirmed SARS CoV-2 infection, usually 3 months from the onset of COVID-19 with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis.”. It is estimated that a minimum of 114,500 individuals who have had COVID-19 in Ireland are experiencing/will experience Long-COVID (Timoney, 2022).

Fatigue is one symptom which can be found to relapse and remit throughout the Long-COVID trajectory and has been cited as a common symptom across both acute and chronic phases (Tenforde et al., 2020). Long- COVID fatigue has not been characterised, but is described similar to ME/CFS with persistent and disabling exhaustion, exercise intolerance, cognitive difficulty and musculoskeletal/joint pain. Fatigue has long-term implications for individuals and society. Townsend and colleagues (2020) reported persistent fatigue at ten-weeks for 52% of participants, culminating in a third unable to return to work. An important characteristic of Long-COVID fatigue is symptom exacerbated by exertion, similar to post-exertional malaise, where post-exertional exhaustion is a cardinal feature of the inability to produce sufficient energy on demand, among those with myalgic encephalomyelitis/ chronic fatigue syndrome (ME/ CFS) (Carruthers, 2011). Previous epidemics such as SARS, H1N1, and Ebola saw large proportions meet ME/CFS diagnostic criteria (Islam et al, 2020). Additionally, higher incidences of ME/CFS have been reported in HCWs (Jason et al., 1998) compared to the general population. Drawing from past experience, an opportunity exists to potentially mitigate against long-term consequences of COVID-19 for HCWs or where not possible, support recovery through meaningful intervention.

Changing the ways of working

If healthcare wants to make a meaningful difference in tackling fatigue levels in HCWs, interventions must recognise the interplay between rest and performance. Removing the structural barriers, particularly in settings where continuity of patient care is required, may optimise rest opportunities and reduce fatigue levels within the constraints of a system which requires 24-hour work . In the case of on-call work, efforts should be made in scheduling to minimise continuous hours of wakefulness before and during duty periods that are unscheduled – this means an end to 24 hour call rotas or more, and a greater level of consistency in scheduling which is biomathematically modelled, and not resource modelled. If HCWs feel fatigued in work, opportunities for rest and sleep could be provided through sleep pods or napping rooms, and having a protocol for returning to work following a rest period which controls for sleep inertia. In the same vein, optimising sleep conditions during rest periods is also important, and procedures to minimise interruptions during non-work periods should be established and disseminated widely.

Modelling this shift from resource to individualised approaches requires good management and leadership in a context where there are ever increasing demands and limited resources. Emphasis on educating staff on the link between preventive measures and performance optimisation, providing goal-orientated activities to track changes in culture, and showing future opportunities for improved healthcare system provision is key to ensuring stakeholder buy-in.

Changing the culture

Employment legislation varies internationally, with differing implications for areas such as sick leave entitlements and reasonable accommodations. This financial pressure may expedite return to work, even if the individuals are not physically, mentally or cognitively ready to return, potentially amplifying Long-COVID related fatigue. Reasonable accommodations are widely recognised across Europe and are associated with positive health benefits (Neumark et al, 2015). They vary in nature and include a graded return to work, flexible hours, ergonomic modification, or change of role. Reasonable accommodations should be tailored to HCWs and developed in collaboration with a professional specialised in the area e.g. occupational physician, occupational therapist, or occupational health nurse.

Establishing a graded return to work programme is important for those experiencing Long- COVID fatigue and draws on the energy conservation principle of pacing. Issues can arise where the ‘goalposts’ for a full return to work are set prematurely. Instead, it can be useful for HCWs to continually review their status with their employer. Two-way communication between employer-employee is key. Establishing a minimum time for rest should post-exertional malaise (PEM) exist, and allowing fatigue only to reach agreed levels upon graded return to work may offer the best means in working within the limitations of Long- COVID fatigue. This is facilitated by ensuring that surveillance of all exposed HCWs is consistent and that individuals are provided with additional psychological and workrelated support. Considerations should also be given regarding the type of work which HCWs are completing both in the context of day-to-day work and graded return to work plans. Tasks should be considered in respect to how physically, cognitively and emotionally demanding they may be through self-reported outcome measurements. Ergonomic changes to reduce physical exertion, and ‘cognitive offloaders’ such as experience of having a team to support in decision-making may assist in managing and pacing in occupational settings. Examples of known ‘cognitive loaders’ modelled from adapted to healthcare are described in Figure 1. These have applicability for individuals in self-management of performance, but also organisation systems such as planning oncall rotas in conjunction with a screening programme to detect ‘at risk’ personnel.

A number of safeguards are recommended for HCWs, including access to mental health services throughout their career trajectory may be useful for psychological needs, while ‘enveloping’ of work activity is important so as to prevent delayed onset of fatigue symptoms due to overload resulting from increased physical demands. The Energy Envelope Theory stems from ME/CFS research and posits that those with fatigue should not expend more energy than they perceive themselves to have (Jason et al, 2013).

Finally, one area of managing stress is using positive psychological based interventions such as increasing self-awareness and emotional regulation, training in resiliency building and mindfulness based behaviour-change practices (Rogers, 2016). These challenge conventional norms of viewing stress as a harmful activity, instead mediating its activity in a way which protects professional performance. Meditation has been shown to reduce activity in stress-promoting regions of the brain (Zeller and Levin, 2013). The risks associated with psychological stressors such as anxiety were higher in those healthcare workers who reported decreased sleep quality during the COVID-19 pandemic (Magnavita et al., 2020), suggesting sleep also may also play a pivotal role for both viral management and occupational-stress managed fatigue.

Creating a system for fatigue tracking

In the absence of Fatigue Risk Management Systems (FRMS) in healthcare, drawing on best practice from parallel industries such as the International Civil Aviation Organisation (ICAO) FRMS task force (ICAO, 2016) could be an innovative approach in identifying occupational and non-occupational fatigue. Such systems mandate fatigue screening and identify at what point fatigue becomes decremental for personal wellbeing and professional performance. This allows timely intervention and mitigation. In the context of the COVID-19 pandemic, no screening outcome tools have been widely endorsed to identify fatigue in healthcare. Monitoring fatigue through fatigue logs which include aggravating and easing factors may be useful in helping to differentiate triggers of fatigue. Using tracking-devices, either automated or self-reported, to track known variables such as heart rate monitoring for PEM management, or which contribute to fatigue in people’s personal lives such as sleep, physical activity and diet may highlight the influence of such lifestyle factors on their own fatigue. Feedback from tracking increases selfawareness within individuals and adapts behaviours at the point of ‘at risk’. It also informs institutional fatigue risk management responses by identifying high level data on fatigue levels within sections of the hospital. Clinical and organisational leadership would benefit from collaborative commitments to implement uniform fatigue screening programmes, throughout occupational health and clinical departments, to monitor performance within health systems.

Training staff of fatigue management

Ensuring effective training of all levels of stakeholders is important to maximise buy-in to fatigue reporting and mitigation. Training on fatigue and risks associated with fatigue can develop institutional capacity and resilience in adapting to the required behaviour changes. It can also encourage self-regulation of individuals’ performance in identifying when ‘at risk’ of performance decrement. An example of a tailored fatigue education programme, modelled and adapted off the ICAO programme (ICAO, 2016) and adapted to a healthcare setting is seen in Table 1 below. Learning and development departments could lead organisations through structured implementation of training programmes across a range of management levels.


There exists growing pressures on healthcare, particularly with the increasing ‘reactiveness’ of the system due to ongoing challenges beyond resource capability. This shouldn’t negate the need to recognise that fatigue in healthcare personnel remains a significant concealed risk to sustainability of healthcare provision. The link between leadership and increased work engagement is important, as it is associated with acquiring additional job resources (Salanova and Schaufeli, 2008) which has positive implications developing systemic changes for fatigue management in healthcare systems. Similarly, through improving staff engagement by focusing on effective fatigue management strategies, there is evidence of strong association of recovery of the workforce (Schaufeli and Bakker, 2004) to sustain further phases of the impact of the pandemic and subsequent fallout. Recognising mitigation systems from successful industries such as aviation in identifying those at risk of fatigue gives healthcare an opportunity to contextualise relevant aspects of good practice and reflects the importance of challenging processes and offering leadership which transforms current practice to a model which is evidence based and effective. One of the leading healthcare innovators of our time, Atul Gawande, said “Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try”. With the increased focus on healthcare systems during the pandemic, one which praised healthcare workers as the front-of-the-frontline, this is an opportunity to show our staff we value them for their heroic efforts, by effectively challenging long-standing issues of poor workforce health and wellbeing – let us not waste it.

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