Workplace Fatigue Within Summer Camp: Perspectives From Camp Health Care Providers and Directors

Theoretical Framework

This study was framed through the lens of performance influencing factors (PIFs), which are characteristics of an employee or position that influence performance as well as the likelihood of employee error (Embrey, 2000). Fatigue is one PIF that has been examined in many contexts, including the medical (Baldwin & Daugherty, 2004; Rogers, 2008) and transportation fields (Atkinson, 2000; Dawson, Chapman, & Thomas, 2012).

Conceptualizations and Causes of Workplace Fatigue

Fatigue is a multifaceted concept involving psychosocial and behavioral processes difficult to define and distinguish from sleepiness (Cavuoto & Megahed, 2017). Fatigue is defined as an “overwhelming sense of tiredness, lack of energy and a feeling of exhaustion, associated with impaired physical and/or cognitive functioning” (Shen et al., 2006, p. 70). Shen et al. (2006) noted that fatigue is often conceptualized as dualities, such as acute versus chronic or psychological versus physiological, but suggested that these dualities do not adequately reflect the multidimensionality of fatigue. Fatigue can be caused by extended work hours, disturbances of a person’s circadian rhythm (Gaba & Howard, 2002), extreme variation in sleep and work hours, and disruptions of the nighttime sleep cycle. Many studies use the terms sleep and fatigue interchangeably, or measure sleep and then draw conclusions about fatigue (Gaba & Howard, 2002; Rogers, 2008; Shen et al, 2006).

Outcomes of Workplace Fatigue

Workplace fatigue may result in numerous negative outcomes, including reductions in workplace productivity (Atkinson, 2000; Cavuoto & Megahed, 2017), increased rates of poor employee decision-making, and accidents and injuries (Atkinson, 2000). These negative outcomes may translate to camp settings; as stated earlier, camp adverse events increase later in the week and fatigue may be a contributing factor. Fatigue may also decrease motivation, concentration, and an employee’s ability to perform tasks correctly (Sadeghniiat-Haghighi & Yazdi, 2015). To compound challenges associated with fatigue-related errors, staff who become fatigued are less able to gauge the effects of fatigue. Therefore, staff who are fatigued do not appreciate how their work performance may be negatively impacted by fatigue.

These outcomes may be particularly detrimental in the context of camp where staff are not only responsible for ensuring their own safety but also the safety of minors under their supervision. Within the camp setting, staff supervise youth in novel environments (i.e., nature, unfamiliar terrain, and overnight) as well as during high-risk activities where accidents and injuries are more likely to occur (Goldlust et al., 2009).

Strategies for Addressing Workplace Fatigue

The literature suggests strategies for addressing workplace fatigue. In a clinical review by Dawson, Chapman, and Thomas (2012), the researchers examined fatigue interventions in work settings with longer than normal shifts or work hours. Informal “fatigue-proofing” strategies included repeating instructions, using verbal and visual confirmation, and self-reporting of fatigue. In addition, Sadeghniiat-Haghighi and Yazdi (2015) suggested workplace fatigue could be managed by promoting both the quality and quantity of sleep. However, Rogers (2008) noted that promotion of sleep quality requires a change in workplace culture, where coming to work well rested is valued, and over-exhaustion is viewed as a risk rather than a sign of dedication.

To better understand how workplace fatigue is experienced by camp employees (i.e., camp directors and nurses) within the camp setting as well as factors that contribute to camp-related workplace fatigue, this study was guided by literature associated with the conceptualization of workplace fatigue, outcomes of workplace fatigue, and strategies designed to mitigate workplace fatigue. This literature supported the research questions of this study as well as the methodological approach.

Participants and Data Collection

This study was approved by the Institutional Review Board of Clemson University, and informed consent was obtained for all study participants. The purposeful sample selected in this study included camp nurses and directors identified through collaboration with the Association of Camp Nursing (ACN). Out of 527 current ACN members, 29 members responded to an e-mail informing them of the study and the opportunity to participate in focus groups about their perceptions of and experiences with camp-related fatigue. Respondents were assigned to one of the five focus groups based on camp role and experience.

Participants were predominantly female (82%, 24) and White (96%, 28). Out of the 29 participants, two thirds (75%, 22) were employed in camp health care positions (e.g., Camp Nurse, Health Center Director, Medical Coordination Director, Director of Health care, and Nurse Manager) and one third (25%, seven) were employed in camp administration positions (e.g., Camp Director and Assistant Director). Most participants (72%, 21) represented only resident camps and the remainder (28%, eight) represented both day and resident camps. Fifteen participants had 5 years or less of camp-related work experience and seven had 15 or more years of experience (see Table 1).

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Table 1.

Participant Description (n = 29).

Participant gender	Female = 82% (24)
	Male = 18% (5)
Participant race	White = 96% (28)	Asian Origin = 0%
	Multiple race = 4% (1)	East Asian (Indian) = 0%
	Hispanic origin = 0%	Pacific Islander = 0%
	African American = 0%	Native American = 0%
Participant position	Health care = 75% (22)
	Camp administration = 25% (7)
Participant experience in camp	1-5 years = 52% (15)	6-14 years = 24% (7)
	15+ years = 24% (7)
Participant camp type	Residential = 72% (21)
	Residential and Day = 28% (8)

Five focus groups were conducted during the 2017 ACN Symposium, the association’s annual conference, at a time unopposed by other programming. Focus groups were comprised of five to seven participants, consistent with the recommendations of Yin (2016) for encouraging meaningful discussion among all participants. A semi-structured interview script guided the focus groups. All focus groups were audio recorded and each lasted approximately 1 hr. Recordings were transcribed using an online transcription service.

Data Analysis and Trustworthiness

Directed content analysis was used to segment participant responses from each transcript into discrete groupings of text (i.e., codes) representing a specific thought or concept (Hsieh & Shannon, 2005). The analysis process was guided by sensitizing concepts identified from the literature prior to data analysis (Patton, 2002). For example, the multidimensionality of fatigue (Shen et al., 2006) was a sensitizing concept informing data analysis. After the coding process was completed, codes were organized into categories based on relationships across codes. The directed content analysis approach allowed the experiences of individuals to be compared, contrasted, and connected to make meaning of not only the experience of the individual but also common group experiences. The experience of wellness is individualized, as is the experience of fatigue. By considering these individual experiences in a collective setting, strategies to reduce adverse events that negatively impact the camp experience can be identified and implemented.

Trustworthiness was established through an audit completed by someone external to the data analysis process (Shenton, 2004) who reviewed the coding interpretation process (i.e., transcripts, codes, and themes) to confirm the findings were consistent with participant responses (Creswell & Miller, 2000). The research team was also attentive to the emergence of alternate perspectives in the data, which strengthened the trustworthiness of the analysis (Yin, 2016) because these perspectives provided other explanations for the study findings based on the perspectives of a broader group of participants. Representative quotes are provided within the results narrative to support the analysis and interpretations.

Theme 1: Fatigue is Conceptualized as a Construct of Time, Types, and Causes

The first subtheme described temporal elements of fatigue, which were divided into discretionary time or work time. Discretionary time reflected time off, and how time may be insufficient or sufficient, as well as used effectively or ineffectively to prepare for work. One participant reflected on the connection between wise use of time off and the ability to work:

And then they [the staff] come in, and they’re like, “I can’t work tomorrow, or the next day, or the next day, or the next day, because I feel so sick. I’m so tired.” Because they partied or did whatever the night before on their day off when they’re supposed to be sleeping, and they’re not making the best decisions to help themselves stay alert.

Work time encompassed the length of shifts or camp seasons, and the effect that length of work time has on fatigue. People tend to get more fatigued as the summer progresses, as well as get more fatigued when time between breaks is longer.

The second subtheme described types of fatigue. Fatigue as a unique feeling was the most frequently discussed idea. One participant shared, “. . . fatigue is a depletion of all my resources. Not only my natural resources but also my stored resources.” Emotional fatigue, physical fatigue, mental fatigue, and compassion fatigue were identified as different types experienced by camp employees. Participants also described how different situations trigger different types of fatigue, and mediating the effects of each type of fatigue requires unique solutions. Emotional fatigue is a common type of fatigue in the camp setting, with one participant noting that, “I think one thing that’s hard, too, when you’re in that emotionally fatigued . . . time of the summer, is when kids are homesick and they’re crying, you want to fall apart too.” In addition, two participants referred to fatigue as a continuum, where different symptoms manifest based on how fatigued one feels: “I think of it as an acute fatigue brought on by an event, and then there’s kind of that chronic fatigue, like you find yourself waking up and thinking, ‘Oh boy. Here we go. Another day’.” One can be somewhat fatigued or extremely fatigued based on the situation.

Participants’ descriptions of the causes were sometimes specific to camp roles. For example, for nurses, the lack of backup staff with sufficient camp health care training was a contributor to fatigue because rarely is someone else available with the necessary training to relieve them of duty, even if they are fatigued:

Because if you don’t [do a task] it’s still going to be there tomorrow . . . what’s gonna happen is . . . a kid is going into diabetic shock. Or there’s a kid that’s fallen down and conked his head, and now you’re dealing with concussion protocol . . . those two things are now stacking up on your desk with 15 other things.

Another cause of fatigue was the around-the-clock responsibilities associated with child care within a shared space. Camp employees have continuous responsibility for the children under their care and supervision, with staff and campers typically sharing small communal spaces. There is less privacy and time to oneself, which is particularly fatiguing for staff. One participant reflected, “We’re asking them to [work] for 12 or more [hours a day], being round everybody else.” Furthermore, the camp schedule was portrayed as fuller and more active than most home schedules, with staff and youth constantly moving. One participant described herself as a “weekend warrior,”

Because it’s like you just joined the SWAT team or the military. And suddenly, you’ve gone from couch potato to get up in the morning at 7:00 am in the morning and go for a jog before breakfast. Now breakfast is done. And now get out and do your activities all day long.

Medication, both the effects of being on medication as well as fatigue associated with caring for children on a “medication vacation,” is another cause of fatigue expressed by participants. Camp employees are becoming increasingly medicated, which may require extra sleep and nutrition for optimal health. One participant noted that issues arise because, “Our campers are starting to get highly medicated. But our staff members are highly medicated. And our nutrition at camp . . . does not coincide with a high medication routine . . . and another reason why they’re getting so tired.” Limited access to technology also plays a role in fatigue, as camp employees are accustomed to constant access to technology and the respite it often provides. One participant summed up this concept saying, “You’re either taking the tech away or limiting it severely, and there’s withdrawal.”

Theme 2: Camp-Related Fatigue is a Distinct Experience Leading to Setting-Specific Outcomes

Fatigue at camp was described as a long-term experience; something that builds and can escalate over time if not adequately addressed. This increase in fatigue over time can impact camp employees and their performance in a number of ways:

I found that staff, when they’re tired and fatigued, that they are more self-focused, little things that maybe wouldn’t normally bother them—suddenly a headache, a sore throat, anything takes them out of their usual duties—because they have less ability to cope with minor stuff.

Seven individual outcomes of fatigue were identified by participants, with illness and injury being the most prevalent. When staff and campers become fatigued, they often become ill or sustain injuries during camp activities. These injuries can be quite severe:

I had a young counselor that decided she wanted to do something [special] for one of the male campers . . . she wanted to make him something from the woodshop. So we all know how that story ended right? She [came] to me with half her finger off . . .

Poor coping skills and staff being less attentive to duties were additional outcomes, where staff are unable to self-regulate when fatigued and therefore neglect their duties, particularly diligent camper supervision. A participant commented that when fatigued, counselors felt “too much of everything. Too much stimuli. And it can make you short, like you said. ‘If a kid asks me a same question one more time, I’m going to scream’.” Participant descriptions of fatigue-related safety issues and inhibited decision-making among camp employees were major risk management concerns.

Theme 3: Fatigue is Managed Using Administrative as well as Peer Supports

Fatigue can be managed in camp using administrative supports and staff schedule changes. These top-down strategies resulted in staff having more time for rest or lower level activities. For example, to help staff gain adequate rest, one camp changed their time-off schedule:

So now we’ve changed . . . instead of [staff] having a day off, their day off basically starts at 6:00 PM and goes to 4:00 PM the next day. So they get 22 hours. But it means that they do have the opportunity to be able to either go home and sleep or we’ve got a space off campus that they can rent . . . and they can actually sleep in.

Support structures, such as stress-relieving activities for counselors, or the presence of “camp moms” to help accommodate the need to talk and manage behaviors, were another administrative support used:

We try to do fun activities for the counselors in the evenings . . . Some of our year round staff just do fun like movie night, or karaoke night, or like camp cooking. Just like little things just to make the counselors feel like they’re getting some engagement as well.

Staff training and top-down accountability also play a role in managing fatigue. Participants described how staff need to be educated on the signs and symptoms of fatigue, and administration needs to hold people accountable for taking appropriate steps to mitigate fatigue. One participant, a camp nurse, discussed having overly fatigued counselors stay in the health center:

If they’re really fatigued, and you can just see it both emotionally and physically . . . I’ll put them in one of our isolation rooms, and I tell them, “No, you’re not getting your phone, your computer. This is to sleep . . . and you’re going out in the morning rested.” Innovative time-on solutions were also mentioned as a way to help reduce fatigue without giving counselors additional time off:

I actually brought a dog to camp a couple of years ago and now I’m trying to reinstitute that this year . . . I call it my Puppy at Camp project . . . [M]y staff would come in, grab the dog and take it to their room or environment. And the campers and the staff were not as tired. I think we need to look at other diversionary tactics.

The availability of personal choices and social support from peers/colleagues is another fatigue management strategy employed by camps. These strategies reflected less formal methods for supporting staff and reducing fatigue. Personal supports, such as providing restful time-off ideas or staff devotionals were mentioned, as well as creating a supportive environment:

Fostering that attitude of cooperation in your staff . . . is what you need to do, but that it’s okay to remember you’re tired. We’ll see what we can do to cover for you. Don’t just keep pushing until you get hurt, somebody else gets hurt, or you say things you don’t want to say.

Role modeling and reiterating staff expectations were the final supports identified. Participants noted that in the midst of summer, “We find ourselves repeating those training days where we said, ‘Part of your essential functions as a counselor, part of your responsibility is to get to bed. And I expect you to get six to eight hours of sleep often’.” Staff members need to see directors and supervisors taking breaks to feel comfortable taking time when they need it:

And we’re [leaders] also role models. So if we’re not taking breaks our staff’s not taking breaks. So they’re getting tired because they think that they’re supposed to emulate what we do and we’re all excellent at what we do.

Theme 4: Alternative Perspectives of Fatigue

As previously noted, the research team was attentive to comments that represented an alternative perspective. One emergent alternative perspective was that fatigue is not necessarily negative and may in fact be a protective factor. Participants discussed the idea that fatigue can teach you about yourself and be a learning experience:

I don’t want us to lose sight though, of fatigue as a protective factor because I think our culture tends not to teach effective coping when we feel fatigued. We tend to pathologize fatigue . . . I think that’s a real skill, is to know when you are getting strung out and how do you cope. What works for you?

As suggested from this alternative perspective, although fatigue can be of great concern in the camp setting, it may also be important to focus on coping mechanisms and other positive lessons learned from fatigue.

Implications for Practice

Although this study was exploratory rather than confirmatory, the results suggest numerous implications for practice. The framing and use of discretionary time for camp employees needs to be evaluated by administrators. Reformatting time off to encourage rest, such as the camp that shifted the timing of their 24-hr break, could help mitigate issues of staff returning to camp more exhausted than when they left. Staff training could further help this cause by educating staff on the signs, symptoms, and outcomes of fatigue, thus encouraging staff to rest and recuperate during time off. Less experienced staff in particular may not feel comfortable admitting they are struggling, and so, camp administrators educating these staff about fatigue as well as strategies to avoid fatigue could be helpful.

Once the summer is underway and fatigue becomes more prevalent, a number of practices could potentially curb the impacts of fatigue. Numerous time-on solutions were suggested, such as slowing down the fast pace of programming, allowing more time for free play where counselors can take a passive supervision role, and expanding restful evening programs such as movies and speakers. Increasing social support structures for camp employees to ensure they feel cared for may also help mitigate fatigue: planning evening programming where staff can relax and gather together, offering quiet spaces for napping, or providing mentors who can lend a sympathetic ear may be effective approaches.

Implications for Research

A future direction for research into camp-related fatigue is to collect data from a larger population of camp employees utilizing validated fatigue measures. For example, the Occupational Fatigue Exhaustion/Recovery Scale (OFER; Winwood, Winefield, Dawson, & Lushington, 2005) is a promising measure validated through confirmatory factor analysis (Winwood et al., 2005) that might be useful for measuring camp-related workplace fatigue.

The study of fatigue in camp can also benefit from the increased interest in mental, emotional, and social health (MESH) of camp participants as well as employees (Owens & Faricy, 2018). One such study examined compassion fatigue in counselors by measuirng burnout, self-care activities, and stress (Stanfield & Baptist, 2019). Further research is needed to better understand whether, and if so how and to what extent, MESH support teams may be involved in fatigue management and response situations for campers and staff. This research can broadly inform strategies for MESH promotion among children, adolescent, and young adults.

Limitations

Although we involved participants from numerous camp organizations representing various health care and administrative roles, this was a convenience sample of ACN organizational members. Out of 527 current ACN members, only 29 members participated in the study. This small sample is not representative of nurses and directors at all camps, and thus, future studies should pursue data collection from a larger sample, including frontline staff that may better reflect workplace fatigue in camp (Mason, 2010). Another limitation in the data collection process was the possible influence of recall and self-report bias. Social desirability and other forms of bias may have influenced participants’ responses (Norwood & Lusk, 2011). Finally, this study did not incorporate a member review process as a mechanism for confirming the interpretation of results. Although this limitation was somewhat mitigated by the external audit, future qualitative studies of workplace fatigue in camp may benefit from the use of a member review technique (Birt, Scott, Cavers, Campbell, & Walter, 2016).