Occupational therapists’ experience of workplace fatigue: Issues and action

3.1 Burnout

While fatigue is proposed by some researchers to be related to burnout [13] the two are not interchangeable concepts. Fatigue, as it relates to burnout, is primarily concerned with emotional exhaustion [24] whereas fatigue as defined for this paper (see Methods section above) “ranges from tiredness to exhaustion, creating an unrelenting overall condition that interferes with individuals’ physical and cognitive ability to function to their normal capacity” [22]. The limited literature that exists specific to occupational therapists focuses on the singular aspect of workplace fatigue, burnout. In the burnout and occupational therapy literature, Gupta et al. [14] present evidenceof significant levels of emotional exhaustion, cynicism, and perceived low professional efficacy among the 76 Canadian OT participants in their study. The construct of “burnout” includes the three inter-related domains of emotional exhaustion, depersonalization/cynicism, and personal accomplishment as detailed by Maslach in her seminal work on burnout [24]. While Gupta’s work [14] and other studies of OTs’ experience of burnout are useful, the concepts of burnout and workplace fatigue are related but not interchangeable constructs. Fatigue must be understood from both psychological and physical domains, cognizant that physical fatigue is different that emotional fatigue and is not under voluntary control such that it can be willed away or overcome by strength of character. Rather, it is governed by physiological mechanisms related to sleep, sleep loss and circadian rhythm [25]. The authors, while leading fatigue awareness and risk management in-services for occupational therapists, noted that participants’ comments routinely aligning with the features of fatigue detailed in the CNA definition [22]. For example, we heard frequent comments about a perceived relationship between fatigue and problems with higher cognitive demands such as goal setting and problem solving. Concerns over driving while fatigued were expressed, as were perceptions that the need to stay current and provide comprehensive, evidence-based, best practice when working with patients was an often unachievable and fatiguing goal. Therapists also expressed a concern to the authors that fatigue made them less compassionate towards patients and increased their irritation and frustration with work and co-workers in general. Some comments about the workplace physical environment (noise, temperature, crowding) as it relates to fatigue were shared with the authors during educational in-services but less commonly than those expressing emotional and cognitive concerns.

3.2 Gap-filling

The reason workplace fatigue appears to have received minimal attention from OTs is unknown. However, Fortune [26] points out that OTs appear to share a professional ethos of “filling the gaps”’ when shortages of workers in the healthcare system are present. This value may translate into an internalized expectation that one’s professional self-worth is more related to continuous “doing”, as opposed to seeking balance and workplace wellbeing. Molineux [27] speculates that this value, and practice, of “gap-filling” actually contributes to role blurring, role overlap, and role ambiguity. Role blurring and ambiguity are known to be contributing factors to workplace fatigue [28] and will be discussed in greater depth in the relevant section below.

3.3 Helping work and psychological/emotional fatigue

Among the several domains encompassed by the term “fatigue,” the psychological aspect of “helping work” warrants further mention: OTs’ experiences of workplace fatigue go beyond long hours, shift work and physically demanding tasks. Compassion fatigue, a term which embraces elements of workplace fatigue, burnout, and secondary traumatic stress (also termed vicarious trauma), results from workplace exposure to the suffering and trauma of other people [29–33]. Emotional fatigue/exhaustion is the perception that one’s emotional resources have been completely expended [34]. Several studies involving nurses reported higher levels of psychological fatigue than physical fatigue over the course of a regular shift [22, 35] and comments shared by OTs with the authors at educational in-services seem to reflect this same pattern. This is not surprising, and the 2013 Canadian Standard commissioned by the Mental Health Commission of Canada, Psychological health and safety in the workplace, [12] clearly points out that stigma and lack of understanding about psychological fatigue in the workplace are prevalent and significant barriers to many healthcare workers’ seeking help. It appears that psychological fatigue, although often overlooked, needs to be considered an integral aspect of all workplace fatigue health and safety investigations and managementprograms.

3.4 Sleep deficiency

Sleep deficiency is a hallmark feature in all domains of workplace fatigue. Coupled with the fact that the American Centre for Disease Control (CDC) called sleep deprivation a public health epidemic [36] to which healthcare providers are not immune, sleep deficiency, as both a consequence and a contributing factor in occupational therapists’ workplace fatigue, warrants careful examination. On average, people need 7.5 to 8.5 hours of sleep per 24 hour period [35–37]. Six or fewer hours of sleep daily is considered to be insufficient [37, 38]. In 2007, researchers concluded that over 31% of US healthcare providers were sleep-deprived and, many, chronicallyfatigued [37].

The literature is rife with examples of the effect of sleep deficiency on workplace performance, personal health, and overall wellbeing. Short-term physical effects of sleep deficiency include involuntary falling asleep for short periods (micro-sleeps), reduced hand-eye coordination and visual perception, slower reaction times, increased errors in repetitive tasks, increased tension, and loss of appetite [28, 39]. Short- and long-term cognitive effects include difficulty concentrating, irritability and loss of empathy, poor judgment and decision-making, reduced capacity for effective interpersonal communication, reduced vigilance, and impaired memory [28, 38–40].

3.5 Fatigue, sleep deficiency, and ethical behaviour

While the physical, cognitive and performance consequences of sleep deficiency are generally well-known, research highlighting the relationship between lack of sleep and individuals’ unethical behavior is emerging. This is a novel, but extremely relevant, finding for occupational therapists. For example, a study of 80 undergraduate business administration students found a statistically significant relationship in the female study participants between sleep deprivation and cheating [41].A second study, reported in the same paper, involving 182 worker/supervisor pairs (workers’ mean age- 37.4 years) found that sleep deficiency has a significant negative relationship with supervisor-rated unethical behavior [41]. These findings may be particularly relevant, given that 35.5% of Canadian OTs are in their mid-thirties (mean age of the study participants) and that OT is a predominantly female profession [42]. The Canadian Association of Occupational Therapists (CAOT) Code of Ethics clearly states that ethical behavior and integrity are core expectations of professional practice [43]. However, sleep deficient workers with increased risk of impaired insight about unethical behaviors are reported to fall back on less cognitively demanding coping skills such as rationalization [41]. An example of an additional consequence of ongoing sleep deficiency appears to be an increased likelihood of prejudicial thinking and decisions based on racial stereotypes [44]. Researchers propose a “resource depletion” explanation such that when fatigue becomes chronic and the resource of sleep is depleted, individuals are less able to repress lower order, prejudicial, thinking. Occupational therapists work in diverse and challenging situations and with patients from many cultures, social and ethnic backgrounds; a high level of complex ethical decision-making is more the norm than the exception. For OTs, research into the relationship between fatigue, ethical decision-making and prejudice is clearly warranted.

3.6 Increased risk to patients, co-workers, and self

As detailed previously, workplace fatigue contributes to, and is exacerbated by, sleep deficiency. Studies comparing work performance in healthy participants after being kept awake for long hours and after consuming alcohol found that being awake for 17 hours was akin to having a blood alcohol level of 0.05% while being awake for 24 hours was similar to a blood alcohol level of 0.10% [28, 38]. Over a one-week period, nightly sleep of only two hours less than the optimal sleep time can lead to a reduction in work performance equal to that of being awake for 24 consecutive hours [45]. Workplace fatigue is also costly: in 2012, it was estimated that fatigue cost US employers $116 billion per year in lost productivity, workplace errors, absenteeism, insurance and workers compensation claims, and worker attrition resulting from illness, injury or the need for less demanding work [45].

3.7 Fertility and health

Long-term health effects of fatigue are reported to include a heightened risk for cardiovascular diseases, diabetes, obesity, gastrointestinal disorders, anxiety and/or depression, and overall susceptibility to illness [28, 46]. Chronic workplace fatigue has also been linked to fertility problems for men and women, as well as increased risk to mother and fetus during pregnancy [47, 48]. This is particularly concerning given that 54.1% of Canadian OTs are under the age of 40 [42] and many are starting families. Workplace fatigue is also clearly associated with higher rates of non-working injury, divorce, domestic abuse, and substance misuse [46] and its impact on family life can be extensive.

3.8 Driving safety

Driving is a further example of a workplace fatigue-related issue extending far beyond the hours of employment. Driving while fatigued was frequently mentioned to the authors by OTs at the educational in-services and comments reflected that OTs drove while ruminating on the day and while anxious about unfinished work. Their comments expressed concerns about the safety of passengers (particularly children), pedestrians and other drivers while they were driving fatigued and in a state of emotional upheaval. Fatigued drivers are dangerous drivers: in a 2011 survey, 10% of nurses had experienced a vehicle crash, which they believed to be a consequence of fatigue, during work commutes [38].

3.9 Workplace culture, decision-making, autonomy and role

Workplace fatigue in healthcare settings is frequently attributed to factors such as inadequate staffing numbers, relentless and excessive workloads, an older, sicker and more obese patient population, and work environments that force workers to engage in risky practices, endangering patients and themselves [38, 50]. The most commonly cited factor is shiftwork; however, shiftwork is not a usual component of OTs’ employment. Resource issues are more common; specifically, understaffing and its subsequent effect on workload and the ability to fulfill all aspects of one’s professional role. Occupational therapists in educational inservices stated that their high caseloads prevented them from doing more than assessing and consulting. They were frustrated about not having the resources to implement treatment and ‘do something’ about the problem they identified. They also mentioned team members who were too quick to push for discharge and feelings of isolation as the only occupational therapist on the team. Occupational therapists, like other health care workers, feel overwhelmed by a perception that they are expected to deliver more and better services with fewer resources [28, 51]. Fatigue risk factors associated with resource scarcity, role ambiguity, and role conflict are highly relevant to OTs. Playing multiple roles in the workplace and a sense of ‘always feeling stretched’ are known to contribute to an accumulation of mental stress and high levels of fatigue [28, 51–53]. Research indicates that stress and worry, both of which are antecedents to fatigue, occur not only when there is an actual loss of resources, but also when workers perceive threats to necessary workplace resources. Generally, among healthcare workers, worry about workplace conditions is high [54].

Peer pressure and workplace culture are identified in the literature as contributing to a situation in which great value is placed on endurance; for example, an employee may gain standing among his or her peers by being willing to work very long hours regardless of fatigue [28, 40]. Additionally, healthcare workers do not always recognize their own levels of fatigue, or it may be dismissed as the norm or even seen as heroic; statements acknowledging fatigue are, at times, viewed as unreasonable and unsupportive [46]. A related concept is work addiction: “ … a dysfunctional and compulsive behavior with deep causes and outcomes impacting all aspects of life … in our society, work addiction is too often seen as an acceptable, even a desirable trait” [55 : 6]. Although work addicts appear to find praise for the high quantity of their output to be exhilarating, this practice is physiologically unsustainable. In a culture of being required to work to extreme limits, in combination with a personal addiction to work, or a self-image highly linked to work, chronic fatigue is inevitable.

Work situations characterized by high job demands and low decision latitude can also be major sources of fatigue and emotional exhaustion due to continuous stress with inadequate opportunity for recovery [34, 56]. Positive effects occur when supervisor and social support increase, and when employees have control over more aspects of their jobs. Increasing decision-making capabilities and work autonomy allows workers to exert more influence over the stress-provoking areas of their work life [54, 56]. Occupational therapists are trained to apply a high level of autonomous and collaborative clinical decision-making but, anecdotally, this does not appear to be the norm in many workplaces and the consequences require more rigorous study.

3.10 Technology

Technology also contributes to healthcare worker fatigue; pagers and smart phones have workers constantly/often “on-call”, and increase workers’ anticipation of preparedness, and likelihood that sleep and leisure activities will be interrupted [37]. Increasingly, electronic remote access to the workplace is expected, such that workers literally bring their laptops and work to bed with them [37]. The Government of Alberta’s guideline, Best practices for the assessment and control of psychological hazard [57] goes into great detail about the impact of technological change on healthcare workers’ experience of workplace fatigue and points out the very technology that has improved patient care has also contributed to extra workplace stress and fatigue in the form of what has become known as “technostress.” The guidelines identify several contributing factors of technostress of particular relevance in the OT workplaces; including rapid technological change without sufficient training, lack of standardization across technologies, higher expectations for the volume of work that can be generated, expectations of multi-tasking, pressure to adopt new technology regardless of perceived need, and feelings of decreased control over one’s own output. Additionally, but equally significant, are the stressors of machine error and software problems with insufficient technologically skilled supportstaff.

3.11 Lifestyle and other factors external to the workplace

Several factors outside of the workplace contribute to fatigue in healthcare workers. Sleep may be disrupted by life style choices, the use of prescription drugs, stimulants such as caffeine, eating large meals before sleeping, and sleep-related illnesses like sleep apnea [37, 40]. Alcohol may induce sleep quickly but results in a fragmented and non-restorative sleep for many [28]. Persistent fatigue is also linked to smoking, being single (especially widowed or separated), and physical inactivity during leisure-time [37, 58].

The literature is equivocal about an aging workforce as a contributing factor in workplace fatigue. In Canada, 46.1% of occupational therapists are over the age of 40 with an average age of nearly 39 years [42]. The fatigue risk of juggling responsibilities for work, children, aging parents and other community obligations cannot be minimized. A study of physiotherapists found that younger practitioners (ages 20 to 29) reported more stressors causing fatigue and burnout than did older practitioners [51]. This is supported by a nursing study [59] that found older nurses experience less fatigue, likely due in part to successful adaptation to the nursing profession, as well as having an established family support system. These researchers concluded that nurses face significant challenges in the first years after graduation in adapting to the work demands of nursing while overcoming inexperience and developing practical work/life skills such as time management. It is reasonable to expect this pattern would be found in the OT profession as well.

3.12 Restorative factors

Several factors were identified in the literature as being restorative to healthcare workers’ wellbeing at work, but much research remains to be done. For example, studies of the role of the family are inconsistent. A study of 846 Australian full-time nurses suggested that being part of a family has potential benefits in moderating work-related stress for nurses [60]. Although unanticipated, the researchers found that being part of a family reduced the risk of work stress evolving into fatigue even though the family sometimes created considerable additional demands. These findings are, however, not consistent across studies in other contexts and countries (for example [61, 62]).

Smart et al. [32] suggest that compassion satisfaction (the ability to receive gratification or pleasure from care-giving, and the feelings of positively contributing to the work setting, colleagues, and society) may serve a protective function against compassion fatigue. They found higher levels of compassion satisfaction were linked to higher self-efficacy beliefs, as well as a sense of community and healthy coping mechanisms. Some researchers stress the advantages of multigenerational workplaces to address fatigue where older, more experienced workers contribute wisdom and expertise, while younger workers bring enthusiasm, energy and technological capabilities [50, 63]. They recommend restructuring the workplace to facilitate this interrelationship as a mechanism to improve efficiency, provide mentorship, infuse energy and new ideas, and foster mutual support and creativity [50]. Encouragingly, research exploring management of multigenerational occupational therapy workplaces has begun and can offer some preliminary lessons and a foundation for further study [64].

4.1 Fatigue risk identification, prevention, and management

At the level of fatigue risk identification standardized fatigue assessment tools exit for both the organizational level (e.g. Queensland Health Fatigue Risk Management System Resource Pack; [see Resource]) and the level of the individual worker (e.g. the Occupational Fatigue and Exhaustion Recovery Scale-OFER15 [59]). Many publications focus control recommendations at the risk elimination level, calling for governments and health authorities to provide adequate funding to increase the number of healthcare workers and expand faculty at the post-secondary level, so an adequate number of healthcare workers will be trained and enter practice [39, 46]. Balancing resource and demand is critically important, however, and fatigue risk management is recognized to be a shared responsibility. Simply adding more workers to the system will not eliminate the problem. Workers’ lifestyle choices, organizational cultures, and professional ethos also contribute to the risk for, and experience of, workplace fatigue. Successful fatigue risk management programs must incorporate all components, going beyond a focus exclusively on resources. For example, mindfulness-based stress reduction programs delivered to healthcare providers on the job site are one innovative approach to workplace fatigue management [66].

At the level of administrative controls, there is a general call for healthcare organizations and accreditation bodies to develop policy standards that mitigate and manage fatigue [35, 50]. Successful development of policies requires consultation among employers, workers, and health and safety personnel. At a minimum, policy development about fatigue should require the organization to identify and document causal factors, perform a risk assessment, control risks by changing those conditions that cause fatigue, and then monitor the work environment and amend the policy as needed [35, 39]. The Queensland Health Fatigue Risk Management System Resource Pack (see Resources) provides a planning guide for fatigue risk management programs that could be used as a template within the OT profession.

Other administrative level controls that include wellness education programs specifically addressing workplace fatigue are also needed in healthcare organizations [46]. This is complicated because of the strong tacit healthcare culture of caring for others, as opposed to focusing on one’s own health needs. Sustained change requires evidence-based knowledge translation strategies with clear investment at all levels, from management to front-line workers. Generally, fatigue risk management is recognized as a shared responsibility between the organization and the healthcare worker. Organizations bear the responsibility of arranging work schedules that provide opportunities for sufficient rest, providing training to support fatigue management, and implementing procedures for monitoring and managing fatigue within the workplace [28, 45]. Organizations should routinely examine “close calls” and incidents to determine to what extent fatigue may have played a causal or contributing role[38, 45].

Occupational therapists share responsibility in managing fatigue, but have minimal training in this area and often lack knowledge about the importance of personal lifestyle factors (such as vicarious trauma, sleep deprivation, and environmental-induced stress [38]). Thus, practicing OTs have a responsibility to obtain training, implement recommendations, and be better equipped to adopt healthier lifestyle and self-management practices and routines [28, 39]. Occupational therapists and other healthcare providers should be aware that their ethical responsibility to maintain fitness to practice includes fatigue risk management and participating in organizational, professional and personal opportunities to contribute to reducing the risk of workplace fatigue [28, 39]. Accompanying the responsibility to self-monitor is the professional obligation to report cases of fatigue in co-workers in accordance with professional practice expectations[28, 46]. At a national level, the university training accreditation process can require curriculum content specific to OTs’ workplace fatigue recognition and management and in that way help future OTs be proactive and take preventative measures. A critical difference could be made in therapists’ efforts to develop and implement fatigue management strategies if provincial regulatory bodies embedded personal fatigue management as a core competency for practice. Regional OT organizations can also play an important role in raising members’ awareness of workplace fatigue issues and responsibilities among their members. One innovative example is the detailed workplace fatigue education and resource website (http://www.otfatiguesaot.info/) developed by the Society of Alberta Occupational Therapists (SAOT) and sponsored by Alberta Government Human Services, Occupational Health and Safety Program. Additional resources available in the public domain that can guide OTs, policy makers and researchers to address the pressing concern of workplace fatigue are summarized in the Resourceslist.