Associations of anxiety and fatigue with hazardous occupational conditions of Korean nurses in early pregnancy: A cross-sectional study

AIM

To identify occupational conditions associated with anxiety and fatigue among Korean nurses in early pregnancy.

BACKGROUND

Pregnant nurses, like non-pregnant hospital nurses, are exposed to dangerous and stressful work environments, which can affect fatigue and anxiety.

DESIGN AND METHODS

This cross-sectional study enrolled 1490 nurses who participated in the early pregnancy module in the Korea Nurses' Health Study between 2014 and 2020. Hierarchical linear regression analyses were employed to identify the factors associated with anxiety and fatigue among nurses in early pregnancy.

RESULTS

One-fifth of participants were working night shifts, and more than two-thirds were working overtime. When using antineoplastic drugs and disinfectants, the rate of use of protective equipment varied depending on the size of the hospital. Working overtime and lifting heavy objects were associated with increased anxiety and fatigue among nurses.

CONCLUSION

Overtime work was associated with both anxiety and fatigue among pregnant nurses. Pregnant hospital nurses were exposed to both night shift and overtime work. Therefore, hospital managers should improve hazardous working environments to protect the health of nurses in early pregnancy and their fetuses.

Occupational fatigue, compassion competence and caring behaviours of intensive care nurses: A structural equation modelling approach

BACKGROUND

No previous study has examined the direct effect of occupational fatigue, inter-shift recovery and compassion competence on caring behaviours, including assurance, knowledge-skill, respect and commitment in intensive care nurses.

AIM

We studied the direct effect of participating nurses' occupational fatigue, inter-shift recovery and compassion competence levels on their caring behaviours and the relationship among these variables.

STUDY DESIGN

This was a descriptive correlational study. All nurses who were registered members of the Turkish Intensive Care Nurses Association were invited to participate in this online survey. This study was conducted with 315 intensive care nurses using convenience sampling between April and July 2022. The data were collected using the Occupational Fatigue Exhaustion/Recovery Scale, which consists of three subscales: acute fatigue, chronic fatigue and inter-shift recovery; the Compassion Competence Scale, including communication, sensitivity and insight subscales; and the Caring Behaviours Inventory-24. In addition, a structural equation model was established using variables correlating with caring behaviours. Independent variables were occupational fatigue, inter-ship recovery and compassion competence; and the dependent variable was caring behaviours in this hypothesized model.

RESULTS

Three hundred and fifteen nurses completed the survey (315/1000) with a response rate of 31.5%. The increase in the inter-shift recovery levels of participants was statistically and positively associated with caring behaviours (95% confidence interval [CI]: 0.001-0.011, β = .154 [moderate effect size], p < .05). The sub-dimensions of the Compassion Competence Scale, that is, communication (95% CI: 0.110-0.443, β = .251 [moderate effect size]) and sensitivity (95% CI: 0.084-0.427, β = .241 [moderate effect size]), were statistically and positively associated with the caring behaviours of participants (p < .05). In addition, independent variables accounted for 35% (large effect size) of the total change in caring behaviours (R2 = 0.350).

CONCLUSIONS

This study suggests that the high inter-shift recovery and compassion competence levels of intensive care nurses are positively associated with their caring behaviours.

RELEVANCE TO CLINICAL PRACTICE

Nursing managers should consider the direct effect of occupational fatigue, inter-shift recovery and the compassion competence levels of intensive care nurses on their caring behaviours to provide high-quality care.

Examining the Relationship Between Nurse Fatigue, Alertness, and Medication Errors

BACKGROUND

Working for extended hours in a physically and mentally demanding profession has subjected nurses to occupational fatigue. Limited evidence exists about nurse fatigue and alertness changes throughout shift work and their relationship with medication errors and near misses.

PURPOSE

The purposes of this study were to: (1) assess the relationship between nurses' fatigue and alertness, (2) evaluate nurses' fatigue and alertness changes throughout their shift, and (3) examine the relationship between nurses' fatigue, alertness, and medication errors and near misses.

METHODS

This prospective study is part of a larger mixed-method study. Fatigue and alertness data from 14 work and non-workdays were collected from a convenience sample of 90 nurses. A wearable actigraph (ReadibandTM) was used to measure alertness, while ecological momentary assessment (EMA) using text messaging was used to measure nurses' fatigue.

RESULTS

A 1-unit increase in fatigue was associated with a 1.06-unit reduction in nurses' alertness score (β = -1.06, 95% CI: [-1.33, -0.78], p < .01). Night-shift nurses experienced a 31-point reduction in alertness from the start to the end of the work shift. Nurses' fatigue, but not alertness, was associated with medication errors and near misses (OR = 1.26, 95% CI [1.07, 1.48], p = .01).

CONCLUSION

Initiating fatigue mitigation measures during mid-shift, especially for night-shift nurses, may be a viable option to mitigate fatigue and alertness deterioration among nurses and to maintain patient safety. The multifaceted nature of fatigue, as captured by EMA, is a stronger predictor of medication errors and near misses than device-measured alertness.

Factor Affecting the Quality of Work Life Among Nurses: A Systematic Review

Objective

This literature review evaluates the factors that affect nurses' quality of work life with the goal of enhancing their overall well-being, work experience, and creating a more supportive and satisfying work environment in the nursing field.

Methods

A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Electronic databases including Scopus, PubMed, SAGE Journal, and Springer were searched for scientific articles on the quality of work life among nurses. After screening and removal of duplicates, we analyzed the full text of the articles to identify potentially relevant studies for eligibility, and then we extracted data from the articles that matched.

Results

The search of the literature resulted in 68 articles. Only 20 articles that met all inclusion criteria were included in the systematic review after full text review.

Conclusion

The literature indicates that nurses' work life quality is affected by three primary factors: personal (socio-demographic), occupational, and psychological. Identifying the factors is critical to finding the right solution for improving work life quality and overcoming factors that decrease nurses' work life quality.

Recovery from shift work

One fifth of today's workforce is engaged in shift work and exposed to various mental and physical health risks including shift work disorder. Efficiently recovering from shift work through physical and mental interventions allows us to mitigate negative effects on health, enables a better work-life balance and enhances our overall wellbeing. The aim of this review is to provide a state-of-the-art overview of the available literature. The role of sleep timing and naps, light therapy and psychotherapy, diet and exercise in recovery from shift work is presented here. We further review the impact of shift schedules and social support on post-shift unwinding.

Nurses' Rest Breaks and Fatigue: The Roles of Psychological Detachment and Workload

BACKGROUND

Rest breaks have been shown to reduce acute fatigue, yet not all nurses who take rest breaks report lower fatigue. Psychological detachment-letting go of work-related thoughts-during rest breaks and workload may be key factors in explaining this phenomenon.

OBJECTIVE

To examine the mediating role of psychological detachment during rest breaks and determine how workload moderated that pathway to lower acute fatigue among hospital nurses.

METHODS

In this cross-sectional study, data were collected from 1861 12-hour shift nurses who answered an online survey between July and September 2021. The survey included measures of occupational fatigue, psychological detachment from work, workload, and questions on breaks, work, health, and demographics. Structural equation modeling was used in Mplus 8.9 software to estimate the direct and indirect effects of rest breaks on acute fatigue at 3 levels of workload.

RESULTS

Nurses, on average, reported high acute fatigue, rarely experienced psychological detachment during rest breaks, and reported heavy workloads. Around 60% were able to sit down for a break on their last shift but with patient-care responsibilities. The relationship between taking a rest break and acute fatigue was fully mediated by psychological detachment from work. However, this relationship only held in the context of manageable workloads.

CONCLUSION

Our findings showed that within-shift recovery is possible when nurses can psychologically detach from work during rest breaks. However, this within-shift recovery mechanism was disrupted for nurses with heavy workloads.

The relationships between clinical teaching behaviour and transition shock in newly graduated nurses

AIM

To explore the relationships between clinical teaching behaviour and transition shock in newly graduated nurses and significant differences in the northwest and northeast China.

DESIGN

A cross-sectional design.

METHODS

A total of 211 (nurses) and 925 (preceptors) were recruited in six Third-class different hospitals from July to August 2019.

RESULTS

The transition shock is negatively correlated with the clinical teaching behaviour in northwest and northeast China, while the transition shock in the northwest is higher than that in the northeast for the behindhand economy and natural limit.

CONCLUSION

The transition process of newly graduated nurses in northeast China with ethnic minorities and the behindhand economy is more difficult. For newly graduated nurses, personal health and a supportive environment need further improvement. Teaching strategies for preceptors need to be enhanced. Two-way feedback is more useful for both the newly graduated nurses and preceptors to improve quality care, and holistic care.

Shift Work and Sleep Disturbance in the Oil Industry

BACKGROUND

Rotating shift work is common in high-hazard industries, despite documented associations with sleep disturbance and impairment. In the oil industry, where rotating and extended shift schedules are used to staff safety-sensitive positions, work intensification and increasing overtime rates have been broadly documented over the last few decades. Research on the impacts of these work schedules on sleep and health has been limited for this workforce.

METHODS

We examined sleep duration and quality among rotating shift workers in the oil industry and explored associations between schedule characteristics, sleep, and health outcomes. We recruited hourly refinery workers from the West and Gulf Coast oil sector members of the United Steelworkers union.

FINDINGS

Impaired sleep quality and short sleep durations were common and associated with health and mental health outcomes common among shift workers. Shortest sleep durations followed shift rotations. Early rise and start times were associated with shorter sleep duration and poorer sleep quality. Drowsiness and fatigue-related incidents were common.

CONCLUSION/APPLICATION TO PRACTICE

We observed lower sleep duration and quality and increased overtime in 12-hour rotating shift schedules. These long workdays with early start times may reduce available hours for quality sleep; here they were associated with reduced exercise and leisure activity which correlated with good sleep. This safety-sensitive population appears severely impacted by poor sleep quality, which has broader implications for process safety management. Later start times, slower rotation, and a reconsideration of two-shift schedules are interventions to consider for improving sleep quality among rotating shift workers.

Examining the impact of 12-hour day and night shifts on nurses' fatigue: A prospective cohort study

Background: Fatigue is prevalent among hospital nurses and has been linked to medical errors and decreased patient safety. However, little is known regarding the relationship between occupational physical activity, sedentary behavior, and fatigue. Objective: To assess the impact of 12-hour shifts on nurses' fatigue and its relationship to occupational physical activity and sedentary behavior. Design: Prospective-cohort study design Setting(s): Midwestern trauma one academic medical center Participants: A total of 80 registered nurses working 12-hour day and night shifts participated in this study and completed momentary measures of fatigue (texting, aim one). Only 52 participants were included in aim two analyses (included activity monitoring, aim two). Methods: Occupational patterns of momentary fatigue was measured via ecological momentary assessments. Occupational physical activity and sedentary behaviors (e.g., step count, time spent sitting, standing, and walking) were measured for 14 continuous days using the ActivPAL3 micro activity monitor. Mixed models were used to examine the effects of shift type and time within a shift on occupational fatigue. General estimation equations were used to examine the relationship between time spent sitting, standing, and walking on fatigue. Results: Regardless of shift type, nurses exhibited a significant rise in fatigue; however, the rise was greater during night shifts compared to day shifts. Walking was positively associated with fatigue during day shifts, and negatively associated with fatigue during night shifts. Conclusions: The rise in fatigue was greater among nurses working night shifts compared to day shifts, which could place them at greater risk for fatigue-related consequences. The relationship between walking and fatigue was moderated by shift-type. Tweetable abstract: Nursing fatigue rises during 12-hour shifts, but the rise is greater for those working night shifts @DrRobertoBenzo.

Ambulatory Oncology Nurses Weigh in About 12-Hour Shifts

BACKGROUND

Studies conducted in hospital settings have associated negative clinical outcomes with 12-hour shifts. Despite this, 12-hour shifts are common in nursing and popular among nurses. Little is known about outcomes associated with 12-hour shifts in ambulatory care settings.

OBJECTIVE

A mixed-methods, quality improvement project was conducted in a large, ambulatory cancer center to evaluate oncology nursing staff perspectives on 12-hour shift work.

METHODS

One hundred ambulatory oncology nurses completed surveys and 11 participated in focus group interviews.

FINDINGS

Nurses expressed predominately positive perspectives about 12-hour shift work in ambulatory oncology care.

CONCLUSIONS

Ambulatory oncology nurses perceived benefits to quality, safety, and satisfaction for both nurses and patients related to 12-hour shifts. Further evaluation of patient, nurse, and organizational outcomes unique to ambulatory settings is essential for nurse executives in formulating data-driven staffing plans. The incorporation of 12-hour shifts should be considered.

Occupational fatigue, workload and nursing teamwork in hospital nurses

AIMS

To evaluate the relationships between workload, nursing teamwork and nurse fatigue and the moderating effect of nursing teamwork on the relationship between workload and fatigue.

DESIGN

This cross-sectional online survey study used data from 810 United States hospital nurses collected between March and April 2021.

METHODS

Workload, nursing teamwork and fatigue were measured using the Quantitative Workload Inventory, the Nursing Teamwork Survey, and the Occupational Fatigue Exhaustion Recovery scale. Hierarchical multiple linear regression models were used.

RESULTS

All the nursing teamwork subscales (i.e. trust, team orientation, backup, shared mental model, team leadership) were significantly negatively related to acute and chronic fatigue. Nursing teamwork components of team orientation, shared mental model and team leadership moderated the relationship between workload and chronic fatigue. The relationships between workload and chronic fatigue were stronger when these components of nursing teamwork were high. No moderating effects were found with acute fatigue.

CONCLUSION

Efforts to increase nursing teamwork may be a promising strategy in managing nurse fatigue. It is equally important to monitor and modify high workload to protect nurses from elevated fatigue.

IMPACT

WHAT PROBLEM DID THE STUDY ADDRESS?: Fatigue is negatively associated with the health and safety of hospital nurses and patients. Nursing teamwork has been shown to improve the nursing care of hospitalized patients; yet, it is rarely explored in relation to nurse fatigue. WHAT WERE THE MAIN FINDINGS?: Greater nursing teamwork is significantly associated with lower acute and chronic fatigue. The relationships between workload and chronic fatigue were stronger when nursing teamwork (i.e. team orientation, shared mental model and team leadership) was high than when nursing teamwork was low. WHERE AND ON WHOM WILL THE RESEARCH HAVE AN IMPACT?: Improving nursing teamwork, in addition to monitoring and modifying workloads, can be a promising approach for managing fatigue in healthcare organizations.

Psychometric properties of the Japanese version of the Occupational Fatigue Exhaustion Recovery Scale among shift-work nurses

Objectives

Shift‐work nurses are at a higher risk of inadequate recovery from fatigue and developing maladaptive fatigue with significant health consequences. Therefore, it is necessary to monitor fatigue and recovery levels with a reliable scale. We investigated psychometric properties of the Japanese version of the Occupational Fatigue Exhaustion Recovery scale (OFER‐J) for shift‐work nurses.

Methods

Japanese shift‐work nurses responded to self‐administered questionnaires at baseline (n = 942) and one month later (n = 334). The confirmatory factor analysis (CFA) and exploratory factor analysis (EFA) were conducted to verify the structural validity and the correlation analysis and one‐way analysis of variance were conducted to test the construct and discriminative validity. Cronbach's alpha coefficient, intra‐class correlation coefficient (ICC), and smallest detectable change (SDC) were calculated to assess reliability.

Results

The CFA showed high correlations between the factors and whilst the goodness‐of‐fit of the three‐factor model was suboptimal, it was in an acceptable range. Most modifications included the error covariance of the Acute Fatigue (AF) and Intershift Recovery (IR) items. The EFA showed that Chronic Fatigue (CF) and AF were not clearly separated, indicating that the two AF items dropped out. Construct and discriminative validity were also well indicated. Cronbach's alpha coefficients were 0.75–0.85. Only CF showed sufficient reproductivity (ICC = 0.74). The SDC for CF, AF, and IR was 14.0, 17.1, and 18.7, respectively.

Conclusions

The validity and reliability of the OFER‐J were verified as acceptable for shift‐work nurses. The OFER‐J could contribute to a data‐based approach to fatigue management in nursing management practice.

A human factors approach to evaluate predicators of acute care nurse occupational fatigue

Nurses function at the point of care and assume a significant role in intercepting errors. They work in a mentally and physically demanding profession that is comprised of shift-work, subjecting nurses to considerable fatigue. Yet, few studies constructed a comprehensive model that integrates personal and occupational factors to explore their relationship with various types of fatigue (acute, chronic, physical, mental, and total). Here, we examine this type of comprehensive fatigue-model, in a report that represents one aim of a larger, mixed-methods study. The study sample comprised of 1137 registered nurses working in eight hospitals in a Midwestern state. Nurses reported higher levels of acute and total fatigue than chronic and physical fatigue. Staffing and resource adequacy, exercise, and sleep were among the strongest predictors. Since fatigue is a multi-faceted construct, a comprehensive fatigue-management strategy that targets both day and night-shift nurses is the optimal way to manage nurse fatigue.

Effectiveness of a Mobile Wellness Program for Nurses with Rotating Shifts during COVID-19 Pandemic: A Pilot Cluster-Randomized Trial

Nurses with rotating shifts, including night shifts, have suffered from low physical activity during the COVID-19 pandemic and lower sleep quality due to the disruption of their circadian rhythm. This study aimed to develop and examine the effectiveness of a mobile wellness program on daily steps, sleep quality, exercise self-efficacy, intrinsic motivation for exercise, self-rated fatigue, and wellness. A cluster randomized controlled trial design was used to examine the effectiveness of the mobile wellness program for nurses with rotating shifts. Sixty nurses from one university hospital participated and were allocated to an intervention group and a control group. The intervention group received a 12-week mobile wellness program to improve their physical activity and sleep quality, and the control group was only given a Fitbit to self-monitor their health behaviors. There were significant differences between the two groups in daily steps (p = 0.000), three components (subjective sleep quality, sleep disturbance, daytime dysfunction) of the PSQI, exercise self-efficacy, intrinsic motivation for exercise, and wellness. In conclusion, this study provides meaningful information that the mobile wellness program using Fitbit, online exercise using Zoom, online health coaching on a Korean mobile platform, and motivational text messages effectively promoted physical activity and sleep quality for nurses with rotating shifts during the COVID-19 pandemic.

Occupational Fatigue and Associated Factors among Saudi Nurses Working 8-Hour Shifts at Public Hospitals

Introduction

Shift work and demanding work schedules contribute to occupational fatigue, negatively affecting patient safety and nurses' well-being, consequently placing nurses and patients at risk for injury and adverse health outcomes. For preventing fatigue and minimizing its negative consequences, information about its characteristics and associated factors is required.

Objectives

This study aimed to assess occupational fatigue "acute fatigue, chronic fatigue, and inter-shift recovery" among Saudi nurses working 8-h shifts. Further, we explored factors associated with fatigue from nurses' perspectives.

Methods

We conducted a mixed-method study with a convenience sample of Saudi nurses (N = 282) working in four public hospitals in Saudi Arabia. Data were collected using the nurses' profile form; the occupational fatigue exhaustion recovery (OFER) scale, for relevant quantitative data; and open-ended questions for qualitative data. We used descriptive and inferential statistics for analysing the quantitative data and content analysis of the qualitative data.

Results

The results showed that Saudi nurses rated themselves moderately fatigued with working 8-h shifts. The inter-shift recovery subscale showed a negative correlation with chronic fatigue and acute fatigue (r = -0.518, r = -0.356, P < 0.001). Sleeping problems, meals per day, and frequency of exercise showed significant relations with chronic fatigue among nurses (p < 0.05). In addition, three categories were derived from the qualitative content analysis. Saudi nurses reported work-related, psychosocial, and individual factors as major contributors to fatigue and recovery.

Conclusion

Occupational fatigue is a multidimensional issue, and nurses and nurse managers are challenged with reducing its prevalence and negative impact on nurses and patients. Our quantitative and qualitative findings suggest the need for a comprehensive approach to fatigue management and mitigation, including organizational support, creative workforce planning, flexible work schedules, and psychosocial support. Fatigue reduction and prevention policies and educational programs are vital strategies to improve nurses' well-being and inter-shift recovery.

Comparison of 12-Hour Biweekly Versus 6-Hour Weekly Shifts on Fatigue in Student Nurses

BACKGROUND

Some challenges affecting student nurse learning include student fatigue, clinical recovery time, and hindered clinical experiences due to students experiencing long clinical shifts.

AIM

The aim of this study was to evaluate the differences between 12-hour biweekly and 6-hour weekly shifts on student nurse fatigue.

METHODS

A descriptive research design was used with second-year nursing students (N = 80) upon completion of their clinical rotations of four distinct cohorts during 2019-2020. All students in these cohorts were invited to complete the Occupational Fatigue Exhaustion Recovery (OFER15) online survey, developed and validated to assess the full spectrum of fatigue.

RESULTS

There were no statistically significant differences in acute fatigue, chronic fatigue, or the inter-shift recovery subscale for the 6-hour and 12-hour clinical groups. Student nurses, like registered nurses, would likely prefer to choose between a 6-hour and 12-hour clinical shift depending on their individual circumstances. In the parameters of this study, there was no statistical significance in shift length and student nurse fatigue.

LINKING EVIDENCE TO ACTION

Student nurse fatigue levels can affect learning inside and outside of nursing clinical experiences. In this study, no statistical significances were found between 6-hour and 12-hour clinical experiences in second-year nursing students. Offering both the 6-hour and 12-hour clinical experiences provides flexibility for students, clinical sites, and the school of nursing.

The influence of workplace incivility on the fatigue of female nurses:the mediating effect of engagement

AIMS

To identify the associations of workplace incivility, engagement and fatigue among Chinese female nurses, and further explore whether engagement can play a mediating role.

BACKGROUND

Nurses are at a high risk of fatigue. However, no research has been done to examine the associations among nurses' workplace incivility, engagement and fatigue.

METHODS

The cross-sectional study was conducted in Jiangsu Province, China. Self-administered questionnaires were distributed to 1,200 female nurses, including The Fatigue Scale, Workplace Incivility Scale, Gallup Workplace Questionnaire and demographic variables. Valid responses were obtained from 1,035 (86.3%) of participants. Hierarchical multiple regression analysis was performed to examine the associations among workplace incivility, engagement and fatigue.

RESULTS

The mean fatigue score was 6.54±3.07. Workplace incivility and engagement were related to fatigue (P<0.01). Engagement partly mediated the association between workplace incivility and fatigue (a*b =0.086, bias-corrected 95% CI: 0.059, 0.116; P<0.01), and the proportion of the mediating effect accounted for by engagement was 33.0%.

CONCLUSION

Chinese female nurses suffered from high level of fatigue. The improvement of female nurses' engagement may be helpful to alleviate the impact of workplace incivility on fatigue.

IMPLICATIONS FOR NURSING MANAGEMENT

Managers should reduce workplace incivility of female nurses by promoting engagement to reduce fatigue.

Can Nurses Self-Assess Fatigue?: Implications for Nurse Leaders

OBJECTIVE

The aims of this study were to describe nurses' self-perceptions of fatigue and to examine nurses' acceptance of specific fatigue countermeasures.

BACKGROUND

The work of nurses places them at a high risk of fatigue. Evidence suggests 75% to 80% of nurses in the United States experience high levels of fatigue.

METHODS

This descriptive, cross-sectional correlational study surveyed 279 nurses.

RESULTS

Results suggest that almost half of nurses (46%) are not able to accurately self-assess fatigue. Nurses expressed acceptance of several workplace fatigue reduction strategies.

CONCLUSIONS

It may be unrealistic to expect nurses to self-assess fatigue levels and make decisions about their ability to safely provide patient care. Reliable methods for assessing fatigue in the workplace are needed. Several strategies exist that may be used to alleviate fatigue, and many were acceptable to nurses. Nurse leaders are well positioned to implement changes that impact the occurrence of nurse fatigue and thereby the quality of patient care.

Acute and chronic fatigue in nurses providing direct patient care and in non-direct care roles: A cross-sectional analysis

Nurses are at risk for work-related fatigue, which can impact their health, well-being, and job readiness. The purpose of this study was to examine the levels, types, and factors associated with fatigue in registered nurses (RNs) in direct patient care (DCRNs) and in non-direct patient care (non-DCRNs) roles. A cross-sectional survey was administered to 313 RNs. Measures included: Multidimensional Fatigue Symptom Inventory, Occupational Fatigue Exhaustion Recovery, Brief COPE, PROMIS® Global Sleep Disturbance, and Job Content Questionnaire. Acute fatigue levels in RNs were similar to those in diseased populations, and nearly 50% reported moderate/high levels of chronic fatigue. DCRNs reported higher levels of acute and chronic fatigue than non-DCRNs, but the differences were small and disappeared when accounting for other factors associated with fatigue including sleep disturbance, job strain, workplace support, maladaptive coping, and especially intershift recovery, which accounted for 20%-41% of fatigue variability. This study suggests that it may not be only nurses providing direct patient care who are at risk for acute and chronic fatigue. Intershift recovery may be particularly important in alleviating acute and chronic fatigue in nurses.

Comparison of Fatigue, Quality of Life, Turnover Intention, and Safety Incident Frequency between 2-Shift and 3-Shift Korean Nurses

This study aimed to compare the fatigue, quality of life, turnover intention, and safety incident frequency between 2- and 3-shift nurses, and analyze their perceptions of the 2-shift system. Participants were 227 nurses working for one year or more in a tertiary hospital in Seoul, South Korea (113 were 2-shift nurses for two months or longer, and 114 were 3-shift nurses with no experience of 2-shift work). The Occupational Fatigue Exhaustion Recovery Scale (OFER) and Quality of Life Scale were used. Turnover intention, safety incident frequency, and perceptions of the 2-shift system were surveyed by questionnaires developed by the researchers. Results showed that 2-shift nurses had lower chronic fatigue (t = -2.38, p = 0.018) and higher recovery between shifts (t = 3.90, p < 0.001) and quality of life scores than 3-shift nurses (t = 3.69, p < 0.001). There were no significant differences for turnover intention (t = -1.48, p = 0.140), frequency of needlestick accidents (t = 0.30, p = 0.763), medication errors (t = -1.46, p = 0.146), or near-miss medication errors (t = 0.78, p = 0.437). Two-shift nurses found it easier to secure rest and personal leisure time, and their shift system was shown to improve work satisfaction by increasing the continuity of care. Additional research is necessary to examine how nurses' health status and emotional satisfaction vary by shift type.

Clinical teaching behaviour effects professional identity and transition shock in new nurses in western china: A cross-sectional study

Aim

To examine the interrelationship between professional identity, clinical teaching behaviour and transition shock for new nurses in Western China.

Design

A cross‐sectional design.

Methods

A total of 779 new nurses were recruited in Gansu province and Lanzhou city from June to July 2019. Each patient was given three questionnaires to complete, and structural equation modelling was used to identify the relationships.

Results

The overall mean scores for the transition shock, professional identity and clinical teaching behaviour were 92.53(SD = 22.17), 89.74(SD = 16.57) 80.12(SD = 12.38), respectively. The most important aspects identified were the Physical aspect, the Sense of Mastery and Committing to Teaching. Professional identity and clinical teaching behaviour were negatively related to transition shock, a better sense of identity coupled with supportive clinical teaching were keys to a smoother journey from new to experienced nurses.

Fatigue and the Female Nurse: A Narrative Review of the Current State of Research and Future Directions

Background: The female nurse exhibits a multitude of personal and environmental characteristics that renders this population especially prone to fatigue. The consequences of fatigue in nurses are widespread and impactful at the personal, organizational, and societal levels. These include high injury rates and burnout in the nurse and poor patient and organizational outcomes. Objective: This article discusses the implications of fatigue in female nurses, including the impacts of fatigue across multiple entities (e.g., worker, patient, organization). It also reviews the current state of the research, including recent work on nurse fatigue and work schedule characteristics, and key areas for future work that would help empirically establish approaches to counter the detrimental and widespread effects of fatigue. Method: A narrative literature review was conducted resulting from an analysis of the literature limited to peer-reviewed studies. Results: A confluence of factors combines to elevate the prevalence and risk of fatigue in the female nurse. Numerous measures have established that performance-based fatigue results from nursing work schedules in nurses. Data also demonstrate that fatigue accumulates across successive shifts. Recent evidence supports the use of objective fatigue measures, including psychomotor reaction time and muscle function-related variables. Current gaps in the literature are delineated in the text. Conclusions: Strategic and well-designed research studies, as well as recent technological advances in fatigue tracking tools have the potential to help workers, administrators, and organizations develop fatigue management programs that could reduce the heavy burdens of fatigue on a multitude of health, safety, and economical outcomes.

Changes in Fatigue Levels and Sleep Measures of Hospital Nurses During Two 12-Hour Work Shifts

OBJECTIVE

The aims of this study were to explore nurses' fatigue levels and sleep measures during two 12-hour consecutive day shifts and examine the relationships between nurses' fatigue levels within shifts and their previous-night sleep characteristics.

BACKGROUND

Monitoring changes in fatigue and sleep is important to enable effective fatigue management.

METHODS

This was a descriptive, repeated-measures study. Data were collected using surveys and actigraphy 4 times during each consecutive shift (7:00 am-7:30 pm).

RESULTS

General fatigue levels started trending up 4 hours after the start of work; highest levels were reported at 7:30 pm. Fatigue levels accumulated across consecutive shifts. Subjective sleep quality was higher the night before the 2nd shift than the night before the 1st shift. Nurses' poor sleep the night before a shift was related to increased fatigue levels during the next shift.

CONCLUSION

It is important to consider when fatigue management interventions will be most effective and to consider previous-night's sleep when monitoring fatigue.

Impact of 12-hr shifts in general hospitals: Study conducted in two intensive care units

AIM

To evaluate the impact of 12-hr shifts on health status, working conditions and satisfaction among nurses and healthcare auxiliaries in medical and surgical intensive care units in a general hospital.

DESIGN

This study was a descriptive and prospective questionnaire study of personnel involved in the organization of 12-hr shifts.

METHODS

The EVREST questionnaire was used, with the addition of two questions on respondents' health status and five questions on their job satisfaction. The study consisted of a first phase immediately before work was organized in 12-hr shifts and a second within 7-9 months of application of this organization.

RESULTS

Positive effects were found among day nurses including decreased periods of pressure during the working day and improved work-life balance. Conversely, night nurses, who are not in favour of 12-hr shifts, reported dissatisfaction caused by a deterioration both in working conditions and in work-life balance.

An Examination of Work Characteristics, Fatigue, and Recovery Among Acute Care Nurses

OBJECTIVE

To examine self-perceived fatigue among nurses and to quantify levels of fatigue and the ability to recover from fatigue between worked shifts across various work characteristics.

BACKGROUND

Fatigue is associated with working long hours, disruption of sleep, and inadequate time to recover between shifts. Fatigue degrades the nurses' performance leading to poorer patient outcomes and increased occupational injuries.

METHODS

This quantitative study surveyed 573 nurses across 5 hospitals in the southeastern United States.

RESULTS

Significant levels of acute fatigue were associated with working labor and delivery and medical-surgical units and working a 12-hour shift. Nurses working night shift and on the behavioral health unit showed a significantly lower ability to recover between worked shifts.

CONCLUSIONS

Fatigue threatens safety and the quality of patient care. Leaders should ensure that nurses take duty-free breaks and schedule adequate time off to recover between worked shifts.

Insomnia, fatigue and psychosocial well-being during COVID-19 pandemic: A cross-sectional survey of hospital nursing staff in the United States

AIMS AND OBJECTIVES

To describe the levels of insomnia, fatigue and intershift recovery, and psychological well-being (burnout, post-traumatic stress and psychological distress), and to examine differences in these measures based on work-related characteristics among nursing staff during COVID-19 pandemic in the United States.

BACKGROUND

The COVID-19 pandemic has created a major physical and psychological burden on nursing staff in the United States and worldwide. A better understanding of these conditions will lead to tailored support and resources for nursing staff during and after the pandemic.

DESIGN

Cross-sectional study.

METHODS

Hospital nurses and nursing assistants (N = 587) were recruited online between May-June 2020. The survey included measures on insomnia (Insomnia Severity Index) fatigue and intershift recovery (Occupational Fatigue and Exhaustion Recovery-15), burnout (Maslach Burnout Inventory-Human Services Survey), post-traumatic stress (Short Post-Traumatic Stress Disorder Rating Interview) and psychological distress (Patient Health Questionnaire-4), and questions on work and demographics. The STROBE checklist was followed for reporting.

RESULTS

The sample had subthreshold insomnia, moderate-to-high chronic fatigue, high acute fatigue and low-to-moderate intershift recovery. The sample experienced increased emotional exhaustion and depersonalisation, increased personal accomplishment, moderate psychological distress and high post-traumatic stress. Nurses who cared for COVID-19 patients had significantly scored worse on almost all measures than their co-workers. Certain factors such as working hours per week and the frequency of 30-min breaks were significant.

CONCLUSION

Nursing staff experienced poor sleep, fatigue and multiple psychological problems during the COVID-19 pandemic. Moreover, staff who were involved in the care of COVID-19 patients, worked more than 40 h per week and skipped 30-min breaks showed generally worse self-reported outcomes.

RELEVANCE TO CLINICAL PRACTICE

Nursing administration is recommended to monitor for fatigue and distress on nursing units, re-visit current scheduling practices, reinforce rest breaks and provide access to mental health and sleep wellness resources with additional support for their front-line nursing groups.

Impact of nurse's worked hours on medication administration near-miss error alerts

Long working hours have been shown to negatively impact adverse events in health care. In this study, a retrospective correlational design was used to evaluate the relationship between working hours and near-miss medication error alerts. During a two-year period, 5372 nurses triggered 420,706 near-miss alerts on 9, 285, 786 medication administrations. Nurses who worked 60 h or more in a week yielded an average near-miss rate of 4.0% compared to 3.0% (p <.001) for nurses who did not. Nurses working extended hours had a significantly increased risk of triggering a near-miss alert compared to those not working extended hours.

Chronic and acute fatigue and intershift recovery in undergraduate nursing students working 12 or 6-hour faculty-supervised clinical shifts

BACKGROUND

Nursing student fatigue and recovery time are important considerations.

PURPOSE

This descriptive research compared chronic/acute fatigue and recovery time between one 12-hour shift or two 6-hour faculty-supervised clinical shifts per week.

METHODS

The Occupational Fatigue and Exhaustion Recovery (OFER) scale was completed by undergraduate students in pediatric and obstetrical courses.

RESULTS

The student (N = 106) mean score on OFER was 37.57 for chronic fatigue, 56.57 for acute fatigue, and intershift recovery was 56.57. No differences in chronic fatigue (P = .40), acute fatigue (P = .14), or intershift recovery (P = .35) were found between groups. Nursing students (79%) preferred 12-hour clinical shifts as compared to 21% who chose two 6-hour clinical.

CONCLUSIONS

No differences in chronic/acute fatigue or intershift recovery between a 12-hour clinical shift or two 6-hour clinical shifts were found. Nursing students preferred the one 12-hour clinical shift.

The impact of extending nurse working hours on staff sickness absence: Evidence from a large mental health hospital in England

BACKGROUND

A pressing international concern is the issue of mental health workforce capacity, which is also of concern in England where staff attrition rates are significantly higher than in physical health services. Increasing demand for mental health services has led to severe financial pressures resulting in staff shortages, increased workloads, and work-related stress, with health care providers testing new models of care to reduce cost. Previous evidence suggests shift work can negatively affect health and wellbeing (increased accidents, fatigue, absenteeism) but can be perceived as beneficial by both employers and employees (fewer handovers, less overtime, cost savings).

OBJECTIVE

This study reports an evaluation of the impact of extending the shifts of nurses and health care assistants from 8 to 12 hours. Using data before and after the policy change, the effect of extended working hours on short term sickness (< 7 days) on staff is examined.

SETTING

The setting is six inpatient wards within a large mental health hospital in England where the shift extension took place between June and October 2017. The Data come from wards administrative records and the analysis is performed using weekly data (N=463).

METHODS

Causal inference methods (Interrupted Time Series and Difference-in-Difference) are used to compare staff sickness rates before and after the implementation, where the outcome variable is defined as the ratio of total sickness hours over the total scheduled working hours (full time equivalents) in a given week. Patient casemix, staff demographics, ward and time variables are included as controls.

RESULTS

Estimation results establish that the extended shifts are associated with an increased percentage of sickness hours per week of between 0.73% and 0.98%, the equivalent of a complete shift per week per ward.

CONCLUSION

This is the first study to use causal inference to measure the impact of longer shifts on sickness absences for mental health workforce. The analysis is relevant to other providers which may increasingly look towards these shift patterns as a means of cost saving.

The Influence of Workplace Incivility on Employees' Emotional Exhaustion in Recreational Sport/Fitness Clubs: A Cross-Level Analysis of the Links between Psychological Capital and Perceived Service Climate

The aim of this study was to explore the influence of workplace incivility on the emotional exhaustion of recreational sport/fitness club providers through a cross-level analysis. A total of 200 recreational sport/fitness club providers from Taiwan were selected for the repeated collection of measures and a 10-day diary method was used. The effect of workplace incivility on recreational sport/fitness club employees' emotional exhaustion on a daily basis was analyzed at the intra-personal level, and the relationship between psychological capital and perceived service climate was studied at the inter-personal level. Five hypotheses were developed and tested using hierarchical linear modeling. The results found that employees' emotional exhaustion and burnout highly correlated with workplace incivility and service climate. Based on the results, recommendations for employees and sport/fitness centers are proposed. Furthermore, research limitations and future directions are discussed.

Understanding the impact of the physical health care environment on nurse fatigue

AIM(S)

The purpose of this study was to investigate factors in the physical health care environment (PHE) contributing to nurse fatigue.

BACKGROUND

Nurses experience high levels of physical, mental and overall fatigue related to the physically demanding and mentally complex nature of bedside care.

METHOD(S)

This study used secondary data analysis of a 2017 focus group session, which explored: (a) challenges nursing professionals face while delivering care, (b) the effect of nurse fatigue on care delivery and (c) system factors that can either reduce or contribute to nurse fatigue. Eleven volunteers from a health care design focused nursing organisation participated in the focus group.

RESULTS

Twenty-seven design elements across four environmental categories were identified in this study as impacting fatigue. The effects of fatigue were found to have implications at the individual level (nurse and patient), the organisational level and the profession at large. Fatigue effects were found to be cumulative.

CONCLUSION(S)

Findings suggest that the PHE can have a substantial impact on nurse fatigue and contribute to profound effects with patient and staff safety implications.

IMPLICATIONS FOR NURSING MANAGEMENT

This study provides nursing managers, hospital administrators, nurses and designers with evidence for utilizing the PHE to mitigate and prevent nurse fatigue.

Exploring the impact of 12-hour shifts on nurse fatigue in intensive care units

AIM

To assess 12-h shift Intensive Care Unit (ICU) nurses' fatigue and identify the associated demographic factors.

BACKGROUND

Literature reveals inconsistencies as to whether 12-h shifts decrease or increase nurse fatigue levels.

METHODS

A cross-sectional survey of 67 ICU nurses working 12-h shifts was undertaken to determine their fatigue levels in two hospitals. The Occupational Fatigue Exhaustion/Recovery Scale (OFER), Spearman's correlation, ANOVA, t-tests, and Chi-Square were used for analyses.

RESULTS

57 out of 67 participants experienced low to moderate chronic fatigue; 36 of those exhibited low to moderate acute fatigue levels; 46 reported low to moderate inter-shift fatigue. Age (ρ = 0.03, r² = -0.28), number of family dependents (ρ = 0.03, r² = -0.27), and years of nursing experience (ρ = 0.03, r² = -0.27) were moderately negatively correlated with acute fatigue, while frequency of exercise per week (ρ = 0.01, r² = -0.31) was moderately negatively correlated with chronic fatigue. Hospital A had higher chronic fatigue levels than Hospital B. Age (ρ < 0.01), age group (ρ = 0.03), shift schedule (ρ = 0.02), and nursing experience (ρ = 0.03) were significantly related to the difference in chronic fatigue levels between the two hospitals.

CONCLUSIONS

More than half of the 12-h shift ICU nurses studied in both hospitals had low to moderate fatigue levels. Age, number of family dependents, years of nursing experience, and frequency of exercise per week were identified as key factors associated with fatigue. The difference in chronic fatigue levels between hospitals suggests that implementing more support for younger and/or less experienced nurses, better strategies for retaining more experienced nurses, and fewer rotating shifts could help reduce fatigue.

One-year trial of 12-hour shifts in a non-intensive care unit and an intensive care unit in a public hospital: a qualitative study of 24 nurses' experiences

OBJECTIVES

The aim of this study was to provide recommendations to hospital owners and employee unions about developing efficient, sustainable and safe work-hour agreements. Employees at two clinics of a hospital, one a non-intensive care and the other a newborn intensive care unit (ICU), trialled 12-hour shifts on weekends for 1 year.

METHODS

We systematically recorded the experiences of 24 nurses' working 12-hour shifts, 16 in the medical unit and 8 in the ICU for 1 year. All were interviewed before, during and at the end of the trial period. The interview material was recorded, transcribed to text and coded systematically.

RESULTS

The experiences of working 12-hour shifts differed considerably between participants, especially those in the ICU. Their individual experiences differed in terms of health consequences, effects on their family, appreciation of extra weekends off, perceived effects on patients and perceived work task flexibility.

CONCLUSIONS

The results indicate that individual preference for working 12-hour shifts is a function of own health situation, family situation, work load tolerance, degree of sleep problems, personality and other factors. If the goal is to recruit and retain nurses, nurses should be free to choose to work 12-hour shifts.

Psychosocial correlates of work-related fatigue among Jordanian emergency department nurses

PURPOSE

This study purposed to assess the psychosocial correlates of work-related fatigue among Jordanian emergency department nurses.

DESIGN AND METHODS

A cross-sectional study was conducted among Jordanian emergency nurses (n = 220). Measures included Occupational Fatigue Exhaustion/Recovery Scale (OFER15) and Copenhagen Psychosocial Questionnaire version Two (COPSOQ II).

FINDINGS

The psychosocial factors correlated with all types of work-related fatigue (acute, chronic, and inter-shift [recovery]) were quantitative demands, work-family conflict, sexual harassment, threats of violence, physical violence, and bullying. Importantly, quantitative demands and sexual harassment were the main predictors of all types of work-related fatigue.

PRACTICE IMPLICATIONS

The psychosocial correlated factors should be considered when developing interventions to minimize work-related fatigue phenomenon. This would lead to a more positive working environment which will promote safe nursing care.

Effects of job conditions, occupational stress, and emotional intelligence on chronic fatigue among Chinese nurses: a cross-sectional study

Purpose: Nurses are undertaking considerable emotional and physical work, which may lead to unrecoverable fatigue. This study aimed to evaluate the level of chronic fatigue and explore its associated factors among Chinese nurses in the hope of providing scientific evidence for fatigue-reduction strategies.

Methods: This cross-sectional study was carried out in Liaoning Province, China in 2018. The study recruited 700 nurses and collected 566 effective respondents. Chronic fatigue, demographic factors, job conditions, and emotional intelligence were assessed through questionnaires. Chronic fatigue was assessed with the Fatigue Scale 11, occupational stress with the Effort–Reward Imbalance Questionnaire, and emotional intelligence with the Wong and Law Emotional Intelligence Scale. Hierarchical multiple regression was used to explore factors related to chronic fatigue and to test the moderating effect of emotional intelligence on the association between occupational stress and chronic fatigue. Simple slope analysis was conducted to visualize the interaction.

Results: The mean score of chronic fatigue among the Chinese nurses was 17.14±6.16. Being married, having long weekly work time, working night shifts, and discontent with the nurse–patient relationship were positively associated with chronic fatigue. Effort:reward ratio, overcommitment, and emotional intelligence were important factors related to chronic fatigue. Emotional intelligence played a moderating role in the relationship between the effort:reward ratio and chronic fatigue. When emotional intelligence was higher, the effect of the effort:reward ratio on chronic fatigue became weaker.

Conclusion: Most nurses surveyed in China might have relatively high levels of chronic fatigue. Our results highlight the importance of interventions on these factors for the reduction of fatigue among nurses in China. Providing more opportunities and support and developing emotional intelligence are crucial strategies to reduce chronic fatigue among nurses in China.

Perception of clinical deterioration cues among medical-surgical nurses

AIM

To examine medical-surgical nurses' capacity and tendency to perceive cues indicating clinical deterioration and nursing characteristics influencing deterioration cue perception.

DESIGN

Cross-sectional, explorative study design.

METHODS

Data were collected over 10 weeks between September-November 2017. Medical-surgical nurses completed an online survey consisting of a demographic questionnaire, the Occupational Fatigue, Exhaustion Recovery scale and 50 detection trials. Descriptive statistics and statistical tests were used to describe and interpret data.

FINDINGS

A significant association was found between nurses' capacity and tendency to perceive deterioration cues. As nurses' capacity to perceive deterioration cues increased, nurses were more likely to classify patient cues as indicators of deterioration. Fatigue, education, and certification were not identified as characteristics associated with deterioration cue perception. However, experience was observed to significantly influence nurses' capacity to perceive deterioration cues based on levels of skills acquisition.

CONCLUSION

Study findings imply that future research should be directed at determining whether other individual factors and organizational system dynamics influence deterioration cue perception.

IMPACT

To better understand how nurses perceive deterioration cues, this study integrated concepts from the Situation Awareness model and Signal Detection Theory. Novice, advanced beginner and competent nurses were found to have a lower capacity to perceive deterioration cues compared with proficient and expert nurses. With simulation increasingly being used as a primary teaching modality in nursing, the development of a simulation-based signal detection training intervention may be beneficial in enhancing deterioration cue perception.

Nurses' 12-hour shifts and missed or delayed vital signs observations on hospital wards: retrospective observational study

OBJECTIVES

12-hour shifts worked by nurses on acute hospital wards have been associated with increased rates of missed care reported by nurses. This study aimed to measure the association between nurses working shifts of at least 12 hours and an objective measure of missed care: vital signs observations taken on time according to an acuity-based surveillance protocol.

DESIGN

A retrospective observational study using routinely collected data from March 2012 to March 2015.

SETTING

32 general inpatient wards at a large acute hospital in England.

PARTICIPANTS

658 628 nursing shifts nested in 24 069 ward days.

OUTCOME MEASURES

The rate of daily delayed and missed vital signs observations. We focused on situations where vital signs observations were required at least every 4 hours and measured the number of instances where observations were delayed or missed, per 24-hour period. For each ward and each day, shift patterns were characterised in terms of proportion of care hours per patient day deriving from 'long' shifts (≥12 hours) for both registered nurses and healthcare assistants.

RESULTS

On 99 043 occasions (53%), observations were significantly delayed, and on 81 568 occasions (44%), observations were missed. Observations were more likely to be delayed when a higher proportion of the hours worked by healthcare assistants were part of long shifts (IRR=1.05; 95% CI 1.00 to 1.10). No significant association was found in relation to the proportion of hours registered nurses worked as long shifts.

CONCLUSION

On days when a higher proportion of hours worked by healthcare assistants are from long shifts, the risk of delaying vital signs observations is higher, suggesting lower job performance. While longer shifts are thought to require fewer staff resources to maintain nurse-to-patient ratios, any benefits may be lost if staff become less productive.

Are long nursing shifts on hospital wards associated with sickness absence? A longitudinal retrospective observational study

Objective

To investigate whether working 12 hr shifts is associated with increased sickness absence among registered nurses and health care assistants.

Background

Previous studies reported negative impacts on nurses’ 12 hr shifts; however, these studies used cross‐sectional techniques and subjective nurse‐reported data.

Methods

A retrospective longitudinal study using routinely collected data across 32 general inpatient wards at an acute hospital in England. We used generalized linear mixed models to explore the association between shift patterns and the subsequent occurrence of short (<7 days) or long‐term (≥7 days) sickness absence.

Results

We analysed 601,282 shifts and 8,090 distinct episodes of sickness absence. When more than 75% of shifts worked in the past 7 days were 12 hr in length, the odds of both a short‐term (adjusted odds ratio = 1.28; 95% confidence index: 1.18–1.39) and long‐term sickness episode (adjusted odds ratio = 1.22; 95% confidence index: 1.08–1.37) were increased compared with working none.

Conclusion

Working long shifts on hospital wards is associated with a higher risk of sickness absence for registered nurses and health care assistants.

Implications for Nursing Management

The higher sickness absence rates associated with long shifts could result in additional costs or loss of productivity for hospitals. The routine implementation of long shifts should be avoided.

Musculoskeletal discomfort, work ability and fatigue in nursing professionals working in a hospital environment

OBJECTIVE

To evaluate the musculoskeletal discomfort, work ability and residual fatigue in nursing professionals working in the hospital setting.

METHOD

Cross-sectional study with professionals from a medium-sized public hospital. The Nordic symptom questionnaire, the work ability index, and the need for recovery scale (fatigue) were used. Data were analyzed descriptively and inferential tests were applied in order to verify the association of fatigue and work ability, and compare the fatigue among sectors analyzed.

RESULTS

Participation of 110 professionals in the study. A total of 86.24% of workers reported musculoskeletal discomfort, with a higher prevalence in the cervical, thoracic and lumbar spine. Approximately 43% of professionals presented residual fatigue. There was a significant association between fatigue and reduction of work ability (p<0.003), as well as association between younger age and greater fatigue (p<0.03).

CONCLUSION

Results demonstrated a high prevalence of musculoskeletal discomfort in the previous year and a considerable number of professionals with residual fatigue. There was a substantial portion of workers with moderate work ability and requiring attention in the medium term.