FATIGUE AND QUALITY OF LIFE IN EMERGENCY HEALTHCARE PROFESSIONALSABSTRACT
Objective: to identify the prevalence of fatigue and the relationship between professional, health and quality of life variables of professionals working in emergency care services.
Method: a cross-sectional study, with 108 healthcare professionals, carried out in midwest Brazil, in 2021, using the Chalder Fatigue Scale and the World Health Organization Quality of Life-brief. The data were analyzed through descriptive statistics, association and correlation.
Results: most participants were female (63.0%), aged between 18 and 25 years (41.7%), nursing technicians (50.0%) who worked in an Emergency Care Unit (75.0%). The mean fatigue assessment score was 5.9, and 72.9% were classified as fatigued. The mean quality of life score was 64.8 (±11.4). Participants who practiced physical activity and maintained a good diet had lower fatigue scores and reported better quality of life. A significant and inversely proportional correlation was identified between fatigue and all domains of quality of life.
Conclusion: this study showed a high prevalence of fatigue. Quality of life was considered low, especially in the physical domain. The greater the fatigue, the worse the overall quality of life and domains. It is reinforced the need for measures and interventions to minimize the impacts of fatigue and low quality of life of professionals working in direct patient care.
DESCRIPTORS:
Fatigue; Quality of life; Emergency medical services; Emergency nursing; Occupational health
RESUMO
Objetivo: identificar a prevalência de fadiga e a relação entre variáveis profissionais, de saúde e qualidade de vida de profissionais atuantes em serviços de urgência e emergência.
Método: estudo transversal, com 108 profissionais de saúde, realizado na região Centro-Oeste do Brasil, no ano de 2021, utilizando a Escala de Fadiga de Chalder e o World Health Organization Quality of Life-brief. Os dados foram analisados por meio de estatística descritiva, associação e correlação.
Resultados: a maioria dos participantes era do sexo feminino (63,0%), com idade entre 18 e 25 anos (41,7%), técnicos de enfermagem (50,0%) que atuavam em Unidade de Pronto Atendimento (75,0%). O escore médio da avaliação da fadiga foi 5,9, e 72,9% foram classificados como fadigados. O escore médio de qualidade de vida foi 64,8 (±11,4). Participantes que praticavam atividade física e mantinham boa alimentação tinham menores escores de fadiga e relataram melhor qualidade de vida. Identificou-se correlação significativa e inversamente proporcional entre fadiga e todos os domínios da qualidade de vida.
Conclusão: este estudo apresentou alta prevalência de fadiga. A qualidade de vida foi considerada baixa, principalmente no domínio físico. Quanto maior a fadiga, pior a qualidade de vida total e domínios. Reforça-se a necessidade de medidas e intervenções a fim de minimizar os impactos da fadiga e da baixa qualidade de vida dos profissionais que atuam no cuidado direto aos pacientes.
DESCRITORES:
Fadiga; Qualidade de vida; Serviços médicos de emergência; Enfermagem em emergência; Saúde ocupacional
RESUMEN
Objetivo: identificar la prevalencia de fatiga y la relación entre variables profesionales, de salud y de calidad de vida de los profesionales que trabajan en servicios de urgencia y emergencia.
Método: estudio transversal, con 108 profesionales de la salud, realizado en la región Centro-Oeste de Brasil, en 2021, utilizando la Escala de Fatiga de Chalder y el World Health Organization Quality of Life-brief. Los datos fueron analizados mediante estadística descriptiva, asociación y correlación.
Resultados: la mayoría de los participantes fueron mujeres (63,0%), edades entre 18 y 25 años (41,7%), técnicos de enfermería (50,0%) que actuaban en una Unidad de Atención de Emergencia (75,0%). La puntuación media de la evaluación de la fatiga fue de 5,9 y el 72,9% fueron clasificados como fatigados. La puntuación media de calidad de vida fue de 64,8 (±11,4). Los participantes que practicaban actividad física y mantenían una buena dieta tenían puntuaciones de fatiga más bajas y reportaban una mejor calidad de vida. Se identificó una correlación significativa e inversamente proporcional entre la fatiga y todos los ámbitos de la calidad de vida.
Conclusión: este estudio mostró una alta prevalencia de fatiga. La calidad de vida se consideró baja, especialmente en el ámbito físico. Cuanto mayor es la fatiga, peor es la calidad de vida general y los dominios. Se refuerza la necesidad de medidas e intervenciones para minimizar los impactos de la fatiga y la baja calidad de vida de los profesionales que trabajan en la atención directa al paciente.
DESCRIPTORES:
Fatiga; Calidad de vida; Servicios médicos de urgencia; Enfermería de urgencia; Salud laboral
INTRODUCTION
The provision of healthcare services is a complex process that is influenced by economic, political and technological conditions, which can increase the demands of work and generate consequences, such as occupational and psychosocial risks. In this way, work environments can influence healthcare professionals’ safety and health1-4.
Critical healthcare services are considered the most stressful work environments, since the users treated in these sectors are in situations of imminent risk of death or intense distress5. Therefore, professionals working in this area are more vulnerable to occupational stress and illness, due to the characteristics imposed by work6-7. Nurses working in emergency rooms present high levels of traumatic stress and fatigue7. Depressive symptoms and professional burnout are also evident in these professionals, with negative impacts on work environments8. Moreover, the emotional repercussions of caring for people in situations of acute distress increase the burnout of these professionals.
Fatigue manifests as exhaustion or tiredness that can limit physical fitness for daily activities, since in many cases rest is not enough to alleviate it9. Fatigued healthcare professionals have impaired motor skills and attention, in addition to poor sleep quality10.
Furthermore, fatigue is intrinsically related to stress in the workplace and to a decline in quality of life (QoL), with the stressful and tense work environment contributing negatively to this deterioration11. The impacts of fatigue at work are decreased productivity, increased absenteeism, higher accident rates and a high probability of developing disability due to a related disease12.
QoL assessment is also capable of indicating how much daily life factors interfere with individuals’ social, individual and environmental contexts. Work activities bring about changes in the way an individual perceives life and the way they react to everyday situations11-12. QoL in work environments resonates with individual QoL, as it modifies factors such as life satisfaction, personal well-being and professional well-being13.
Changes in fatigue levels and QoL in healthcare professionals working in emergency departments are due to lifestyle, work environment and sociodemographic factors1. Professionals working in emergency departments experience situations of high demand and complexity of patients, more than one employment relationship, lack of adequate supplies, incorrect staffing and team coordination10, which can result in fatigue and, consequently, affect QoL.
It was considered that high levels of fatigue and low QoL in healthcare professionals working in critical areas can result in a reduction in the quality of care provided, that there is a scarcity of studies that aimed to assess the relationship among these variables and that identifying them can guide managers in planning policies and activities aimed at reducing fatigue and improving QoL7,10. The present study aims to identify the prevalence of fatigue and the relationship between professional, health and QoL variables of professionals working in emergency services. The guiding hypothesis is that most professionals are fatigued and that fatigue is related to low QoL.
METHOD
The study was written guided by the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) tool14.
This is a cross-sectional study, developed in a municipality in the countryside of the state of Mato Grosso do Sul, specifically in the Mobile Emergency Care Service (SAMU) and the Emergency Care Unit (ECU), which make up the Emergency Care Network. Data collection took place between June and November 2021. The study population consisted of 163 nursing professionals and physicians working in these services.
Nursing professionals or physicians who had been providing direct care to patients in emergency services for at least one year were selected, excluding professionals who had been absent for more than 30 days at the time of data collection. All professionals who met the inclusion criteria were invited to participate in the study, and there were no refusals.
Based on a study carried out with 244 healthcare professionals15, and considering the data identified with a significance level of 5%, a test power of 95%, “Z” = 1.96 and a finite population of 163 healthcare professionals, it would be necessary to assess at least 104 professionals.
Data collection was carried out by the main researcher in person with each participant, in a private room, respecting biosafety standards, due to the COVID-19 pandemic. The interview lasted an average of 30 minutes, and was conducted in the professionals’ own service. The characteristics, fatigue and QoL of participants were assessed, according to three instruments described below.
The characterization questionnaire analyzed demographic variables (sex and age group), occupational variables (position, workplace, job tenure and length of work in emergency care) and lifestyle habits, assessed by physical activity (“Do you practice any physical activity?” Yes/Sometimes/No), diet (“Are you able to maintain a good diet?” Yes/Partially/No), consumption of coffee, soft drinks and energy drinks (“Do you usually drink coffee, soft drinks or energy drinks?” Daily/A few times a week/Rarely or never) and smoking habits (Yes/No).
The Chalder Fatigue Scale was used to estimate individuals’ level of physical and mental fatigue. It consists of 11 questions, with four answer options and a score of 0 to 3 for each item, related to the intensity of fatigue symptoms. The result was a bimodal score, in which values 0 and 1 are considered 0, and values from 2 to 3, 1. The total score ranges from 0 to 11, with results equal to or greater than 4 indicating fatigue16.
The World Health Organization Quality of Life-brief (WHOQOL-Bref) was used to assess individuals’ QoL. It consists of 26 questions, divided into four domains: physical, psychological, social relationships and environment. The score for each domain and the total score are converted into a value ranging from 0 to 100, with a higher score indicating a better QoL17.
The collected data were tabulated, checked and exported to the Statistical Package for the Social Sciences® (SPSS 25.0) for statistical analysis. Qualitative variables were expressed as absolute and relative frequencies, and quantitative data as mean (standard deviation), median, minimum and maximum variation/interquartile range. Data normality was assessed by the Shapiro-Wilk test and, considering that the data did not present a normal distribution, the analyses were conducted using nonparametric tests.
To analyze the association between fatigue and total QoL scores and occupational demographic and lifestyle variables, the Mann-Whitney U test (variables with two categories) and the Kruskall-Wallis test (variables with three categories) were used. To identify the correlation between fatigue and total QoL scores and domains, Spearman’s correlation test was used. A p-value <0.05 was considered significant.
This study was approved by the Universidade Federal de Mato Grosso do Sul Research Ethics Committee. After understanding the objectives of the study, they read and signed the Informed Consent Form (ICF).
RESULTS
Of the 163 professionals working in services at the time of data collection, 55 were excluded according to the listed criteria and 108 met the inclusion criteria. Of this total, 81 were assigned to ECU, 18 to SAMU, and nine to both.
Table 1 shows sample characterization data. Most participants were female (63.0%), aged between 18 and 35 years (41.7%), worked as nursing technicians (50.0%) at ECU (75.0%) and had worked in the service for more than five years (54.6%). Regarding habits, 47.2% did not practice physical activity; 41.7% reported that they did not have a good diet; 14.8% were smokers; and 65.7% consumed coffee, soda and energy drinks daily.
Furthermore, Table 1 presents the data on the association between the total fatigue and QoL score and the categories of demographic, occupational and lifestyle variables.
The mean score on the Chalder Fatigue Scale was 5.9 (3.2). Lower fatigue scores were identified in participants who practiced physical activity and had a good diet. Regarding total QoL, the mean score was 64.8 (11.4), being significantly higher in participants with a good diet.
The prevalence of professionals with fatigue was 72.9%. In the analysis by item on the scale, it was identified that the majority responded “more than usual” or “much more than usual” to the questions “do you have problems with tiredness?”, “do you need to rest more?” and “do you feel sleepy or drowsy?”, “do you lack energy?” and “do you have difficulties concentrating?”, as shown in Table 2.
Frequency of response of emergency professionals to questions from the Chalder Fatigue Scale. Três Lagoas, MS, Brazil, 2021. (n=108)
Regarding the analysis of QoL domains, the one with the lowest score was the physical one, as shown in Table 3.
Assessment of overall quality of life and domains of emergency care professionals. Três Lagoas, MS, Brazil, 2021. (n=108)
The results indicated significant and inversely proportional correlations between fatigue and all QoL domains, with the highest correlations between fatigue, total QoL and the physical domain, according to Table 4.
DISCUSSION
This study aimed to assess the relationship between fatigue, QoL and sociodemographic and health characteristics of professionals working in emergency services. It was identified that 72.9% of participants were fatigued and had low QoL, with a worse score in the physical domain.
Healthy lifestyle habits impact overall health18. In this study, it was clear that professionals with less fatigue reported having a good diet and practicing physical activity. Studies show that practicing physical activity improves the level of fatigue in healthcare professionals18-19. Professions considered stressful and with high mental demands require constant suggestions of healthy practices, such as regular sleep, balanced diet and leisure19. A study carried out with 4,402 medical students in the United States found that those who practiced aerobic and strength exercises are less likely to suffer from burnout and have a higher QoL20. Another study, conducted with 2,667 nurses on the front lines of the pandemic in China, identified a negative correlation between the mean number of days of exercise per week and fatigue19.
In fatigue assessment, feeling easily tired, needing to rest more, being sleepy, having a lack of energy and having concentration problems were most frequently reported by professionals. This result supports the worst QoL score in the physical domain, since excessive fatigue can trigger physical manifestations and, consequently, mental health, and alter QoL globally21. A systematic review indicated that burnout among nursing professionals can affect their QoL and productivity at work, and work environments are a potential physical, mental and psychological stressor21. Moreover, this burnout affects the relationships among professionals at work and the care provided22. Thus, physical and mental health assessment is vital for maintaining the quality of care provided as well as attention to worker health.
Another study that assessed fatigue in nursing staff using the Chalder Fatigue Scale found that 35.1% of the sample of 47 participants presented fatigue23. Another study using the same scale with 1,335 Norwegian nurses found significant associations between excessive fatigue and pain severity scores for arms/wrists/hands and hips/legs/knees/feet, headaches/migraines, sleep duration of less than six hours, and total symptom scores for insomnia, drowsiness, anxiety, and depression24. This supports the present study, in which there were complaints of drowsiness, lack of energy, and difficulty concentrating. Thus, fatigue in these professionals, in addition to physical symptoms, also involves sleep disorders and emotional aspects.
Concerning QoL, a study conducted during the Covid-19 pandemic with nursing professionals, through the application of the Work Limitations Questionnaire, demonstrated greater changes in the physical domain, followed by time management25. However, healthcare professionals’ QoL may have been impacted during the pandemic, especially at the beginning of it, as observed in a study conducted with 572 nursing professionals that identified an average score of 56.79, the lowest in the social and environmental domains, measured by the WHOQOL26. This study was conducted at a time when activities were already returning to normal and the Covid-19 vaccine was already available to healthcare professionals. The low QoL identified is mainly related to physical issues (the domain with the worst score), such as exhaustion, pain and fatigue itself.
It was also found that fatigued professionals have a worse QoL, which may be related to some factors, such as the context of work environments, field of activity (emergencies and intensive care), work shift and physical and psychological issues (fatigue and exhaustion). A study with 2,852 nurses from 39 Lebanese hospitals found that musculoskeletal disorders are related to chronic occupational fatigue27. Therefore, it is necessary to understand the influence that these combined factors (environment, physical health and psychological health) can exert on aspects that involve both patient care and professionals’ health and, thus, propose measures that improve overall health and, consequently, their QoL.
It is known that management activities in the workplace are extremely important for reducing the levels and impacts of fatigue, through critical reflection on improving occupational health23. In the present study, the details of the fatigue scale demonstrated that failures in concentration and difficulty in reasoning were reported by professionals, aspects that can directly affect professional emergency performance, in which immediate interventions are necessary that impact patient survival.
Another important factor is the impact of the association of these variables on the care provided. A study that aimed to assess fatigue and quality of care reported by nurses demonstrated that higher levels of acute fatigue among professionals were associated with decreased perceptions of individualized nursing activities provided to patients in their last shifts, specifically related to personal life conditions and control over decision-making28. Therefore, it is suggested that addressing acute and chronic fatigue among nurses can contribute to promoting better provision of nursing care, thus impacting its quality. Studies suggest that this type of approach among professionals, with practices such as meditation and physical activity, as well as other guided activities, can alleviate high levels of fatigue29, especially in those who are in more critical care units30.
Furthermore, behavioral interventions can bring benefits to these professionals. A systematic review of 136 intervention studies conducted to improve nurses’ health, well-being and work-related outcomes identified that interventions can mainly improve dietary habits, body composition, physical activity and stress, with important results for smoking behavior, self-efficacy, physical health, well-being/QoL, burnout/fatigue and depression/anxiety. The best interventions were those that focused on behavior change30.
Regarding limitations, we can mention that the interviews were conducted during the pandemic, an event that generated great stress among healthcare professionals and the general population, which may have influenced the responses. Another limitation is that this was a cross-sectional study conducted in only one specific socio-labor context, which does not allow generalizations or the establishment of cause-and-effect relationships among variables. In addition to this, we believe that it would be important to assess occupational stress. As a strength, it is worth noting that the study was conducted with professionals from emergency services in Brazil, a developing country that is still little studied regarding the subject in question.
It is understood that healthcare professionals are an idiosyncratic audience for analyzing fatigue levels and QoL, since work environments require physical and psychological effort and communication skills, characteristics that are exhausting and require attention, which may have influenced the high prevalence of fatigue and the low QoL scores identified. The association between fatigue and QoL demonstrates that work-related issues can interfere with professionals’ personal life11. Thus, planning interventions aimed at preventing, maintaining and improving healthcare professionals’ physical and mental health can have positive consequences on QoL. Support groups for spirituality and mental health, psychotherapy, physical activity groups and workplace gymnastics, in addition to improving work processes, are suggested activities to minimize the situation.
CONCLUSION
The sample studied showed a high prevalence of fatigue, with the majority reporting being tired, needing more rest, being sleepy, discouraged and having concentration problems. Physical activity and a good diet were associated with lower fatigue scores. QoL was considered average, with a worse score in the physical domain, and a good diet was associated with better QoL. Fatigue showed significant correlations with all QoL domains, in which it was observed that the higher the fatigue score, the worse the QoL. Therefore, it is urgent to implement measures and interventions that aim to mitigate the effects of fatigue and improve the QoL of professionals who work directly in patient care, especially in emergency services.
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» https://doi.org/10.3390/ijerph17010017
NOTES
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ORIGIN OF THE ARTICLE
Extracted from the dissertation “Avaliação da qualidade do sono em profissionais de saúde da urgência e emergência e suas implicações na fadiga e na qualidade de vida”, presented to the Graduate Program in Nursing, Universidade Federal de Mato Grosso do Sul, in 2022.
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FUNDING INFORMATION
This work was carried out with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES - Coordenação de Aperfeiçoamento de Pessoal de Nível Superior) - Financing Code 001 and the Universidade Federal de Mato Grosso do Sul (UFMS)
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved by the Ethics Committee in Research of the Universidade Federal de Mato Grosso do Sul, under Opinion 4.700.303/2021. Certificate of Presentation for Ethical Consideration 40558320.5.0000.0021.
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TRANSLATED BY
Letícia Belasco.
