Transferred Files Related Lit

CHAPTER II
REVIEW OF RELATED LITERATURE AND STUDIES

Reviewed and synthesized in this portion are available relevant studies on Level of
Fatigue, Coping Mechanisms and Quality of Nursing Care of Intensive Care Unit Nurses.
Nursing care in ICU
In the intensive care unit people are constantly looked after and monitored by a highly
specialized team, which includes consultants, physiotherapists, dieticians and nurses, each of
them with specialist knowledge and skills. Specially trained nurses provide round-the-clock care
and monitoring, and there is a high ratio of nurses to patients - each person in ICU is usually
assigned his or her own 'named' nurse.
ICU nurses play a vital role in the patient’s care, including the following:
 Taking regular blood tests

 Changing the patient’s treatment in line with test results
 Giving the patient the drugs and fluids that the doctors have prescribed
 Recording the patient’s blood pressure, heart rate and oxygen levels
 Clearing fluid and mucus from the patient’s chest using a suction tube
 Turning the patient in his or her bed every few hours to prevent sores on the skin
 Cleaning the patient’s teeth and moistening the mouth with a wet sponge
 Washing the patient in bed
 Changing the sheets
 Changing a patient’s surgical stockings, which help circulation when he or she is inactive
(lying still) for a long time
 Putting drops in the patient’s eyes to make it easier to blink
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Intensive care units (ICUs)

What is an intensive care unit (ICU)?
Intensive care refers to the specialised treatment given to patients who are acutely unwell and require critical medical
care.
An intensive care unit (ICU) provides the critical care and life support for acutely ill and injured patients.
Unless you are an emergency admission, you will need a referral from your doctor or specialist to be admitted to ICU.
Who is cared for in ICU?

Patients may have a planned admission following surgery, an unexpected admission after an accident or be admitted
because of a sudden and critical deterioration to their health.
ICU teams are multi-disciplinary, made up of highly skilled intensive care nurses, doctors and specialists trained in
providing critical care for patients with a variety of medical, surgical and trauma conditions.
Some hospital ICUs specialise in providing care for particular health conditions or injuries including:
 major trauma
 severe burns
 respiratory failure
 organ transplants
 complex spinal surgery
 cardiothoracic surgery.
What to expect in ICU

ICU is one of the most critically functioning operational environments in a hospital.
Every ICU in a hospital has a different environment that will reflect the specialist medical and surgical procedures
they perform.
Most ICUs are fairly large sterile areas with a high concentration of specialised, technical and monitoring equipment
needed to care for critically ill patients.
The ICU environment can be confronting for some patients and visitors who may find the activity, sounds, machines,
tubes and monitors intimidating.
When you visit someone you care about in ICU it can be an uncomfortable experience – you may feel helpless,
overwhelmed, frustrated and sad. Your feelings and apprehension are understood by the staff that provide support for
the people you care about.
Typically ICU also has a higher ratio of doctors and nurses to patients.
ICU equipment
It can be a frightening and uncertain time for you, family and friends to see people you care about being monitored
and supported by machines.
In ICU you will see many patients connected to a heart monitor, others will be supported with breathing assistance
from artificial ventilators, be on dialysis machines and receiving a variety of intravenous infusions via tubes and drips.
Be prepared to see lots of lines, tubes, wires and monitoring equipment. Almost all ICU equipment uses alarms to let
staff know about a change in a patient’s condition. Not all equipment alarms signal an emergency situation.
Visitors
Every ICU has a visitor policy to ensure the wellbeing of their patients. You will need to ask ICU hospital staff about
their specific visiting hours and requirements.
Visiting is usually restricted to people the patient considers to be immediate family.
If you are feeling unwell or have an existing health condition you should reconsider visiting ICU or discuss your
circumstances with ICU staff before you plan to visit.
Hygiene
As intensive care patients are very vulnerable to infections, it is important that visitors wash their hands before
entering ICU to prevent transferring infection.
Mobile phones
Mobile phones should be turned off in ICU as they may interfere with vital electrical equipment supporting patients.
Gifts
Restrictions are in place to allow easy access to vital medical equipment and to patients.
If you are unsure what you can bring with you check with ICU staff before you plan to visit.
Patient and family support services

Counselling
Admission to ICU because of critical illness or accident can have a huge physical and emotional impact on your life
and your family.
Some ICUs have a dedicated counsellor to provide support for patients and their families. These counsellors are
highly experienced and have a thorough knowledge of ICU procedures.
Hospital counselling support services are also available at all major hospitals.
Pastoral care
For many people, emotional and spiritual thoughts tend to surface when someone they care about is in a critical
condition in hospital.
Many hospitals provide chaplaincy and pastoral counselling services for patients, families and staff who need
compassionate, professional and spiritual guidance and support.
Some hospitals also have a non-denominational chapel available for times of reflection and prayer.
Interpreter service
An interpreter service is available for patients and families if English is not your first language.
These interpreters are specifically trained to interpret medical terms into other languages. It is important that you use
this service if you are having problems understanding doctors explaining information or are being asked to provide
consent for medical procedures.
Speak to ICU staff if you would like to use interpreting services.
Costs of ICU
Your costs will depend on the procedures you need, time spent in ICU and the specialised care you require.
For an Australian patient in a public hospital in Western Australia:
 public patient – no cost to you unless advised otherwise
 private patient – costs can be claimed through Medicare and your health insurance provider.
Remember
 Visiting ICU can be a confronting experience.
 Patients are monitored 24 hours a day.
 Doctors, nurses and specialists are highly trained in delivering critical care.
 https://www.healthywa.wa.gov.au/Articles/F_I/Intensive-care-units-ICUs
AUTONOMY
file:///C:/Users/May%20Therese/Downloads/Empowerment_and_autonomy_among.pdf
Empowerment and autonomy among continuing care

nurses/residents
Turnbull, Andrea.University of Alberta (Canada), ProQuest Dissertations Publishing, 2001.
MQ60405.
https://search.proquest.com/central/docview/304745773/fulltextPDF/822D4FECDF2F4DBF
PQ/14?accountid=35994
Authority and autonomy of staff nurses providing

patient care: A study of nursing power
Blanchfield, Kathleen Cleary.University of Illinois at Chicago, Health Sciences Center, ProQuest
Dissertations Publishing, 1992. 9310087.
https://search.proquest.com/central/docview/304027402/abstract/822D4FECDF2F4DBFPQ/19?acco
untid=35994
Abstract
TranslateAbstract
The purpose of this study was to examine differences between staff nurses' and nurse leaders'
perceptions of staff nurse authority, autonomy, and the importance they attach to authority
and autonomy. The relationship of the independent variables of age, gender, basic education,
highest level of education, years of experience, shift worked, unit, past unit experience, hospital
affiliation, certification, and involvement in shared governance was explored with the dependent
variables of authority, autonomy, importance of authority, and importance of autonomy. Until this
study, no one had simultaneously examined staff nurses' authority and autonomy. By studying
authority and autonomy together, a positive correlation was found, and more importantly,
independent variables that relate to these concepts were identified.
The Nursing Authority and Autonomy Scale (NAAS), a 38 item tool was adapted, developed, and
refined. Five hundred and ninety registered nurses, from four Midwestern hospitals, participated in
this study. Data were analyzed using descriptive statistics; specifically, Pearson product-moment
correlation coefficient, Hotelling's T$\sp2$, MANOVA, one-way ANOVA, two-way ANOVA, and
multivariate analysis. Findings indicated that significant differences exist between staff nurses'
and nurse leaders' sense of staff nurse autonomy, and importance of authority and autonomy. In
addition, selected demographic and organizational variables (i.e., unit specialty, hospital affiliation,
shift worked, and highest level of education) impacted nurses' perceptions of
staff nurse authority, autonomy, importance of authority, and autonomy. Of particular interest, was
the finding that staff nurses have a significantly higher perception of
staff nurse autonomy than nurse leaders.
Differences between staff nurses' and nurse leaders' perceptions of staff nurse authority
and autonomy can lead to serious misunderstandings and conflict. This can hamper empowerment
of staff nurses who are charged with the responsibility of delivering and managing effective patient
care. The success of cost effective patient care rests on the empowerment of staff nurses with
legitimate authority and autonomy. Further study is indicated to insure that legitimate empowerment
with sufficient staff nurseauthority and autonomy is occurring.
PLS READ
file:///C:/Users/May%20Therese/Downloads/Authority_and_autonomy_of_staf.pdf
Intuition, autonomy, and level of clinical proficiency

among registered nurses
Handy, Catherine M.New York University, ProQuest Dissertations Publishing, 1999. 9935638.
https://search.proquest.com/central/docview/304514689/abstract/822D4FECDF2F4DBFPQ/10?acco
untid=35994
Abstract
TranslateAbstract
To investigate whether intuition and autonomy vary according to the nurse's level of clinical
proficiency, 177 female nurses/nursing students were studied. The subjects were grouped as
follows: 61 Novice/Advanced Beginners, Registered Nurses (RNs) with less than one year of
experience or senior nursing students; 58 Intermediate nurses, RNs who were neither
Novice/Advanced Beginners nor Experts; and 58 Experts, RNs selected by their supervisor as a
clinical expert. All subjects were from New York City hospitals, schools of nursing, and a home care
agency. All subjects completed a demographic data sheet, the Himaya Intuition Semantic Scale
(HINTS) (intuition), and the Edwards Personal Preference Schedule (EPPS) (autonomy subscale).
The groups were compared on intuition by a series of two planned t-tests (alpha = .025). This
process was repeated for autonomy. The hypothesis that Expert nurses possess greater intuition
than Intermediate nurses who, in turn, possess greater intuition than Novice/Advanced Beginners
was not supported. The hypothesis that Expert nurses possess greater autonomy than
Intermediate nurses who, in turn, possess greater autonomy than Novice/Advanced Beginners was
only partially supported (Expert > Intermediate, p = .009).
Trends were seen for home care nurses to possess more autonomy and for Intermediate nurses in
the hospital to possess the least autonomy.
Subsequent review of the data revealed that the Novice/Advanced Beginner group possessed the
most baccalaureate or higher degrees outside of nursing (62.3%); 48.3% of the Intermediates and
37.9% of the Experts possessed such degrees. It is postulated that this may help explain
the autonomy findings. In addition it was also postulated that the EPPS may not have provided a
true measure of the female nurses' autonomy.
The intuition results indicate that all nurses are equally intuitive. Expertise in nursing may require
that one have intuition and other traits, such as the ability to critically think in a rapid fashion.
Areas for further study include studying autonomy with other tools and continuing to study expertise
in nursing practice.
EMPOWERMENT
An examination of leadership readiness and

empowerment among full-time nursing faculty
Bilder, Loretta Lynn.Indiana University of Pennsylvania, ProQuest Dissertations Publishing, 2014.
3617332.
https://search.proquest.com/central/docview/1527075300/abstract/E28F72A8E68145C5PQ/5?accou
ntid=35994
Abstract
Leadership skills in faculty and administrators are vital given the complex challenges faced in higher
education, yet little is known about how best to prepare for a leadership role. According to the
literature in other disciplines, empowerment can be identified as a primary antecedent to leadership
readiness. Empowerment has been studied related to job satisfaction and burnout among faculty
members and results indicate that it plays a significant role. However, there are no published
research studies related to empowerment as a measure of leadership
readiness among nurse educators. The purpose of this study was to examine the relationship
between empowerment and leadership readiness and explore select demographical variables and
their influence on leadership readiness in nursing education. A descriptive correlational design was
used to examine the relationship between empowerment and leadership readiness among full-time
nursing faculty. Additionally, an open-ended response was used to elicit data related to reasons why
participants did not rate themselves as ready to assume a leadership role within nursing education.
A national sample (N =125) of full-time nursing faculty and administrators from 32 states
participated. Full-time faculty and administrators reported a moderate level of both structural and
psychological empowerment as measured by the CWEQ-II and the PEI. Leadership readiness was
measured using two researcher developed tools. Results indicate that there is a moderate, positive
correlation between leadership readiness and empowerment. Years of experience in nursing
education, previous experience holding a formal leadership position within nursing education, and
psychological empowerment were identified as significant predictors of leadership
readiness. Nurse educators often assume leadership roles, not by choice but by default, without
sufficient preparation and with a lack of support for development. Nurses who are ready to assume
the role, may be capable of transforming the academic environment to one where open
communication is encouraged, more opportunities exist, and there is empowerment, autonomy, and
shared decision-making. Findings of the study provide data on which to base recommendations to
address the shortage of leaders within nursing education, to fill the predicted void as current leaders
retire, and to guide future research.
Workplace empowerment and job performance in

ambulatory care nursing
Govers, Margaret Joyce.The University of Western Ontario (Canada), ProQuest Dissertations
Publishing, 1997. MQ28576.
https://search.proquest.com/central/docview/304436587/abstract
/E28F72A8E68145C5PQ/17?accountid=35994
Abstract
TranslateAbstract
The purpose of this study was to test the Structural Theory of Behaviour in Organizations proposed
by Rosabeth Moss Kanter (1977, 1993), among nurses in ambulatory care settings. The
relationship among perceived levels of empowerment, and perceived job performance were
examined. A descriptive correlational survey design was used to test hypotheses from Kanter's
theory in a convenience sample of 71 registered nurses employed in ambulatory care settings in a
large urban tertiary care centre. The Conditions for Work Effectiveness Scale (Chandler, 1986), the
Job Activities Scale, the Organizational Relationships Scale (Laschinger, 1996b), the Ambulatory
Care Job Performance Survey and a brief demographic questionnaire were used. The ACJPS is a
measure of job performance developed for this study based on activities found to be common in
various ambulatory care nursing settings (Hackbarth, Haas, Kavanagh, and Vlasses, 1995). The
results of this study are supportive of Kanter's (1993) theory and suggest that
workplace empowerment structures are influential in ambulatory care staff nurses' job performance.
(Abstract shortened by UMI.)
PROFESSIONAL DEVELOPMENT
Professional development among registered nurse to

bachelor of science in nursing, accelerated Bachelor of
Science in Nursing, and traditional bachelor of science in
nursing students
Barbe, Tammy Diane.University of Northern Colorado, ProQuest Dissertations Publishing, 2010.
3415976.
https://search.proquest.com/central/docview/734814032/abstract/5E38A4AD1FEC4BD6PQ/7?accou
ntid=35994
Abstract
TranslateAbstract
With multiple degree trajectories for basic entry into the nursing discipline, educators have debated
whether professionaldevelopment is equally achieved at the Bachelor of Science in Nursing (BSN)
level. The purpose of this study was to determine whether there is a difference
in professional development and leadership behaviors among students who take different
trajectories to earn BSN degrees.
This study used a non-experimental, cross-sectional design with a convenience sample of 96

nursing students from a public university in the southeast United States.
The Professional Development Self-Assessment Matrix (PDSAM) was used to measure the level
of professional development and the Self-Assessment Leadership Instrument (SALI) was used to
measure leadership behaviors. Together with a demographic survey, these tools were administered
to participants using SurveyMonkey, a secure online instrument service.
Results from the PDSAM suggested a significant difference between

the professional development of students within the different nursing programs Students in the RN to
BSN program reported higher professional development scores compared to those in the traditional
and accelerated programs There was no significant difference in
the professional development scores of traditional or accelerated students.
Based on the SALI, leadership behaviors did not vary according to the involvement of nursing
students in traditional BSN, RN to BSN, or accelerated BSN programs. Accelerated students
reported higher leadership behaviors compared to traditional students; however, leadership
capabilities of nursing students could not be attributed to their education in the nursing programs.
PLS. SEE
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The Nurse and the Work Environment
The emotional well-being of the nurse within the multi-

skill setting
French, Heleen; du Plessis, Emmerentia; Scrooby, Belinda.Health S A;
Philadelphia Vol. 16, Iss. 1, (2011): 1I,2I,3I,4I,5I,6I,7I,8I,9I.
https://search.proquest.com/central/docview/874012037/fulltextPDF/8310CF48AE0445B2P
Q/6?accountid=35994
March 25, 2019
The emotional well-being of nurses working in a multi-skill setting may be negatively influenced by their
challenging work environment. A qualitative, explorative, descriptive and contextual study was
conducted to investigate this phenomenon. The purpose of this study was to explore and describe the
experience, as well as perceptions of coping mechanisms, of nurses working in the multi-skill setting,
and to formulate recommendations to promote their emotional wellbeing. The population consisted of
nurses working in a multi-skill setting (a Level-2 hospital) and included professional nurses, enrolled
nurses and nurse assistants. An all-inclusive sample was used. Semi-structured interviews were
conducted with three professional nurses, six enrolled nurses and one nurse assistant. These interviews
were analysed according to the method described by Creswell (2003:192). The findings indicated that
nurses have positive as well as negative experiences of the multi-skill setup. They cope by means of
prioritising tasks, faith, self-motivation and mutual support. They also made suggestions for the
promotion of their emotional well-being, on personal as well as managerial levels. Recommendations
for further research, nurse education and practice were formulated. Recommendations for practice
include ‘on-the-spot’ in-service training, appropriate task allocation, clearly defined scope of practice,
time for rest and debriefing, strengthened relationships with management, promotion of strengths and
creating a support system.
Introduction Background This article explores nurses’ emotional well-being amidst the growing
phenomenon that they are compelled to apply a multi-skills approach in emotionally demanding work
environments. Health services in South Africa present a challenging work environment for nurses. These
challenges include staff shortages, lack of training, overcrowded hospitals, insufficient health service
management, lack of support by supervisors, long work hours and task overload (Aucamp 2003:1,5; De
Haan 2006:4; Hall 2004:30). Limited growth in the number of nurses and the simultaneous increased
number of patients due to high levels of poverty and the HIV and/or AIDS pandemic add to these
challenges and consequently put more demands on nurses (Mostert & Oosthuizen 2006:429; Subedar
2005:89). The emotional well-being of nurses working in a multi-skill setting may be negatively
influenced by their challenging work environment. A qualitative, explorative, descriptive and contextual
study was conducted to investigate this phenomenon. The purpose of this study was to explore and
describe the experience, as well as perceptions of coping mechanisms, of nurses working in the multi-
skill setting, and to formulate recommendations to promote their emotional wellbeing. The population
consisted of nurses working in a multi-skill setting (a Level-2 hospital) and included professional nurses,
enrolled nurses and nurse assistants. An all-inclusive sample was used. Semi-structured interviews were
conducted with three professional nurses, six enrolled nurses and one nurse assistant. These interviews
were analysed according to the method described by Creswell (2003:192). The findings indicated that
nurses have positive as well as negative experiences of the multi-skill setup. They cope by means of
prioritising tasks, faith, self-motivation and mutual support. They also made suggestions for the
promotion of their emotional well-being, on personal as well as managerial levels. Recommendations
for further research, nurse education and practice were formulated. Recommendations for practice
include ‘on-the-spot’ in-service training, appropriate task allocation, clearly defined scope of practice,
time for rest and debriefing, strengthened relationships with management, promotion of strengths and
creating a support system. Page 1 of 9 Die emosionele welstand van verpleegkundiges werksaam in ‘n
multivaardigheidsopset kan moontlik negatief beïnvloed word deur die uitdagende werksomgewing. ‘n
Kwalitatiewe, verkennende, beskrywende en kontekstuele studie is uitgevoer om hierdie verskynsel te
ondersoek. Die doel van hierdie studie was om die ervaring van verpleegkundiges, asook hul persepsies
van hanteringsmeganismes, in ‘n multi-vaardigheidsopset te verken en beskryf, sowel as om
aanbevelings vir die bevordering van hulle emosionele welstand te formuleer. Die populasie het bestaan
uit verpleegkundiges werksaam in ‘n multivaardigheidsopset (‘n Vlak-2 hospitaal) en het professionele
verpleegkundiges, ingeskrewe verpleegkundiges en verpleegassistente ingesluit. ‘n Alles-insluitende
steekproef is gebruik. Semi-gestruktureerde onderhoude is met drie professionele verpleegkundiges, ses
ingeskrewe verpleegkundiges en een verpleegassistent gevoer. Hierdie onderhoude is volgens die
metode deur Creswell (2003:192) beskryf, geanaliseer. Die bevindinge het getoon dat verpleegkundiges
positiewe sowel as negatiewe ervaringe van die multivaardigheidsopset het. Hulle gebruik
taakprioritisering, geloof, selfmotivering en wedersydse ondersteuning as hanteringsmeganismes. Hulle
het ook voorstelle gemaak vir die bevordering van hul emosionele welstand, op persoonlike sowel as
bestuursvlak. Aanbevelings vir verdere navorsing, verpleegonderwys en die praktyk is geformuleer.
Aanbevelings vir die praktyk sluit in ‘in-die-oomblik’ indiensopleiding, toepaslike taaktoewysing,
duidelikheid oor bestek van praktyk, tyd vir rus en ontlading, verbeterde verhoudings met bestuur,
bevordering van sterk karaktereienskappe en die skep van ‘n ondersteuningsnetwerk. Original Research
http://www.hsag.co.za doi:10.4102/hsag.v16i1.553 One of the consequences of these challenges is that
nurses working in health care services have to perform multi-skill tasks on a daily basis (Triolo, Kazzaz &
Wood 2005:45). In other words, they have to perform tasks for which they did not receive formal
training and which are outside their scope of practice (Adamovich et al. 1996:206). Although this
approach is widely implemented, concerns exist that its application is motivated by economical
considerations rather than patient care, which could lead to lower quality care (Canadian Association of
Social Workers 1998). These factors may not only introduce medico-legal risks (Pera & Van Tonder
2004:172; Searle 2007:111; Verschoor et al. 1996:53), but also lead to nurses experiencing stress and
burnout. This, in turn, can have a negative impact on their emotional wellbeing (Aucamp 2003:3;
Csikszentmihalyi & Csikszentmihalyi 2006:96; Kozier et al. 2000:167; Smeltzer & Bare 2004:101; Van
Vuren 2006:127). Research in this area seems to focus on nurses’ well-being and satisfaction with their
work environment (Bégat, Ellefsen & Severinsson 2005:221; Bégat & Severinsson 2006:610). Boswell
(2004:57) also focused on nurses’ well-being, concluding that one of the most important considerations
for nurses to leave the profession is difficult work circumstances, coupled with a feeling of
worthlessness resulting from a lack of support by management. Another example of research in this
area is a study conducted by Ablett and Jones (2007) on the resilience and well-being of hospice nurses
rendering palliative care. In the South African context, Jooste (2003), for example, explored nursing
staff’s lack of involvement in and motivation for the delivery of quality health care, as well as the role of
nurse managers in addressing nurses’ motivational needs in the work situation. Yet very limited
evidence exist regarding the emotional wellbeing of the nurse in the multi-skill setting. The researcher’s
own experience as a professional nurse working in a multiskill setting confirmed the emotionally
demanding nature of this work environment. Owing to a high workload and shortage of medical and
nursing staff, nurses at this specific setting are expected to attend simultaneously to trauma patients,
patients in labour and pre-operative and postoperative medical patients, and to implement skills that
are not necessarily within their scope of practice. Problem statement In view of the aforementioned
discussion and the researcher’s experience, the study sought to investigate (1) what the nurse’s
experience of working in a multi-skill setting is, (2) what the perception about coping mechanisms within
a multi-skill setting is, and (3) what can be done to promote the emotional well-being of nurses working
in a multi-skill setting. Objectives The study thus aimed to (1) explore and describe the experience of the
nurse working in a multi-skill setting, (2) explore and describe the nurse’s perception about coping
mechanisms within a multi-skill setting, and (3) formulate recommendations to promote the emotional
well-being of the nurse working in a multi-skill setting. Definitions of key concepts Level-2 hospital The
facility is defined as a district or regional hospital with maternity and specialist services (De Kock & Van
der Walt 2004:2; Uys & Middleton 2004:63). The Level-2 hospital where this research took place consists
of a trauma unit, a theatre for uncomplicated surgical procedures, a maternity section, and a 40-bed
unit for patients in need of medical as well as pre-operative and post-operative care. The hospital is
served by visiting medical specialists and a psychologist, mostly on an outpatient basis and catering for
private patients (patients with a medical aid). Doctors visit the hospital only for rounds and are available
afterwards only via a callout system. Nurses, including professional and enrolled nurses and nurse
assistants, are available 24 hours a day and are responsible for the care of private and public health care
patients in all the mentioned sections. Only two professional nurses are allocated per shift and are
responsible for taking the lead in patient care. Together with a small team of enrolled nurses and nurse
assistants, they are responsible for the nursing care in the trauma unit and maternity ward, as well as for
the routine care of the medical and pre-operative and post-operative patients. These nurses are
consequently compelled to apply multiple skills in emergency situations, for example intubating patients
and attending to widely varying and complex health needs of patients. Professional nurse A person who
is trained, competent and accountable for practicing nursing in an independent and comprehensive
manner (South Africa 2005). In this study, such professional nurses implemented multitasking in a Level-
2 hospital where both private and public health services are rendered. Enrolled nurse A person who is
trained, competent and accountable for rendering basic nursing care (South Africa 2005). In this study,
such nurses were defined as enrolled nurses who implemented multitasking in a Level-2 hospital where
both private and public health services are rendered. Nurse assistant A person who is trained,
competent and accountable for rendering elementary nursing care (South Africa 2005). In this study,
nurse assistants implemented multitasking in a Level-2 hospital where both private and public health
services are rendered. Multi-skill An approach to care according to which nurses are expected to
perform tasks outside of their scope of practice and for which they were not originally trained
(Adamovich et al. 1996:206). This concept also refers to the combination of two Page 2 of 9 Original
Research http://www.hsag.co.za doi:10.4102/hsag.v16i1.553 or more roles or skills within a multi-skill
role (Cameron 1997:1). In this study, multiple skills were expected from nurses in a Level-2 hospital
where both private and public health services are rendered. Emotional well-being The ability to
acknowledge, accept and express one’s own emotions appropriately and accept personal limitations
(Kozier et al. 2000:167), coupled with the ability to function comfortably and productively (Smeltzer &
Bare 2004:101). This study focused on the emotional well-being of the nurse working in a multi-skill
setting. Research method and design Research approach This study was performed according to an
explorative, descriptive and contextual design with a qualitative approach. This design was deemed
appropriate, as it is applied when exploring and describing qualitative, subjective material in an attempt
to understand human experiences (Burns & Grove 2005:27; Polit & Beck 2006:16), in this case those of
nurses working in a multi-skill setting and their perceptions of coping mechanisms within this setting.
This information was used to formulate recommendations to promote the emotional well-being of these
nurses. Research method Population The population consisted of all the nurses (professional nurses,
enrolled nurses and nurse assistants) working in a multi-skill setting at a specific Level-2 hospital. Sample
Because the entire study population worked in a multi-skill setting, the sample was all inclusive. Data
collection Individual semi-structured interviews, as discussed by Brink, Van der Walt and Van Rensburg
(2006:52), were used to collect data. This data collection method allows the researcher to explore the
experiences and perceptions of participants by asking questions relating to the research problem and
objectives, whilst being allowed to ask prompting and follow-up questions. Based on the research
objectives, the following interview questions were used: • What is your experience of the multi-skill
setting? • What is your opinion on effective coping mechanisms within a multi-skill setting? • In your
opinion, what can be done to enhance the emotional well-being of the nurse within a multi-skill setting?
The researcher approached potential participants personally to explain the purpose of the research and
expectations regarding participation. This explanation was also provided in writing and adequate time
was allowed for answering the potential participants’ questions about the research. After informed
consent was obtained, interviews were scheduled for a convenient time and place for each participant.
Some interviews were conducted in an office at the hospital, whilst others took place at the participants’
homes. Interviews were audio-recorded and transcribed. Field notes were compiled after each
interview. A rich set of saturated data was obtained during interviews with: • three professional nurses
• six enrolled nurses • one nurse assistant. All participants were female and the sample included Black
and White participants. The participants are collectively referred to as ‘nurses’ in the discussion of the
results. Data analysis Results, in the form of transcribed interviews, were analysed using the method
described by Creswell (2003:192). All the transcribed interviews were reviewed to form a general
impression of the responses. Themes were identified according to the research objectives and grouped
into columns. During a subsequent round of revision, notes were made pertaining to the identified
themes. Each theme was given a descriptive heading and divided into categories, with similar categories
being grouped together. An independent co-coder was appointed to co-analyse the data. After
discussion with the co-coder the results were divided into appropriate main and subcategories.
Literature control A literature control was conducted after data analysis, with the aim of confirming the
results, pointing out unique results and reflecting current knowledge about the research topic (Burns &
Grove 2005:95). Databases used to search for relevant literature included Nexus (National Research
Foundation), SAePublications, ScienceDirect and EBSCOhost (Academic Search Premier, CINAHL,
PsychInfo). Ethical considerations Ethical permission for the research was obtained from the Ethics
committee of the North-West University (reference number 07K08). Permission to conduct the research
at the identified Level-2 hospital was subsequently obtained from the hospital manager. The potential
participants were then approached and the purpose and nature of the research, and potential benefits
and risks (e.g. the potential for emotional upset) were explained to them. Ethical principles as discussed
by Brink et al. (2006:31–34) were implemented. The principle of respect for participants was
implemented by obtaining informed consent, providing information on the study and offering
participants the choice to withdraw. The principle of beneficence was upheld by explaining the risk–
benefit ratio to the participants, namely that they may not experience immediate benefits from
participating and that a counsellor would be available after the interview for the purpose of debriefing,
if needed. The Page 3 of 9 Original Research http://www.hsag.co.za doi:10.4102/hsag.v16i1.553
principle of justice was adhered to through ensuring fair selection and treatment and the right to
privacy, anonymity and confidentiality. Trustworthiness The framework for trustworthiness as described
by Babbie and Mouton (2004:276) and also Hek and Moule (2006:78) was applied in this research. The
framework entails four main criteria for trustworthiness, namely truthfulness, applicability, consistency
and neutrality. Truthfulness was ensured through: • the researcher’s experience of working in a Level-2
hospital • audio-recording interviews to ensure that the researcher did not forget or misinterpret the
participants’ words • writing field notes directly after each interview to ensure that no significant
observations would be forgotten • reporting the participants’ own words to indicate the range and
variety of responses representing each topic • continuing with data collection until data saturation was
obtained • analysing and discussing responses with a co-coder to ensure that the participants’ true
opinions were identified (triangulation) • consulting the two study supervisors to review the process and
the findings • comparing the findings with published studies and other literature (triangulation).
Applicability was achieved through rich description, whereby the research process, the characteristics of
the participants and the context are supplied to allow readers to determine to which extent the
circumstances are similar to their own context. Consistency was ensured by initial independent analysis
by the researcher and co-coder, after which findings were compared during a consensus meeting.
Neutrality was ensured by the researcher’s keeping the original interview schedule and the audio
recordings, the transcripts, notes and memos to provide an audit trail. Results and discussion Four main
response categories emerged, which were subsequently divided into subcategories. Participants’
experiences were similar, irrespective of their position (professional nurse, enrolled nurse or nurse
assistant) and are therefore presented as a whole. As shown in Table 1, the following main categories
were identified: • positive experience of the multi-skill setting • negative experience of the multi-skill
setting • personal coping mechanisms within the multi-skill setting • promotion of emotional well-being
within the multi-skill setting. In the subsequent discussion of these response categories, statements by
the participants are included in support of the results and findings are discussed in relation to existing
literature to facilitate critical reflection. Positive experience of the multi-skill setting Several reasons
emerged for nurses’ positive experience of the multi-skill setting. An opportunity to gain experience
Nurses experience the multi-skill setting as a learning environment as they work in different units and
new patients are attended to in the trauma unit daily. Nurses learn to function independently and to
rely on their own decisionmaking skills. A participant stated: ’With different people and different
patients … from casualty and the whole ward, you learn a lot.’ The finding is in line with that of
Adamovich et al. (1996:206), who state that the multi-skill setting provides an opportunity for learning
additional clinical skills, professional development, broadening one’s scope of practice and improving
efficiency through coordinating clinical services. An opportunity to prepare for possible further studies
Nurses find opportunities to sharpen clinical skills in the multi-skill setting, which can be helpful when
doing a bridging course to improve their position. Participants stated: ’Even if I can go to be a staff
nurse, I won’t have a problem. I don’t think I will struggle … it’s nice for me to learn rather just to do the
vital observations.’ ’Normally they teach us, they say that we must know. I think also maybe if you want
to study further, like if you want to be a staff nurse or maybe [a] sister …’ This result appears to be
specific to this study, as the researcher could not find any related existing literature confirming or
contrasting the finding. Page 4 of 9 TABLE 1: Experiences, coping mechanisms and strategies to promote
well-being of nurses working in the multi-skill setting. Positive experience of the multi-skill setting
Negative experience of the multi-skill setting Personal coping mechanisms within the multi-skill setting
The promotion of the emotional well-being of nurses in the multi-skill setting • An opportunity to gain
experience • An opportunity for possible further studies • An opportunity for task sharing •
Misrepresentation of the term ‘multi-skill setting’ • Stress brought on by staff shortages • Subjective
consequences of task overload • Unreasonable task allocation • Duties beyond scope of practice •
Insufficient resting time • Negative perceptions towards management • Task prioritisation • Faith • Self-
motivation • Mutual support amongst colleagues • Personal promotion of emotional well-being: ◦ in-
service training ◦ support system • Managerial involvement to promote emotional well-being: ◦
appointment of additional staff ◦ appropriate staff allocation ◦ managerial involvement Original
Research http://www.hsag.co.za doi:10.4102/hsag.v16i1.553 An opportunity for task sharing The multi-
skill setting creates the opportunity for nurses to learn skills and gain confidence when assisting senior
nursing staff to share the workload, when required. A participant stated: ‘And, sometimes, if it’s very
busy you can help the sister; you can put up the new admission’s drip or maybe put up the catheter …’
Although Mathijs (2008:35) confirms that this phenomenon, known as task shifting, is widely practiced
and respondents in this study experienced it as a positive aspect of working in a multi-skill setting, they
also shared that such situations are a source of stress (see Table 1). Negative experience of the multi-
skill setting In spite of the positive experience, nurses also experience the multi-skill setting as stressful.
The high workload, high level of responsibility and staff shortages lead to the experience of the multi-
skill setting as unpleasant and, sometimes, even intolerable. Misrepresentation of the term ‘multi-skills
setting’ Nurses were of the opinion that the term ‘multi-skill setting’ is justified in its use only when all
the nurses working in this setting possess the necessary clinical skills, as reflected by the following
statements: ‘You can’t place someone who is supposed to work in casualty if you do not have the skills
to work there. Most of the time you do not have an idea of what is going on. So, it does not help that
you have people who are so-called “multi-skilled”.’ ’They say it’s a multi-skill hospital; it is because we
are working everywhere … Casualty, ward, everywhere we work. Theatre, even though we are not
supposed to work there, we must work in theatre as well.’ Literature supports the notion that ‘multi-
skill’ and ‘multiskilling’ are ambiguous terms, which are applied and interpreted in various ways
(Adamovich et al. 1996:206; Cameron 1997:1). There is little consensus about the responsibilities of
multi-skill staff, the skills and competencies that these staff should have or how to apply a multi-skills
approach appropriately. This is also true in the South African context, which confirms the need for
research such as this study. Stress brought on by staff shortages Nurses experience staff shortages as
stressful. It appears that the imbalanced representation of the different categories of nurses, namely the
shortage of professional nurses relative to the number of enrolled and assistant nurses, is a very specific
area of concern, as evident from the following statements: ‘[There is] a shortage of staff.’ ’There’s a
shortage of sisters.’ ‘I think there is a shortage of staff and not everyone has the same skills.’ Bégat et al.
(2005:222) confirm that the nursing staff shortage impedes the nurse’s ability to render quality patient
care, which Aucamp (2003:20) confirms is perceived as a source of stress. Richards (2003:1) also
mentions that the nature of work circumstances is one of the main causes of work dissatisfaction
amongst nurses. Subjective consequences of task overload Nurses experience several subjective
consequences of task overload, namely increased levels of stress, physical and emotional exhaustion,
loss of concentration, work dissatisfaction and interpersonal conflict, all of which may have a negative
influence on emotional well-being. The following statements support this finding: ‘It’s strenuous and
difficult.’ ’You become tired; sometimes you get overloaded …’ ‘You loose concentration [in] your work.’
’Sometimes you forget what you were doing.’ ‘Sometimes you don’t finish your work.’ ‘You feel stressed
and you feel guilty.’ ’It’s difficult, because you are one nurse and there are many things to do at one
time.’ ’You feel stressed and tired and sometimes you get confused.’ Aucamp (2003:21) confirms that
workload is a determining factor in emotional exhaustion. Bégat et al. (2005:228) further mention that
the less time a nurse has to complete tasks, the more physical symptoms of stress are evident or
experienced. Demir, Ulusoy and Ulusoy (2003:823) also found that work overload leads to burnout and
work dissatisfaction. Unreasonable staff allocation Nurses find the allocation of staff in the multi-skill
setting as unreasonable and confusing. They are rotated between wards in an unorganised manner and
have to be prepared to work in different specialties owing to the unpredictable nature of patient
presentation at a hospital. Participants shared the following: ’We are working stressfully … [in] the
wards and casualty at the same time.’ ‘I know they say this is a multi-skill hospital. Actually, I think it’s
because you work all over, casualty and the ward. And we have to work in [the] children’s ward. We
have a paediatrics ward as well. I just see everything [as] disorganised here.’ ‘Maybe the ward is full and
we are maybe three assistant nurses. We have to go up and down: casualty, private ward, children’s
ward.’ This seems to be a unique finding of this research. Duties beyond scope of practice Nurses
experience stress and fear when they are forced to practice outside their scope of practice. Sustained
exposure to this stressful situation leads to burnout with a consequent negative effect on emotional
well-being. Participants made the following statements: ’We don’t have enough staff and some of the
things we [just] cannot do. Our scope doesn’t allow us to do that.’ ’We always work outside of our
scopes, every day.’ ’I’m not even trained to do the SSD [central sterilisation department], but I’m doing
those things.’ Page 5 of 9 Original Research http://www.hsag.co.za doi:10.4102/hsag.v16i1.553 ’It seems
as if it’s not my scope of practice, it makes me stressed … because I’m putting myself in danger. What if
they [the Nursing Council] find me doing those things and I’m not supposed to do those things?’ Stewart
and Arklie (1994:183) also found that nurses whose roles are not clearly defined and who perform tasks
beyond their scope experience increased levels of burnout. Insufficient resting time Some nurses were
of the opinion that there are not enough opportunities to rest during the work day, as reflected by the
following statements: ’You have to go on tea. Sometimes, because there’s a shortage [of staff], you can’t
even go on tea.’ ’You can’t even go to lunch sometimes. You [have] not [gone] since the morning.’ This
seems to be a unique finding of this research. Negative perception towards management Nurses
indicated a negative perception towards the mangement of the hospital owing to management not
attending to the nurses’ emotional needs. The following statements illustrate this finding: ’… but the
management is not right … they don’t care about the employee’s feelings.’ ’They don’t care about our
opinions.’ ’It breaks your self-esteem … you don’t feel motivated.’ ’You satisfy their needs. They don’t
care.’ Boswell (2004:56) and Mynhardt (2006:547) both found that health care workers’ perception
about management has an important effect on their level of motivation in the workplace. The more
nurses perceive that they are being treated fairly, the more they are engaged with their work and
motivated to perform additional tasks. Personal coping mechanisms within the multi-skill setting Task
prioritisation Nurses were of the opinion that prioritising is an important coping mechanism in the multi-
skill setting. Nurses felt in control when they could complete more important tasks before performing
less important ones. This decreases stress and creates an effective work environment. It also contributes
to work satisfaction and emotional well-being. The following statements support this finding: ’I try to
divide my time …’ ’I prioritise.’ ’I complete one task at a time, and you do what you can. I finish the most
important things first and then I can start with the next thing. You then feel in control of things.’
Literature confirms that the degree to which nurses have time to plan ahead has a definite influence on
their general well-being (Bégat et al. 2005:227). Faith Nurses rely on their faith in God as a coping
mechanism in the multi-skill setting. The following statements support this finding: ’ I just pray: “God,
help me”.’ ’Just maybe, that you can pray and just believe every day. Because if you trust God, He will
help you to cope.’ This seems to be a unique finding of this research, as literature to support this finding
could not be found. Self-motivation Nurses often use self-motivation as a coping mechanism in a multi-
skill setting, as illustrated by the following statements: ’I tell myself that the work must be done, I have
to keep going.’ ’I just tell myself that this thing doesn’t have to bother me. And I don’t get stressed. It
doesn’t help to become stressed. It only makes things worse.’ Coon (1998:407) describes self-motivation
as continued positive thinking and behaviour and the ability to persevere in spite of negative
circumstances. Bégat et al. (2005:227) confirm that nurses use self-motivation to cope with difficult
work circumstances. Mutual support amongst colleagues Nurses experience mutual support amongst
colleagues as very important within the multi-skill setting. It serves as a coping mechanism and is a
motivational factor in this stressful work environment. The following statements support this finding:
’Sometimes we help each other.’ ‘You learn how to co-operate with people. Colleagues … are not [all]
the same.’ ’You help each other.’ ’You know what? Actually, we are working as a team, but sometimes
it’s difficult to work with some other people because … instead of working like maybe I want [to work] –
we have to work together – they just remain behind and then they push you to do the things [to
complete the tasks].’ Trust and mutual support amongst colleagues are described by both Boswell
(2004:57) and Van Rhyn and Gontsana (2004:26) as important contributory factors to work satisfaction.
Aucamp (2003:4) also states that nursing colleagues can be important resources amongst one another
to aid in the management of stress in the workplace. Similarly, Levert, Lucas and Ortlepp (2000:37)
report that limited support amongst colleagues is an integral cause of burnout. The promotion of the
emotional well-being of nurses within the multi-skill setting The promotion of emotional well-being on a
personal level, as well as at management level emerged from the research. Personal promotion of
emotional well-being Nurses mentioned several strategies that can be applied at a personal level to
promote emotional well-being. These further categories include the following: Page 6 of 9 Original
Research http://www.hsag.co.za doi:10.4102/hsag.v16i1.553 In-service training: Nurses suggested in-
service training as a strategy for the promotion of emotional well-being. The following statements
illustrate this finding: ’Maybe training … can also help.’ ’I think if maybe you gain more knowledge.
[Through] training people gain more knowledge and it will help them in a ward maybe to do their work
properly. And quality work … You can improve them – and then they will also feel more self-confident in
their work.’ ’It will decrease stress.’ Muller (2005:141) confirms that nurses should receive the necessary
training to ensure competent performance. Support system: A support system, in the form of training
about topics related to emotional well-being, was suggested. This could provide nurses with practical
advice to cope with stress. Participants also suggested that establishing a ‘haven’ could be valuable in
the promotion of their emotional wellbeing. They explained this ‘haven’ as a place where nurses can go
to talk about stressful experiences and obtain perspective in order to once again function effectively in
the workplace. The following statements reflect their views: ’… might sometimes need counselling as
others, other things in hospitals are [traumatic].’ ’Maybe even to give nurses education on mood swings.
Sometimes, others … can be rude if they like …’ ’Sometimes when you feel, when you feel that work is
too much, [that] there’s too much work and you get too busy, then you become frustrated and you
become rude.’ Hall (2004:34) also suggests that employers should support employees by presenting
programmes on the management of stress, as well as creating opportunities for counselling. These
services should be avaialable free of charge for nurses of all categories (Hall 2004:34). In addition, the
former Minister of Health, Dr Manto Tshabalala-Msimang, promoted the notion of ‘wellness centres’ for
health care workers to promote their well-being (Khumalo 2008:9) Managerial involvement to promote
emotional well-being Nurses suggested several practical strategies whereby management can improve
the work environment, consequently contributing to the emotional well-being of nurses. Appointment
of additional staff: Nurses felt that the appointment of additional permanent staff is essential to ensure
that there are enough human resources available on a daily basis, as reflected by these statements:
‘Firstly, they can try to have more staff.’ ’I think they can employ more nurses.’ ’First thing they [the
management] must do [is to] employ people and stop using agencies.’ ’They should at least appoint
people permanently.’ ’Sometimes there are too few staff …’ ’There’s a lot of people on the roster but
they don’t want to call people to come on duty. And they don’t want to give people employment … they
only use agencies.’ Literature confirms that inadequate staff numbers not only hold risks for patient
safety, but can also have a negative impact on the well-being of the nurse (American Nurses Association
2007). Appropriate staff allocation: Nurses explained that they found it stressful to have to work in
various wards or sections and then be held accountable for the care of all the patients. Statements to
support these views are as follows: ’I think there should be specific people that are always there for
casualties … and a doctor also in casualties. I think there should be a permanent [attending] doctor for
casualties …’ ’… maybe [if] there are nurses for theatre, nurses for casualties and nurses for the ward.’
This seems to be a finding specific to this study. Managerial involvement: Nurses perceived management
not to be adequately involved with staff on a personal level, as illustrated by the following statements:
’Maybe from the hospital management, if they can maybe try to understand the staff …’ ’When they
voice [complaints], they must help them. Not to just leave them like that …’ ’We need support from our
hospital manager, the matron, the ward manager, unit manager. I think if they can [set up] meetings
with nurses and … communicate with the nurses more, it can be better.’ ’They just sit in their office and
they wait for people to come and say who did what.’ ’They must treat nurses equally.’ ’… they must ask
for opinions from nurses.’ Boswell (2004:59) confirms that, in general, there is a lack of trust between
nurses and management, because of nurses’ perception that their well-being does not receive enough
attention. Limitations of the study The sample consisted only of female nurses, whilst the opinion of
male nurses may have contributed to the results of the study. In addition, some nurses were reluctant to
participate in interviews after work hours, leading to fewer participants being available.
Recommendations Recommendations for further research, nursing education and nursing practice were
formulated. Recommendations for nursing practice focus on the promotion of the emotional well-being
of the nurse within a multi-skills setting. Recommendations for further research Further research on the
following research topics related to the emotional well-being of the nurse in the multi-skill setting is
recommended: • specialised training • management style • support networks Page 7 of 9 Original
Research http://www.hsag.co.za doi:10.4102/hsag.v16i1.553 • task allocation and productivity • patient
experience of the quality of health care in the multi-skill setting • scope of practice • economic
implications of the multi-skill setting • personal circumstances of nurses working in a multi-skill setting •
relationships between concepts portrayed in Figure 1 (also see later for a discussion). Recommendations
for nurse education Participants suggested in-service training on specific topics as a strategy to promote
their emotional well-being. In addition, it may be valuable to include the recommendations for
promoting the emotional well-being of nurses in formal as well as informal training (see
’Recommendations for nursing practice’). Recommendations for nursing practice These
recommendations describe how emotional wellbeing of nurses working in the multi-skill setting can be
promoted. Firstly, adequate in-service and formal training opportunities should be provided. This should
include appointment of training staff, encouragement of ‘onthe-spot’ training and provision of financial
support for further training. Furthermore, tasks should be allocated according to nurses’ individual
training and capabilities. The scope of practice of each nursing category should be available in writing
and should be monitored. Nurses should be allowed time to rest during shifts and a suitable area for
debriefing should be available. Improvement of relationships between management and nurses should
be a priority. Also, the strengths nurses display, for example their coping mechanisms as emerged from
this research, should be acknowledged and promoted. Lastly, a functional support system for nurses
should be established. Application of these recommendations may contribute to creating a positive
work environment that is less stressful and more conducive to promoting the emotional well-being of
the nurse. This, is turn, may lead to nursing staff being more motivated towards and engaged in their
work and so contribute to quality nursing care. Conclusion The purpose of this study was to explore and
describe the experiences of nurses working in the multi-skill setting Page 8 of 9 Internal conflict Multi-
skill setting Negative experience • No consensus about the concept ‘multiskill’ • Staff shortage leads to
frustration and work dissatisfaction • Task overload leads to burnout • Unpredictable and unorganised
work environment • Role stress • Exhaustion • No motivation from management Promotion of
emotional well-being • Formal and in-service training opportunities • Allocation of tasks according to
training and competencies • Scope of practice • Adequate resting time and establishment of a ‘haven’ •
Improved relationships between management and nurses • Functional support network Positive
experience • Stimulating personal growth • Stimulating personal motivation • Stimulating personal
confidence Coping mechanisms • Prioritising • Faith • Self-motivation • Mutual support FIGURE 1:
Components of the emotional well-being of the nurse in the multi-skill setting. Original Research
http://www.hsag.co.za doi:10.4102/hsag.v16i1.553 and their perception about coping mechanisms
within this setting. Findings provided insight into the unique experiences and perceptions of these
nurses, which allowed recommendations for promoting their emotional well-being to be formulated.
The results showed that nurses have contrasting experiences of the multi-skill setting and conclusions
from the study are presented schematically in Figure 1. On the one hand they experience it as a
stimulating setting that offers learning opportunities, but, on the other hand, they also experience it as
an unorganised setting associated with high demands such as responsibility for all wards in the hospital
in a high-paced environment, where they are compelled to perform tasks beyond their formal
capabilities. This leads to fear and internal conflict, which have a negative influence on nurses’
emotional well-being. Nurses furthermore experience a lack of support and engagement from
management, leading to demotivation. Nurses use personal coping mechanisms such as task
prioritisation, faith, colleague support and self-motivation to cope in the multi-skill setting.
Factors characterizing supportive nursing care units for

registered nurses
Hall, Debra Sue.University of Kentucky, ProQuest Dissertations Publishing, 2004. 3133591.
https://search.proquest.com/central/docview/305173268/abstract/8310CF48AE0445B2PQ/12?accou
ntid=35994
March 25, 2019
The purpose of this two phase comparative study was to explore the relationships between nursing
unit environment (shared governance, traditional governance, specialized inpatient care unit) with
measures of Registered Nurse (RN) occupational stress and occupation-related outcomes in a
hospital with a reputation for excellent nursing care. Survey data from 69 staff nurses in one of the
three different patient care areas were analyzed using parametric and nonparametric univariate,
bivariate and multivariate analyses as appropriate. A sample of nurses working in each of the units
also were interviewed about common work stressors encountered, coping mechanisms used to deal
with work stress, decision-making, and sources of work support. No significant differences were
found among the three types of nursing unit governance structure on occupational stress,
methods of coping with occupational stress, job control, and self-efficacy. Significant differences
were found related to amount of supervisor support, co-worker support, unit efficacy, turnover,
absenteeism, and job satisfaction. Nurses working in the shared governance and specialty units had
more job satisfaction, perceived co-worker support and unit efficacy than RNs working in the
traditional governance unit. Specialty unit structure was associated with less turnover and shared
governance and specialty unit structure were associated with less absenteeism related to illness.
Supervisor support was associated with more positive occupation-related outcomes than unit
governance structure. Gender and education were associated with perception of work stress.
Fatigue and Work Environment
Finally, workload, stress and other environmental factors that may influence levels of fatigue likely vary
across healthcare work environments. Several of the existing studies investigating the relationships
between work hours, workload, fatigue and performance in nursing have focused on critical care
environments (Carayon et al., 2005; Scott et al., 2006). Yet, fatigue may be present and impacting
performance and ultimately nurse and patient safety across a range of healthcare environments. It is
thus important to quantify dimensions and states of fatigue across a range of diverse nursing work
environments. (Barker, L.,2009)
In summary, nurses are frequently required to complete long working hours and a combination of both
physically and mentally demanding tasks, which may lead to increased levels of multiple dimensions
(mental and physical) of fatigue as well as acute and chronic fatigue states. However, these demands,
and the resulting levels of fatigue, may vary across healthcare work environments and may have
implications for both patient and nurse safety. Further research is needed to better quantify the levels
of fatigue present in diverse nursing work environments. The relationship between fatigue and
performance within nursing should also be further considered. To that end, the goals of this study were
to quantify the perceived dimensions and states of fatigue present in registered nurses; investigate the
relationships between perceived fatigue and perceived performance; and identify differences in
perceived fatigue levels and dimensions across demographic and work environment variables in
registered nurses(Barker, L.,2009)
INTRODUCTION The term fatigue has been used consistently in the literature to describe a state of
tiredness that is clinically significant and pathological in nature [1]. It is usually defined as a condition of
feeling very tired, weary or sleepy resulting from insufficient sleep, prolonged mental or physical work,
extended periods of stress or anxiety. However, a new whole definition of fatigue has been proposed by
Phillips recently [2], “Fatigue is a suboptimal psychophysiological condition caused by exertion. The
degree and dimensional nature of the condition depends on the form, dynamics and context of exertion.
The context of exertion is described by the value and meaning of performance to an individual; rest and
sleep history; circadian effects; psychosocial factors spanning work and home life; individual traits; diet;
health, fitness and other individual states; and environmental conditions. The fatigue results in changes
in strategies or resource use such as original levels of mental processing or physical activity that are
maintained or reduced.” Fatigue is probably the most common symptom of illness affecting sufferers of
both acute and chronic conditions [3]. It results from the interaction between mental and physical
factors, which are very difficult to evaluate separately [4], and it is usually associated with boring or
repetitive work-related tasks. At the broadest level, occupational fatigue has been linked to an
imbalance between the intensity and duration and timing of work with recovery time [5]. Indeed, acute
fatigue may occur when there is inadequate time to rest and recover from a work period. It tends to
disappear after taking some rest [6]. On the other hand, cumulative (chronic) fatigue occurs when there
is insufficient recovery from acute fatigue over time [7]. Fatigued workers may find themselves working
closer to their maximal capabilities, putting themselves at greater risk for the development of not only
musculoskeletal injuries, but also psychosocial disorders [8]. Several studies have identified that fatigue
is a contributing factor for accidents, injuries and death in a wide range of settings, because people with
fatigue symptoms are less likely to produce safe performance and actions [9,10]. Consequently, in order
to avoid chronic fatigue, it is important to develop effective strategies or measures to prevent [11] and
detect acute fatigue and to recover from it [12,13]. In general, fatigue is not well understood and it is
typically measured as a multidimensional phenomenon with subjective and performance based
indicators. The objective measures of fatigue are largely related to its physiological parameters, while
subjective indicators report self-perceived feelings [14]. Within occupational settings, the need to
minimize assessment time and to maximize compliance by ensuring that measures are simple, easy and
valid for the work, influences the selection of measures that are used and the measurement regime [15].
Assessing perceived fatigue (measured through the use of self-report measures) seems to be adequate
to measure fatigue. There are several instruments developed to assess fatigue for clinical use, and a few
– for occupational context. The Swedish Occupational Fatigue Inventory (SOFI), is an example of a self-
report instrument developed for occupational assessment of fatigue, which has been used in both
contexts over the last fifteen years [16–24]. Considering that there is no Portuguese version of the SOFI,
the aim of this study is to present the translation and cultural adaptation process of the SOFI into
Portuguese and to examine the psychometric properties of the Portuguese version among assembly
workers.
PORTUGUESE VERSION OF THE SWEDISH

OCCUPATIONAL FATIGUE INVENTORY (SOFI)
AMONG ASSEMBLY WORKERS: CULTURAL
ADAPTATION, RELIABILITY AND VALIDITY
Santos, Joana; Carvalhais, Carlos; Ramos, Catarina; Coelho, Tiago; Monteiro, Pedro Ribeiro Rocha;
et al.International Journal of Occupational Medicine and Environmental Health;
Heidelberg Vol. 30, Iss. 3, (2017): 407-417.DOI:10.13075/ijomeh.1896.00760
https://search.proquest.com/central/docview/1907272696/fulltext/4843AE8B930A41E4PQ/2?accounti
d=35994
March 25, 2019
workers.
Level of Fatigue and Nursing Care
High rates of medical errors are well documented within the healthcare industry. Nurses,
in particular, play a critical role in the quality and safety of healthcare services. Fatigue is a
factor that has been linked to stress, safety, and performance decrements in numerous work
environments. Within healthcare, however, a comprehensive definition of fatigue encompassing
multiple dimensions has not been considered, but is warranted since nurses perform tasks
consisting of diverse physical and mental activities (Barker, 2009).
The daily demands of critical care nursing, including psychosocial stressors and heavy
patient workloads in the ICU, make the nurse particularly vulnerable to fatigue, and subsequently
accidents and errors (Ruggiero, 2002).
The ongoing empathic connection of caring for others, especially those with significant trauma
or stress, has consequences that can manifest as psychological distress and an inability to
empathically connect. Compassion fatigue may encompass, but go beyond, burnout where nurses
may be less empathetic with patients and more irritable with coworkers.6 Rather, CF is a state of
destructive emotional distress in which one feels isolated, confused and helpless in caring for
others9 or what has been labeled a state of exhaustion - physically, spiritually and
emotionally.2,4
The nurse may succumb to the overall stress from human suffering if they do not have an
adequate outlet to decompress or maintain a professional and emotional work/life balance.2 In
CF, nurses absorb the emotions of traumatic stress from patients, colleagues and families and
have little time to mourn and disconnect.9 Personal mediators of CF have been proposed to
include level of empathy, resilience and hope - all of which may lead to a positive sense of
accomplishment from caring and act as a resistance against CF.7 Additionally, age (being older),
years of education and experience may provide some protection against CF. Management
support in the work environment, reasonable work hours and caseloads, and specialized trauma
training are management strategies that may build resilience and buffer against CF.10
Compassion fatigue has negative effects on the emotional and physical health of nurses and their
sense of job satisfaction. Moreover, CF impacts the healthcare organization as the nurse is more
pessimistic about the ability for positive change. Consequently, productivity and quality go
down, decrease absenteeism increases, intention to leave one's job rises and turnover
increases.11-13 Compassion fatigue can take away a major attribute of effective nursing -
empathy and caring - that is essential to building trust in the nurse-patient relationship.
Compassion fatigue leads nurses to withdraw or distance themselves from the patient and family
and focus on the technical aspects of the job, avoid the essential development of the nurse-patient
relationship and generally become more pessimistic about the ability for positive change.14
Fatigue is one particular factor, which has been linked to stress, safety, and performance decrements in
numerous work environments (Goode, 2003; Leung et al., 2006; Leung et al., 2004; Lorist et al., 2000;
Miller, 2005; Ochoa et al., 1998; Schellekens et al., 2000). Within nursing, fatigue has been found to be
related to nursing injuries and adverse health consequences (Geiger-Brown et al., 2004; Josten et al.,
2003; Lipscomb et al., 2004; Trinkoff et al., 1998; Yip, 2001), nursing satisfaction levels (Edell-Gustafsson
et al., 2002; Geiger-Brown et al., 2004; Josten et al., 2003; Taylor et al., 2004), and patient safety
(Carayon et al., 2005; Rogers, A. E. et 8 al., 2004b). Specifically, fatigue and work-related stress are
associated with an increased prevalence of low back pain and musculoskeletal disorders in the neck,
shoulders and knees in nurses from a number of countries around the world (Smith et al., 2003; Trinkoff
et al., 2002; Yip, 2001). With regard to patient safety and medical errors, fatigue is related to an
increased risk for error in nursing tasks due to slowed reaction times, lapses of attention to detail, errors
of omission, compromised problem-solving, reduced motivation, and decreased energy (Implications of
fatigue on patient and nurse safety, 2005; Rogers, A. E. et al., 2004b; Scott et al., 2006).
Fatigue is a complex construct, and which has not yet been clearly defined independent of context
(Ahsberg, 2000; Akerstedt et al., 2004; Friedberg et al., 1998; Hockey, 1983; Soh et al., 1996). A
summary of existing literature indicates that fatigue is a multicausal, multidimensional, nonspecific and
subjective phenomenon which results from prolonged activity and psychological, socioeconomic, and
environmental factors that affect both the mind and the body (Soh et al., 1996; Tiesinga et al., 1996).
Although occupational fatigue is frequently defined as a multidimensional construct (Ahsberg, 2000; De
Vries et al., 2003; Tiesinga et al., 1996), much of the existing research related to fatigue in nursing has
focused solely on sleep, emotional exhaustion, and burnout components and their implications for
performance and safety (AbuAlRub, 2004; Aiken et al., 2001; Chen et al., 2001; Gold et al., 1992;
Kandolin, 1993; Lindborg et al., 1993; Suzuki et al., 2005; Taylor et al., 2004). However, as nursing work
frequently consists of both physically and mentally demanding tasks, a broader definition of
occupational fatigue – one that includes physical and mental dimensions related to the broader
construct of total fatigue – is critical for understanding the consequences of fatigue in this population. In
addition, the general literature related to fatigue distinguishes between fatigue states, acute and
chronic. Many existing models or definitions of occupational fatigue do not differentiate between these
states, and assume that occupational fatigue is acute (Winwood et al., 2005). Nurses, though, are
frequently exposed to long working hours with little recovery time between shifts (Josten et al., 2003;
Rogers, A. E. et al., 2004b; Winwood et al., 2006b); thus, both chronic and acute fatigue states should be
considered. (Barker, L.,2009)
workers.
MATERIAL AND METHODS Sample A cross-sectional study was conducted at a multinational corporation
devoted to the production of mechanical cables for the automotive industry. The Portuguese version of
the SOFI was applied to 290 workers of the production section at the end of their shifts. Each of them
received an instruction sheet, a demographic form the SOFI as well as the consent form. Two hundred
and eighteen workers delivered the SOFI fulfilled (the response rate of 75.17%). The company works 24
h a day and working hours are distributed over three shifts (the morning shift: 6 a.m. to 2 p.m.;
afternoon shift: 2 p.m. to 10 p.m.; night shift: 10 p.m. to 6 a.m.). The dominant gender of the sample
was female (92.7%). The average age was 36.20±9.37 years old (18 years old – the youngest and 61
years old – the oldest). The shift distribution was 56.8% (the afternoon shift), 23% (the morning shift)
and 20.1% (the night shift). The company’s management board approved this study, and all participants
gave their written informed consent. Instrument The initial version of the SOFI consisted of 25
expressions which represented 5 dimensions/sub-scales: Lack of energy; Physical exertion; Physical
discomfort; Lack of motivation and Sleepiness [25]. Each dimension was defined by the content of 5
expressions related to physiological, cognitive, motor and emotional responses [26]. An 11-grade
response scale was used, where only the 2 extreme values had a verbal label, 0 “not at all” and 10 “to a
very high degree” [25]. However, after testing the validity of all the dimensions of the SOFI [25,27–30],
the final version maintained the 5 dimensions but with 20 expressions (4 items per dimension), namely:
Lack of energy (worn out, spent, drained, overworked), Physical exertion (palpitations, sweaty, out of
breath, breathing heavily), Physical discomfort (tense muscles, numbness, stiff joints, aching), Lack of
motivation (lack of concern, passive, indifferent, uninterested) and sleepiness (falling asleep, drowsy,
yawning, sleepy). The internal consistency for each factor of this version varied between 0.81–0.92.
During this process, the 11-grade response scale was replaced by a 7-grade response scale, where the
extreme values were verbally labeled, 0 “not at all” and 6 “to a very high degree” [30]. The Swedish
Occupational Fatigue Inventory was already translated and validated into the Spanish and Chinese
languages [14,26], with good psychometric characteristics. In this work the final version of the original
SOFI (5 dimensions; 20 items; 7-grade response scale) was studied. Translation and cultural adaptation
process This process was carried out according to the guidelines of the International Society for
Pharmacoeconomics and Outcomes Research (ISPOR) [31], beginning with the permission to use the
SOFI to the main author of the instrument. Two authors of this research, who are fluent in English, and
an English translator, translated it from English into Portuguese. At this stage, the clarification of some
expressions was discussed with the original instrument’s author. After the forward translations had
been analyzed, a single forward translation was achieved. Two professional English translators carried
out the back translation. The back translation results were reviewed, and a harmonization of all new
versions and source version was performed in order to detect and deal with any discrepancies that could
have arisen between different language versions, ensuring conceptual equivalence [31,32]. To assess the
level of comprehensibility of the translation, a cognitive debriefing was made, involving a pretest with
22 participants. In addition, a multidisciplinary panel (3 experts in the field of psychology, ergonomics
and occupational health research) was asked to proofread and provide the opinion on the face and
content validity of the preliminary version. Although the draft was shown to be acceptable in the
preliminary pilot survey, slight changes were made to the original expressions. Data analysis Descriptive
techniques were used for analyzing and characterizing the subjects. The confirmatory factor analysis
(CFA) of the Portuguese version to verify the 5-dimensional structure proposed by Åhsberg [30] was
carried out. In this sense the following goodness of fit indices were used: the ratio Chi2 and degrees of
freedom (Chi2 /df), confirmatory fit index (CFI), Tucker Lewis index (TLI), goodness of fit index (GFI),
Parsimony Goodness-of-Fit Index (PGFI) and root mean square error of approximation (RMSEA). The
model’s adjustment was considered good for the CFI, GFI and TLI values above 0.90, the RMSEA values
between 0.06 and 0.10, and the PGFI values above 0.60 [33]. To examine whether each dimension of the
observed variables was strongly related to each other, the convergent validity was evaluated. The
Average Variance Extracted (AVE) and the Composite Reliability (CR) were estimated [33,34]. Values of
the AVE > 0.50 and CR > 0.70 are indicative of convergent validity and adequate construct reliability [33].
Whether the items that reflect a dimension are not correlated with another dimension, i.e., if the AVE
for each dimension is greater than the average variation shared between each factor and other factors
in the model is determined by the assessment of discriminant validity [33]. The discriminant validity was
estimated according to the proposal submitted by Fornell and Larcker [34] who claimed that for 2
factors i and j, if the AVEi and AVEj > squared correlation between factors i and j (ρij 2 )), an evidence of
discriminant validity existed. Factorial validity was assessed by the analysis of factorial weights of the
items (λ). If all the items of a dimension have λ ≥ 0.5, it is assumed that the dimension has factorial
validity; if λ2 ≥ 0.25 is an indicator of an appropriate individual reliability of the item [33]. Internal
consistency of each dimension and for total scale were estimated through Cronbach’s Alpha (α). Alpha
values of 0.70–0.95 were regarded as satisfactory [35]. The analysis was performed using the AMOS®
version 22.0 software integrated with IBM SPSS™ version 22.0 (SPSS Inc., USA), at a significance level of
5%.
Lack of energy worn out 2.54 1.810 –0.787 spent 2.91 1.996 –1.208 drained 3.15 1.950 –1.115
overworked 2.69 1.978 –1.168 Physical exertion palpitations 1.81 1.685 –0.767 sweaty 3.12 2.110 –
1.253 out of breath 0.95 1.446 2.714 breathing heavily 1.56 1.688 0.220 Physical discomfort tense
muscles 2.91 1.948 –1.136 numbness 2.02 2.007 –0.873 stiff joints 2.33 2.003 –1.012 aching 2.58 1.993
–1.197 Lack of motivation lack of concern 1.39 1.519 –0.215 passive 1.47 1.650 0.384 indifferent 1.14
1.639 1.343 uninterested 0.92 1.484 3.026 Sleepiness falling asleep 1.66 1.864 –0.229 drowsy 1.51 1.620
0.850 yawning 1.62 1.595 0.373 sleepy
Santos, Joana; Carvalhais, Carlos; Ramos, Catarina; Coelho, Tiago; Monteiro, Pedro Ribeiro Rocha;
et al.International Journal of Occupational Medicine and Environmental Health;
Heidelberg Vol. 30, Iss. 3, (2017): 407-417.DOI:10.13075/ijomeh.1896.00760
Fatigue in the workplace
Human fatigue in prolonged mentally demanding

work-tasks: An observational study in the field
Ahmed, Shaheen.Mississippi State University, ProQuest Dissertations Publishing, 2013. 3590189.
March 25, 2019
In the United States, 37.9% of workers reported fatigue, and 65.7% of those reported health-related lost
of productive time compared with 26.4% of those without fatigue. Workers with fatigue cost employers
$136.4 billion annually, which is $101.0 billion higher compared with workers without fatigue (Ricci,
Chee, Lorandeau, & Berger, 2007). The prevalence of fatigue is growing every year. For example, in the
Netherlands, in the workplace, 50% of women and 33% of men reported fatigue in 2008 as compared to
38% of women and 24% of men 15 years before (M. A. Boksem & Tops, 2008). The increase in fatigue
could be associated with the increase in mentally demanding jobs, and/or sedentary jobs, which require
less physical activity (M. A. Boksem & Tops, 2008). In the United States, service industries held
approximately 70% of jobs in 2008, which are mostly sedentary with less physical but not necessarily
less mental demand ("U.S. Bureau of Labor Statistics," 2013). In the 48 years between 1960 and 2008,
approximately 30% of jobs were converted from moderate physical activity to sedentary jobs ("U.S.
Bureau of Labor Statistics," 2013). In the same period, task-dependent energy consumption decreased
140 calories for men and 124 calories for women per day ("U.S. Bureau of Labor Statistics," 2013), which
has been considered as the primary cause of mean weight gain of the U.S. population (Church et al.,
2011). In the Netherlands, a 4.7 hour per week increase in sedentary work-tasks has been observed
between 1975 and 2 2005; the non-occupational sedentary period was found unchanged though (van
der Ploeg et al., 2013). In the literature, studies have been observed to evaluate fatigue purely based on
performance (Linsey M. Barker & Nussbaum, 2011). However, No significant differences in performance
were observed for vigilance (screening) tasks between sitting and standing (Drury et al., 2008; Ohlinger,
2009). Most mentally demanding work-tasks are designed to be performed in sitting positions, which
makes the jobs even more sedentary. Prolonged sitting multiplies the odds for mortality irrespective of
physical activities (van der Ploeg Hp, 2012). Lack of physical activities either in the occupation or in non-
occupation boost the risk for bad health consequences (Mork, Vasseljen, & Nilsen, 2010; A. H. Taylor &
Dorn, 2006). For example, a sedentary job with low physical demands significantly contributes to central
and total obesity (Choi et al., 2010), which has been considered as the etiology of many life-threatening
diseases (Bray, 2004; Gilson, Burton, Van Uffelen, & Brown, 2011). Moreover, prolonged sitting has also
been observed as the primary cause of fatigue in lumbar and truck muscles, which may add up to the
overall body fatigue (Areeudomwong et al., 2012; van Dieën, Westebring-van der Putten, Kingma, & de
Looze, 2009). Sitting over an extended period of time introduces prolonged static postures resulting in
discomfort (El Falou et al., 2003; Pietri et al., 1992) and muscle fatigue even for low exertion activities
such as 5% Maximum Voluntary Contraction (MVC) (Sjogaard, Kiens, Jorgensen, & Saltin, 1986) and
2%MVC (van Dieën, et al., 2009). Fatigue has been reported throughout the literature for these low
physically demanding work-tasks (Blangsted, Sjøgaard, Madeleine, Olsen, & Søgaard, 2005; Kroemer,
1997; Sjøgaard, Lundberg, & Kadefors, 2000). 3 Many of these sedentary tasks, including computer
work-tasks such as programming and simulation, are substantially mentally demanding, which
introduces mental fatigue (M. A. Boksem & Tops, 2008). Many physically demanding activities in
industries have been automated, which have converted most physical workload into mental workload.
Elimination of physical workload does not necessarily reduce the task demands on workers (Moore,
2000) because the total amount of time in a working day has not been reduced. Individuals reported
fatigue at the end of the day (M. A. Boksem & Tops, 2008; DeLuca, 2005) even though the task was
designed to be performed without experiencing fatigue. For example, programming and simulation
impose substantially higher mental demands with very little physical activities (Sjøgaard, et al., 2000),
which establishes a perfect imbalance of the use of body resources. This type of imbalance job or work-
task may contribute to the development of cognitive fatigue, physical fatigue and total fatigue (Sjøgaard,
et al., 2000). Peer-reviewed articles on fatigue have increased 90% over the past decade (Friedberg,
2013). Most of the fatigue research has been focused primarily on the population with medical
conditions. Only a few studies have been conducted on fatigue in the workplace. Moreover, studies on
occupational fatigue have been focused on the effect of sleep disorder and shift work, which has been
considered as the primary cause of fatigue. Poor design of jobs/work-tasks could be a reason for sleep
disorders (Torbjörn Åkerstedt, Fredlund, Gillberg, & Jansson, 2002). Therefore, sleep disturbance could
be considered as an indirect objective measure of fatigue in the workplace. In addition to a measure like
sleep disturbance, other variables related to a work-task could be more useful and direct in predicting
fatigue. Studies on fatigue in the workplace with low 4 physical, but significantly mentally demanding
work-tasks, have rarely been found throughout the literature. Hence, only a few variables related to a
work-task have been found throughout the literature to measure fatigue objectively. Some variables
that could affect fatigue in the workplace include workload, duration of work-task and rest breaks. To
prevent task-dependent musculoskeletal disorders at seated workstations, such as low back problems,
individuals should move or change their positions every 30 minutes or less (Babski-Reeves, Stanfield, &
Hughes, 2005). However, typically, breaks in the workplace are 15 minutes after two-hours of work, 30
minutes to an hour for lunch after four hours of work, and a second 15-minute break after six hours of
work. While this break allocation is clearly insufficient (Mital, Bishu, & Manjunath, 1991), it is reasonable
to assume that this traditional break schedule may not hold for office situations where workers
generally work continuously, even with a lunch break (Balci & Aghazadeh, 2003; Galinsky, Swanson,
Sauter, Hurrell, & Schleifer, 2000; Henning, Jacques, Kissel, Sullivan, & Alteras-Webb, 1997; Lindegard et
al., 2012; Toomingas, Forsman, Mathiassen, Heiden, & Nilsson, 2012). Therefore, the effect of the
duration of work tasks on fatigue is an important consideration for worktasks with low physical, but high
mental demand (Beynon, Burke, Doran, & Nevill, 2000; Dababneh, Swanson, & Shell, 2001; Toomingas,
et al., 2012). The context-specific definitions and measurement techniques have substantially limited
the opportunity to translate the findings from one context into another. Moreover, a limited number of
studies in relation to sedentary computer work-tasks, especially programming and simulation types of
jobs, makes it difficult to transform the findings from other areas to these low physically, but high
mentally demanding work-tasks. For 5 example, the hyperbolic relationship of muscle fatigue with
respect to the muscle power and time could hold for overall physical, cognitive or total fatigue with
respect to workload and time.
Table 2.1 Definitions of Fatigue Developer/Reference Definition The North American Nursing Diagnosis
Association (Carpenito-Moyet, 2006) The self recognized state in which an individual experiences an
overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work.
(Ream & Richardson, 1997) A subjective, unpleasant symptom which incorporates total body feeling
ranging from tiredness to exhaustion, creating an unrelenting overall condition which interferes with
individuals' ability to function to their normal capacity. (Aaronson et al., 1999) The awareness of a
decreased capacity for physical and/or mental activity due to an imbalance in the availability, utilization,
and/or restoration of resources needed to perform activity. (Shen, Barbera, & Shapiro, 2006) Fatigue is
an overwhelming sense of tiredness, lack of energy and a feeling of exhaustion, associated with
impaired physical and/or cognitive functioning; which needs to be distinguished from symptoms of
depression, which include a lack of self-esteem, sadness and despair or hopelessness. (Brown, 1994)
Psychological fatigue is defined as subjectively experienced disinclination to continue the task. (Hancock
& Verwey, 1997) Fatigue is an individuals’ multi-dimensional physiological-cognitive state associated
with stimulus repetition which results in prolonged residence beyond a zone of performance comfort
(Job & Dalziel, 2001) Fatigue refers to the state of an organism’s muscles, viscera, or central nervous
system, in which prior physical activity and/or mental process, in the absence of sufficient rests, results
in insufficient cellular capacity or system wide energy to maintain the original level of activity and / or
processing by using normal resources. (Williamson et al., 2011) Fatigue is biological drive for
recuperative rest (Gander et al., 2011) Fatigue is the inability to function at the desired level due to
incomplete recovery from the demands of prior work and other waking activities. Acute fatigue can
occur when there is inadequate time to rest and recover from a work period. Cumulative (chronic)
fatigue occurs when there is insufficient recovery from acute fatigue over time. Recovery from fatigue,
i.e., restoration of function (particularly of cognitive function), requires sufficient good quality sleep.
Due to the rapid growth of service sectors in the post-industrialized world (Soubbotina & Sheram, 2000),
recent fatigue studies have also focused on service sectors, for example, health care (Linsey Marinn
Barker, 2009). Although research on 9 industrial fatigue focused initially on physical activities, such as
heavy load handling (Chapman, 1990), psychological fatigue was equally perceived for these physically
demanding tasks (Collier, 1943). It is still not known today, whether fatigue is primarily because of
physical or psychological aspects, or both (DeLuca, 2005). A concept of total fatigue considering both
physical and mental fatigue is proposed to define fatigue in the industrial context or for the healthy
working population (Babski-Reeves & Crumpton, 1999). Later, a formalized definition of fatigue for
nurses based on the concept of total fatigue is proposed (Linsey Marinn Barker, 2009). “Total fatigue is a
state comprised of at least two dimensions: mental fatigue and physical fatigue. Mental and physical
fatigue dimensions are present in nurses exposed to excessive mental and physical demands through
their work tasks and schedules. These fatigue dimensions contribute to a state of total fatigue, which
over time can result in these workers not being able to function at their normal capacity and can lead to
an increased risk for injury or medical error” The concept of total fatigue or the definition of total
fatigue is appropriate if a work-task consists of both mental and physical demand simultaneously (e.g.
nursing). Many work-tasks in today’s world have significantly higher mental demand as compared to
physical demand (e.g. programming and simulation). Neither a suitable definition for mentally
demanding work-tasks nor a generalized definition of fatigue has been established yet. Another missing
dimension in most definitions of fatigue is associated with the low level of arousal and the on-set of
boredom occurring in non-challenging jobs with poor quality of supervision and very little control over
the job (Finkelman, 1994). For 10 example, data entry jobs which are neither physically nor mentally
demanding may increase the risk of a very low level of both physical and mental arousal (Finkelman,
1994). Both overuse and underuse of resources could create fatigue (Finkelman, 1994). Because the
objective of this dissertation is to study fatigue, a generalized definition for fatigue is proposed here:
Fatigue is the imbalance created by either underuse or overuse of body resources, which causes a drive
for balance by maintaining a healthy lifestyle, including food habit, daily sleep, proper rest, workload,
exercise, etc. 2.2 Measurement of fatigue There are various objective and subjective methods by which
to measure fatigue. Objective measures tend to focus on changes in physiological human responses
(e.g., heart rate variability or decreased levels of muscle contraction force) (Stokes, Cooper, & Edwards,
1988). Subjective measures of fatigue utilize questionnaires to obtain workers’ perceptions of their
fatigue level. However, subjective fatigue measures can be poorly correlated with physiological
responses (Berrios, 1990), raising the question of validity for objective and/or subjective fatigue
measures. The seemingly lack of direct relationship between subjective perceptions and physiological
changes or responses may have led to the vast collection of fatigue measures (Linsey Marinn Barker,
2009; Barofsky & Legro, 1991). A brief review on both subjective and objective measures of fatigue is
provided in section 2.2.1 11 2.2.1 Subjective measurement of fatigue Many questionnaires (instruments)
have been developed to measure fatigue in populations with and without medical conditions Table 2.2.
Some of these instruments are one-dimensional while some are multidimensional. Commonly assessed
fatigue characteristics have been negative feelings or perceptions. Some questionnaires have also
included positive fatigue perceptions (e.g. fatigue after exercise) such as Swedish Occupational Fatigue
Inventory (SOFI) (Elizabeth Åhsberg & Gamberale, 1998). Most fatigue questionnaires solicit the degrees
to which an individual perceives the fatigue dimension(s). One primary difficulty in synthesizing fatigue
research is the diversity of the questionnaires in terms of length: 1. questionnaire length can range from
a single question (e.g., the CR-10 scale (G. Borg, 1990)) to 83 questions (Stein, Martin, Hann, & Jacobsen,
1998); 2. answer format (e.g., Yes/No responses (Chalder et al., 1993) ), Likert-type scales of various
lengths (e.g, (Elizabeth Åhsberg & Gamberale, 1998)), visual analog scales (e.g.,(Lee, Hicks, & Nino-
Murcia, 1991)); 3. time period for assessment (now, (Kogi, Saito, & Mitsuhashi, 1970)), past few hours
(Schwid, Covington, Segal, & Goodman, 2002), past week (Hann, Denniston, & Baker, 2000), past four
weeks (J. D. Fisk et al., 1994), duration of illness onset (Grohar-Murray, Becker, Reilly, & Ricci, 1998); and
4. scoring methodology (e.g. factor analysis for scales with multiple questions (Elizabeth Åhsberg &
Gamberale, 1998; Kogi, et al., 1970; B. F. 12 Piper et al., 1998; Schwartz, Jandorf, & Krupp, 1993), mean,
median, minimum and maximum for single dimension scales (G. A. Borg, 1982) ). Despite these
differences, subjective measures of fatigue remain one of the most frequently used techniques for a
variety of applications. 13 Table 2.2 Fatigue scales (DeLuca, 2005) Name of Scale Author, Year Initial
Population Specified Fatigue Subscales Item Length Item Scoring Time Frame Fatigue Symptom Checklist
Japanese (Kogi, et al., 1970) English (Haylock & Hart, 1979) Healthy, Cancer Drowsiness and dullness,
projection of physical disintegration, difficulty in concentration 30 Yes/No Now Borg Rating of Perceived
Exertion (RPE) scale (G. Borg, 1970b) Healthy Rating of perceived exertion Single item 6-20* Now Borg
Category Ratio Scale (CR-10) (G. Borg, 1982; G. A. Borg, 1982) Healthy Rating of perceived exertion
Single item 0-10** Now Piper Fatigue Scale (PFS) (B. F. Piper, 1990; B. F. Piper, et al., 1998; B. F. Piper et
al., 1989) Cancer Behavioral/severity, effective meaning, sensory, cognitive/mood 22 items (+5 short
answer) 0-10 One item asks for duration Fatigue Severity Scale (Krupp, LaRocca, Muir-Nash, & Steinberg,
1989) MS, Lupus, healthy None 9 1-7 Not stated past 2 weeks appropriate*** Single Item Visual
Analogue Scale (VAS) (Krupp, et al., 1989) MS, Lupus, healthy None 1 Visual analogue scale Not stated
Visual Analogue Scale for Fatigue (VAS-F) (Lee, et al., 1991)Sleep disordered and healthy Energy, fatigue
18 Visual analogue scale Not stated Fatigue Assessment Instrument (FAI) (Schwartz, et al., 1993) Lyme,
CFS, Lupus, MS, Dysthymia, healthy Fatigue severity, situationspecific, consequences of fatigue,
responds to rest/sleep 29 1-7 Past 2 weeks Fatigue Scale (FS) (Chalder, et al., 1993) Primary care
patients Physical, mental 14 YES/No Not stated Checklist Individual strength (CIS) (J. H. Vercoulen et al.,
1994) CFS Subjective experience of fatigue, concentration, motivation, physical activity 24 7-point scale
Not stated Fatigue Impact Scale (FIS) (J. D. Fisk, et al., 1994) MS Physical, cognitive, psychosocial 21
(short form: 5 items) 0-4 Past 4 weeks * Designed to increase linearly with workload & heart rate. Some
items anchored with verbal expressions ( e.g., very light = 9, very hard = 17). ** Borg designed this
category scale to display ratio properties. Some items are again anchored with verbal expression. ***
Krupp, personal communication. **** In Swedish. English translations of each item provided, but not
validated. ***** A variation on the Chalder Fatigue Scale. 14 Table 2.2 (continued) Name of Scale
Author, Year Initial Population Specified Fatigue Subscales Item Length Item Scoring Time Frame
Myasthenia Gravis Fatigue Scale (MGFS) (Grohar-Murray, et al., 1998) Myasthenia gravis Perception of
fatigue, task avoidance, observable motor signs or symptoms 26 1-5 In general since illness onset
Multidimensional Assessment of Fatigue (MAF) (Belza, 1995) Rheumatoid arthritis Degrees, severity,
distress, impact on activities of daily living 15 1-10 One item asks for duration Multidimensional Fatigue
Inventory (Smets, Garssen, Bonke, & De Haes, 1995) Students, physicians, cancer, CFS, soldiers General
fatigue, physical fatigue, mental fatigue, reduced motivation, reduced activity 20 1-7 Not stated Swedish
Occupational Fatigue Inventory (SOFI) (Elizabeth Åhsberg & Gamberale, 1998) Healthy persons in 16
different occupation Lack of energy, physical exertion, physical discomfort, lack of motivation,
sleepiness 25 0-10 At present Multi-component Fatigue Scale (Paul, Beatty, Schneider, Blanco, & Hames,
1998)***** MS, myasthenia gravis Mental, physical 15 0-5 At present, & compared to recent past
Multidimensional Fatigue Symptom Inventory (MFSI) (Stein, et al., 1998) Cancer Global, somatic,
effective, behavioral, cognitive symptoms of fatigue 83, (short form: 30 items) 0-4 Last week Fatigue
Descriptive Scale (FDS) (Iriarte, Katsamakis, & de Castro, 1999) MS Spontaneous mention of fatigue,
antecedent conditions, frequency, impact on life 5 0-3 Note stated Fatigue Symptom Inventory (FSI)
(Hann, et al., 2000) Cancer Intensity, duration, impact on quality of life 13 0-10 Past week Rochester
Fatigue Diary (RFD) (Schwid, et al., 2002) MS Lassitude (reduced energy) 12 (1 item, 12Xover 24 hours)
Visual analogue Past 2 hours IOWA Fatigue Scale (IFS) (Hartz, Bentler, & Watson, 2003) Primary care
patients Cognitive, fatigue, energy, productivity 11 5-point scale Child Fatigue Scale (CFS) (Hockenberry
et al., 2003) Children with cancer (also versions for parents & staff) Lack of energy, not able to function,
altered mood 14 Frequency (yes/no), intensity (1- 5) Past week * Designed to increase linearly with
workload & heart rate. Some items anchored with verbal expressions ( e.g., very light = 9, very hard =
17). ** Borg designed this category scale to display ratio properties. Some items are again anchored
with verbal expression. *** Krupp, personal communication. **** In Swedish. English translations of
each item provided, but not validated. ***** A variation on the Chalder Fatigue Scale. 15 Two fatigue
assessment scales such as CR-10 scale (G. Borg, 1982; G. B. E. Borg, 1987) and SOFI (Elizabeth Åhsberg &
Gamberale, 1998; E. Åhsberg, Gamberale, & Gustafsson, 2000) for subjective fatigue measure have been
widely used both in industries and in laboratories. A brief literature review for both scales is provided in
section 2.2.1.1 and 2.2.1.2. 2.2.1.1 Rating of perceived exertion scale Rating of Perceived Exertion (RPE)
Scale is used to measure the perception of feeling for physical load that is imposed on an individual (G.
Borg, 1970b). The modified CR-10 scale known as CR10 (Gunnar Borg, 1998) is commonly used to
measure ratings of perceived exertion. CR10 means category ratio scale between 0 and 10, although the
initial development of the scale was a category scale with no zero at the beginning of the scale. Table 2.3
Borg ratings of perceived exertion (RPE) scale (G. Borg, 1970b). 6 No exertion at all 7 8 Extremely light 9
Very Light 10 11 Light 12 13 Somewhat hard 14 15 Hard(heavy) 16 17 Very hard 18 19 Extremely hard 20
Maximal exertion 16 Both category scale and CR10 scales are given in Table 2.3 and Table 2.4
respectively. The number values in Table 2.3 represent heart rates as ten times of the number values
such as 6 for 60 beats per minute, 7 for 70 beats per minute, 20 for 200 beats per minute and so on.
Instead of absolute values of heart rate comparison, Borg later developed the category ratio (CR10)
scales to measure perceived exertion based on individual’s perception (G. A. Borg, 1982) which is given
in Table 2.4. The 0 in CR10 represents no perceived exertion, and 10 represents the maximum perceived
exertion. The last dot (.) after the number 10 represents the absolute maximum or highest possible
exertion (G. A. Borg, 1982). Table 2.4 Borg category ratio (CR10) scale (G. A. Borg, 1982). 0 Nothing at all
“No Perception” 0.3 0.5 Extremely weak Just noticeable 1 Very weak 1.5 2 Weak Light 2.5 3 Moderate 4
5 Strong Heavy 6 7 Very strong 9 10 Extremely strong “Max Perception” Absolute Maximum Highest
possible Studies have observed that sitting discomfort or perceived exertion is related to sitting fatigue
(Helander & Zhang, 1997; Uenishi, Tanaka, Yoshida, Tsutsumi, & Miyamoto, 2002). Moreover, the most
widely used fatigue measuring scales (Swedish 17 Occupational Fatigue Inventory (SOFI)) have measured
perceived exertion to predict physical fatigue (Elizabeth Åhsberg, Garnberale, & Kjellberg, 1997). Many
studies claim that increasing the duration of study would introduce fatigue in their study participants
(Ahmed, 2010; Cham & Redfern, 2001). Therefore, perceived exertion over time can be a measure for
fatigue (Cham & Redfern, 2001; Orlando & King, 2004). Borg (1982) scales have been used to measure
fatigue in many previous studies, especially for prolonged and mentally demanding activities
(Bansevicius, Westgaard, & Jensen, 1997; Cham & Redfern, 2001). Instead of perceived exertion,
perceived fatigue can be solicited to measure unidirectional subjective fatigue (Bansevicius, et al., 1997).
2.2.1.2 Swedish Occupational Fatigue Inventory (SOFI) The Swedish Occupational Fatigue Inventory
(SOFI) is the most widely used instrument to measure fatigue developed due to work tasks in industries
and laboratories for healthy population. The validity and reliability of SOFI have been observed over a
wide range of populations (Ada, Chetwyn, & Jufang, 2004; E. Åhsberg, et al., 2000; González Gutiérrez,
Jiménez, Hernández, & López López, 2005; Johansson, Ytterberg, Back, Holmqvist, & von Koch, 2008),
tasks (E. Åhsberg, et al., 2000; Linsey M. Barker & Nussbaum, 2011; Muller, Carter, & Williamson, 2008)
and shift work (Karlson et al., 2006). Moreover, the scale has been proven valid and reliable to measure
both mental and physical fatigue simultaneously (E. Åhsberg, et al., 2000; Elizabeth Åhsberg, et al., 1997;
Linsey M. Barker & Nussbaum, 2011). The right three columns in Table 2.5 represent the long form of
the SOFI scale consisting of a total of 25 dimensions/expressions while the short form is reduced to five
dimensions by factor analysis (Elizabeth Åhsberg, et al., 1997). 18 The left column in Table 2.5 describes
the concept of total fatigue comprising both physical and mental fatigue practiced by some researchers
(Babski-Reeves & Crumpton, 1999; Linsey Marinn Barker, 2009). Table 2.5 Swedish Occupational Fatigue
Inventory Scale (SOFI) and the type of fatigue Type of Perceived Fatigue Dimension Sub-dimension
Range: 0 to 10 (“not at all” to very high degrees) Physical Fatigue Breathing heavily Out of breath
Physical Exertion Taste of blood Sweaty Palpitations Aching Hurting Physical Discomfort Stiff joints
Numbness Tense muscles Mental Fatigue Uninterested Passive Lack of Motivation Indifferent Lack of
Initiative Listless Sleepy Yawns Sleepiness Drowsy Fall asleep Lazy Total Fatigue Overworked Spent Lack
of energy Drained Worn out Exhausted 2.2.2 Objective measurement of fatigue In contrast to the
subjective measure of fatigue, fatigue is difficult to measure objectively. Some researchers have argued
that fatigue can only be measured validly by 19 using self-reported fatigue (Hancock & Desmond, 2001).
Physiological changes are linked to the development of both cognitive and physical fatigue or vice versa
(Satoshi et al., 2009). However, the association between objective physiological changes and perceived
fatigue have not been observed to be significant, especially for low intensity physically demanding tasks
(de Looze, Bosch, & van Dieen, 2009). Subtle changes in physiology for a short period of time may
multiply over time to produce a significant change over a prolonged period of time. Nevertheless, these
low physically and highly mentally demanding work-tasks have not been studied for a long period of
time to measure the effect of fatigue. Many of the objective measures that have been used in the
previous studies may not be generalized to other contexts. For example, mental fatigue has been
observed to be correlated with eye blink rate in general (Stern, Boyer, & Schroeder, 1994), information
processing speed in patients with chronic fatigue syndrome (J. H. M. M. Vercoulen et al., 1998), level of
physical activity over a two-week period in patients with chronic fatigue syndrome (Bazelmans,
Bleijenberg, Vercoulen, van der Meer, & Folgering, 1997), a cognitive decline in short term memory for
healthy subjects (D. van der Linden, M. Frese, & T. F. Meijman, 2003; van der Linden, Frese, &
Sonnentag, 2003). Physical fatigue has been found to be associated with muscle fatigue (Vollestad,
1997), heart rate and heart rate variability (Bricout, Dechenaud, & FavreJuvin, 2010). Some objective
measures for different types of fatigue are listed in Table 2.6. Most of these objective measures are
significantly contextual and should not be generalized to other contexts. 20 Table 2.6 Objective
measures of fatigue Objective Measure Reference Subject Subject Age (years) Type of Fatigue Measured
Study Duration Task Type Task intensity Findings Heart rate, systolic & diastolic blood pressure (Hurum,
Sulheim, Thaulow, & Wyller, 2011) 44 CFS Patient & 52 Healthy 12 – 18 CFS 24h No task Low At night
(sleep), HR, mean arterial blood pressure and diastolic blood pressure were significantly higher in CFS
patients as compared with controls (p < 0.01). During daytime, HR was significantly higher among CFS
patients (p < 0.05), whereas blood pressures were equal among the two groups. Physical variables
(Ward, 1941) 600M & 1200F with 4 percent CFS General Objective Measure Industrial Task Low to
moderate increased pulse rate, low blood pressure, pallor, tremor, and weight loss Heart rate (Hancock
& Desmond, 2000a) 16 20-24 Total Fatigue (mental and physical) 3h Nursing Task high Heart rate was
significantly affected by the simulated nursing task. However, heart rate variability was not found
significant Oxygen consumptio n rate (Hancock & Desmond, 2001) 25 18-24 Physical Fatigue Exercise
High Fatigue, work decrement, and endurance were not reflected in oxygen consumption rates.
Interface pressure (de Looze, et al., 2009) 12M & 15F 20-30 Comfort and Discomfor t 15min Sitting,
driving low Interface pressure was found more related to comfort than discomfort In-chair movement
using interface pressure (McArdle, Katch, & Katch, 2010) 1M & 7F 23-45 Sitting Discomfor t (or Comfort)
2h Sitting, driving Low In-chair movement significantly increases over time Pupil diameter, eye
movement velocity, (Chi & Lin, 1998) 10 18-32 Visual fatigue 20-60minVisual Display Terminal high
Significant relationship between subjective rating of visual fatigue and the pupil diameter and eye
movement Left & right forearm muscle (ECU & FCU) (L. E. Hughes, BabskiReeves, & SmithJackson, 2007)
9M & 9F 18-33 45min Typing Task Low to high Time pressure and force increase muscle activities.
Muscle activities in upper trape ziusmuscle (Kimura, Sato, Ochi, Hosoya, & Sadoyama, 2007) 6M
Localized Muscle Fatigue (indirect measure) 2h Typing, 1Kg load was placed on wrist Medium to high
Significant relationship established between subjective Rating of Perceived Exertion (RPE) and muscle
activity 21 Table 2.6 (continued) Objective Measure Reference SubjectSubject Age (years) Type of
Fatigue Measured Study Duration Task Type Task intensity Findings Back muscles (McLean, Tingley,
Scott, & Rickards, 2000) 15F & 3M Localized Muscle Fatigue 1h 20min Regular work in computers low No
significant change in cervical paraspinal extensors, the lumbar erector spinae, the upper trapezius, and
the forearm extensors. (regular computer activities were performed) Upper arm and shoulder muscles
(Seghers, Jochem, & Spaepen, 2003) 8M & 8F 19-39 Discomfort 1h30min Regular VDT Low to medium
No statistical result provided between muscle fatigue and EMG from Right m. trapezius pars
descendens, Right m. deltoı¨deus pars anterior, Right m. splenius capitis, Right m.
sternocleideomasoideus, Left m. trapezius pars descendens, Left m. deltoı¨deus pars anterior, Left m.
splenius capitis, Left m. sternocleidomastoid FCU, ECU (Gerard, Armstrong, Martin, & Rempel, 2002)
16M 22-57 Discomfort, localized muscle fatigue 90min Typing tasks Low to medium No objective muscle
fatigue observed, but significant increase in discomfort which accounted as fatigue for the study
Interface pressure (Porter, Gyi, & Tait, 2003) 8M & 10F Mean 40 with std =12 Discomfort 2.5h Real Road
Driving Low No significant relationship between discomfort and subjective rating of discomfort Interface
pressure (Kyung & Nussbaum, 2008) 12M & 15F 20-35 Comfort & Discomfort 15min Laboratory
Simulation Low Interface pressure was more associated with comfort than discomfort Muscle activity in
L1, L5 and C7 (BabskiReeves, et al., 2005) 4M & 4F 18-33 Localized Muscle Fatigue 2h VDT task low No
significant difference was found for a particular sitting position. However, significant difference was
observed between different sitting positions. 22 Two of the objective measures, including change in
resting heart rate and saliva cortisol concentration have been used in many previous studies to measure
fatigue objectively, which are discussed in section 2.2.2.1 and 2.2.2.2. 2.2.2.1 Heart rate & heart rate
variability Both heart rate (Causse, Sénard, Démonet, & Pastor, 2010) and heart rate variability (Ahsan,
Herbert, Toshio, & Marimuthu, 2010; Tiller, McCraty, & Atkinson, 1996) have been used to measure
factors such as workload (Blain, Meste, Blain, & Bermon, 2009) and stress (Causse, et al., 2010), which
causes fatigue (Dorrian, Baulk, & Dawson, 2011; Grech, Neal, Yeo, Humphreys, & Smith, 2009; Hancock
& Desmond, 2000b), especially for the prolonged periods of work tasks (Dorrian, et al., 2011; Sood,
Nussbaum, & Hager, 2007). Heart rate variability can differentiate the activities between the
parasympathetic and sympathetic nervous systems (Ahsan, et al., 2010) by which the functions for
autonomic nervous system can be monitored (Tiller, et al., 1996). For example, the imbalance of the
autonomic system can be detected by heart rate variability (Karita, Nakao, Nishikitani, Nomura, & Yano,
2006), which is an indication of fatigue (Masaaki Tanaka et al., 2011). Increase in sympathetic activities
and decrease in parasympathetic activities have been recently determined as the underlying cause of
daily fatigue (Jiao, Li, Chen, & Wang, 2005; M. Tanaka, Mizuno, Tajima, Sasabe, & Watanabe, 2009;
Masaaki Tanaka, et al., 2011). More specifically, prolonged cognitive load increases sympathetic activity
while decreasing parasympathetic activity significantly resulting in mental fatigue (Mizuno et al., 2011).
Because the activities of the autonomic nervous system are changed based on task demands, measuring
sympathetic and parasympathetic activities by using heart rate (Hurum, et al., 2011) and 23 heart rate
variability (Collet, Averty, & Dittmar, 2009) analysis can be used as an objective measure for fatigue
(Boneva et al., 2007). Moreover, the heart rate measure is very effective for tasks that have both mental
and physical parts (e.g. sports game, badminton, soccer, cricket, etc.) (Bricout, et al., 2010). Heart rate
and heart rate variability have been observed to be a good measure for physical and mental fatigue,
respectively (Bricout, et al., 2010). Many previous studies have found heart rate and heart rate
variability as sensitive measures for fatigue (Jiao, et al., 2005; Yamamoto, LaManca, & Natelson, 2003;
Yoshiuchi, Quigley, Ohashi, Yamamoto, & Natelson, 2004). 2.2.2.2 Saliva cortisol concentration Cortisol
hormone has been observed as a stress hormone, regulated by hypothalamic-pituitary-adrenal axis
(HPA) (Chrousos, 1995; Chrousos Gp, 1992). Hypothalamus secretes corticotropin releasing hormone
(CRH) according to the information received, including other hormones, serotonin and dopamine levels,
immune system, and cortisol hormone itself. Whereas, the pituitary gland releases hormones such as
adrenocorticotropic hormone, (ACTH) acts on the adrenal glands to produce the cortisol hormone,
which facilitates balancing the functions of the body (Figure 2.1) (Hall & Guyton, 2011; Saladin, 2008).
The cortisol hormone is secreted in four phases for healthy individuals with no medical conditions as
given below (Weitzman et al., 1971): 1. Phase 1: A 6-hr period of “minimal secretory activity” (4 hr
before and 2 hr after lights out); 2. Phase 2: A 3-hr period called “preliminary nocturnal secretory
episode” (3rd to 5th hr of sleep); 24 3. Phase 3: A 4-hr period, the “main secretory phase” (6, 7, 8 hr of
sleep and 1st hr after awakening); and 4. Phase 4: The 11 hr of “intermittent waking secretory activity.
The trend of diurnal cortisol secretions is altered by the nature of work-tasks to cope with the challenges
imposed by the tasks (A. Dahlgren, et al., 2005; Jens C. Pruessner, et al., 1999; H. Webb et al., 2008; H. E.
Webb et al., 2011). In contrast to the usual logarithmic decline in cortisol concentrations (Figure 2.4), it
could rise or flatten under physical or mental challenges or both (Figure 2.3) (Greig, Marchant, Lovell,
Clough, & McNaughton, 2007; Jens C. Pruessner, et al., 1999; H. Webb, et al., 2008). Flattening of
cortisol secretions is still considered higher relative to the usual cortisol concentration. Workload has
been observed to affect the levels of cortisol concentration in the early morning (A. Dahlgren, Akerstedt,
& Kecklund, 2004; A. Dahlgren, et al., 2005; A. Dahlgren, Kecklund, & Akerstedt, 2006). Morning cortisol
concentration for patients with chronic fatigue syndromes (CFS) has been observed to be significantly
low, 28 meaning the restoration of cortisol levels has not been achieved due to the HPA axis
dysregulation (Cleare et al., 2001; Demitrack et al., 1991; Nater et al., 2008). Hyper activities of HPA axis
have also been observed for patients with CFS to cope with the challenges imposed by diseases or other
factors (Gottschalk et al., 2005). Studies have shown that significantly higher cortisol responses occur
during mentally demanding work tasks performed for a prolonged period of time (Bohnen, Houx,
Nicolson, & Jolles, 1990; Engelmann et al., 2011). Therefore, changes in cortisol hormone level as an
objective measure for fatigue have been observed (Adam, Hawkley, Kudielka, & Cacioppo, 2006; Chida &
Steptoe, 2009; Kumari et al., 2009; Nozaki et al., 2009; J. C. e. a. Pruessner, 1997; Rubin, Hotopf,
Papadopoulos, & Cleare, 2005a). The cortisol concentration for both populations with and without
medical conditions has been observed to be significantly sensitive with respect to fatigue, either induced
by diseases or work tasks or some other factors (Chida & Steptoe, 2009). Moreover, cortisol secretion by
the hypothalamic-pituitary-adrenal (HPA) axis determines “hypercortisolemia” which is connected with
low sleep efficiency and fatigue; while “eucortisolemia” or “hypocortisolemia” is associated with high
sleep efficiency and objective sleepiness (Vgontzas, Bixler, & Chrousos, 2006). Because sleep is
significantly related to fatigue and the secretion of cortisol is affected by the sleep quality, cortisol
concentration should be a reliable measure of fatigue (Anna Dahlgren, Kecklund, & Åkerstedt, 2005;
Strickland, Morriss, Wearden, & Deakin, 1998). Hence, salivary cortisol concentration can be a good
biochemical measure to assess negative health consequences (H. Webb, et al., 2008) resulting in fatigue
over time (A. Dahlgren, et al., 2005, 2006), especially for mentally demanding work-tasks (Bohnen, 29 et
al., 1990). Moreover, work-tasks which are less physically demanding (e.g. seated work-tasks) and highly
mentally challenging (e.g. programming and computer simulation) alter the HPA axis activities, which
changes the salivary cortisol concentration (H. E. Webb, et al., 2011). Therefore, salivary cortisol
concentrations can be used as an objective measure in studies related to fatigue. 2.2.3 Quantifying
physical and cognitive fatigue simultaneously A primary limitation in the literature is the lack of studies
that have quantified physical and mental fatigue simultaneously. Interesting findings were reported
from those studies that have quantified both mental and physical fatigue simultaneously. For example,
Liu et al. found that brain activity changes (changes in both electromyographic and magnetic resonance
imaging signals) when working under muscle fatigue (Liu et al., 2003); meaning that physical fatigue or
extraneous physical activities change cognitive functions (Fukuda et al., 1994; LaManca et al., 1998). A
recent study has also deemed that cognitive fatigue impairs physical performance (Marcora, Staiano, &
Manning, 2009). These findings demand studies that quantify both mental and physical fatigue
regardless of the structure of the tasks, such as primarily physical in nature, primarily cognitive in
nature, or mixed (Linsey M. Barker & Nussbaum, 2011). Moreover, it is still unknown that whether
fatigue is primarily because of physical or psychological variables, or both (DeLuca, 2005). Therefore,
fatigue should be studied as a whole rather than localized.
Fatigue and Quality Nursing Care
1.2.4 Fatigue and performance Many previous studies have observed significant performance
declines due to fatigue (Bartley & Chute, 1947; Hockey & Earle, 2006; Huang et al., 2009; R.
G. Hughes & Clancy, 2008; Patterson & Yealy, 2010; Welford, 1968). Studies have also found
relationships between prolonged activities and the decline in performance over an extended
period of time (van der Linden & Eling, 2006; D. van der Linden, M. Frese, & T. F. Meijman,
2003). For example, the Central Nervous System (CNS) has to work harder to sustain
postural stability when fatigued (Kanekar, Santos, & Aruin, 2008). However, the relationship
between fatigue and performance has not been observed to be strongly correlated (Daniel,
1970; D. van der Linden, M. Frese, & T. F. Meijman, 2003) because often different
physiological compensation is required in fatigue states to maintain the similar level of
performance (Kanekar, et al., 2008; Rai, Foing, & Kaur, 2012; Robert & Hockey, 1997; Scott
& Earnest, 2011; Dimitri van der Linden, Michael Frese, & Theo F. Meijman, 2003).
Performance has been observed to be unaffected by psychomotor tasks when subjects are
required to maintain a certain level of performance; strategies have been changed to
sustain the same levels of performance though (Kanekar, et al., 2008; Selen, Beek, & van
Dieën, 2007). Therefore, many previous studies have not found significant relationships
between the subjective fatigue and objective measures of fatigue, including working
memory (S. K. Johnson, Lange, DeLuca, Korn, & Natelson, 1997), short-term memory (Susan
K. Johnson, Deluca, Diamond, & Natelson, 1998; Krupp & Elkins, 2000), executive function,
complex attention (Krupp & Elkins, 2000), vigilance (Paul, et al., 1998), verbal fluency, and
verbal memory (Krupp & Elkins, 2000). As compared to a non-fatigued state, higher energy
is required to perform the same 31 activities while an individual is in a fatigue state (Scott &
Earnest, 2011). Higher physiological compensation is required to sustain performance when
fatigued (Gates & Dingwell, 2010; Hockey & Earle, 2006; Rai, et al., 2012; Robert & Hockey,
1997; Selen, et al., 2007). When resources are replenished, a performance decline is obvious
(Wickens, 2002, 2008). Some recent studies have also observed both performance decline
and physiological compensation (e.g. change in muscle activities, CNS responses)
(Huysmans, Hoozemans, van der Beek, de Looze, & van Dieën, 2008; Kanekar, et al., 2008).
Therefore, fatigue will either affect performance or increase physiological cost or both. Most
studies, in general, have observed that performance is affected by fatigue (Linsey M. Barker
& Nussbaum, 2011). 2.3 Factors that affect fatigue Many factors that affect the
development of fatigue, include gender, age, ethnicity, marital status, sleep hours,
occupation, time spent in the occupation, weekly working hours, shift schedule, shift length,
work setting, daily rest after work, other responsibilities, exercise, food habit and families.
The top three factors, including sleep and shift, workload and the duration of work-tasks,
have been considered as the statistically significant predictor of fatigue in the workplace. US
National Health Interview survey conducted between 2004 and 2008 reveals that shorter
sleep and longer work-hours, which significantly contribute to fatigue, increase the risk of
task-dependent injury (Lombardi, Folkard, Willetts, & Smith, 2010). Rest breaks within
workdays, between workdays and in the weekends, if not taken properly, could substantially
accumulate fatigue over time (Hooff, Geurts, Kompier, & Taris, 2007). In addition to the
disturbance of sleep and workload (or work-hours), rest breaks have been considered as 32
one of the most effective tools to recover from fatigue accumulation (Bakker, Demerouti,
Oerlemans, & Sonnentag, 2013; Binnewies, Sonnentag, & Mojza, 2009; Sonnentag,
Binnewies, & Mojza, 2008; Sonnentag & Fritz, 2007). In regard to the rest-breaks, offwork
activities could be another type of work but not the primary occupation, have been
considered significantly effective to recover from fatigue (ten Brummelhuis & Bakker, 2012).
Factors that affect fatigue are discussed here. 2.3.1 Sleep and shift work Average daily sleep
of an individual was significantly higher in 1910 (9 hours per night) than today (7 to 7.5
hours per night) (Coren, 1997). A recent poll by the National Sleep Foundation revels that
29% felt sleepy at work and 36% have fallen asleep or nodded off while driving ("sleep in
America Poll," 2008). Extensive research has been performed for sleep-related factors (e.g.
sleep deprivation) in relation to the development of fatigue (Alison, Jill, & Adam, 2011; D.
Dawson & Fletcher, 2001). Change in working shift causes sleep disturbance due to the
change of circadian rhythm (Torbjörn Åkerstedt, 2003), which has also proven to be one of
the reasons for fatigue (Torbjörn Åkerstedt, et al., 2002; Torbjörn Åkerstedt & Wright Jr,
2009; Östberg, 1973). Poor sleep has been proven to be one of the most important
predictors of fatigue as compared to many other factors, including work load, gender, and
exercise (T. Åkerstedt et al., 2004). 2.3.2 Workload Workload has been proven to be one of
the primary causes of fatigue in working population (Maarten AS Boksem, Meijman, &
Lorist, 2006; Dorrian, et al., 2011; Finkelman, 1994; Guastello et al., 2013; MacDonald,
2003). The limited ability to 33 process information is associated with performance decline
(Eppler & Mengis, 2004; Speier, Valacich, & Vessey, 1999; Wickens, 2008). In addition to
information overload, information underload can also cause monotony, resulting in poor
performance (Young & Stanton, 2002) and fatigue (Finkelman, 1994) and increase the risk
for negative health consequences (Frankenhaeuser & Gardell, 1976). One of the first
explanations of performance under overload, and underload of information is given by the
YerkesDodson Law of arousal and performance (Figure 2.5) (Yerkes & Dodson, 1908).
According to Yerkes-Dodson law, an optimal level of arousal by manipulating mental
workload is required to achieve maximum performance. To overcome the situations of
underload and overload, an optimum level of automation has been proposed so that the
highest performance could be achieved. Figure 2.5 Visualization of Yerkes-Dodson Law. 34
The term mental workload, however, is difficult to determine. No consensus definition of
mental workload has been found in the literature (Table 2.7). Despite the disagreement on
the definitions of mental workload, some common characteristics of mental workload are
summarized as given below (Hacker, 1998): 1. Mental workload is associated with the task
demands 2. Mental workload is conceptualized by cognitive information processing which
integrates mental processes, representations of work tasks, and states of personal
characteristics such as consciousness, mood, etc. 3. Mental workload is associated with
multidimensional characteristics of task requirements such as the design of tasks, individual
behavior towards the task performance, psychosocial aspects, etc. Table 2.7 Definitions for
mental workload Source Definition (Wilson & Eggemeier, 1991) “Mental workload refers to
the portion of operator information processing capacity or resources that is actually
required to meet system demands.” (Gopher & Donchin, 1986) “Mental workload may be
viewed as the difference between the capacities of the information processing system that
are required for task performance to satisfy performance expectations and the capacity
available at any given time.” (Kramer, Sirevaag, & Braune, 1987) “The cost of performing a
task in terms of a reduction in the capacity to perform additional tasks that use the same
processing resource.” The complex nature of mental workload has also been understood in
the development of two most commonly used scales to assess perceived workload (Gary &
Thomas, 1988; Hart & Staveland, 1988). The subjective workload assessment technique 35
(SWAT) developed by Gary and Thomas (1988) focuses on three characteristics of mental
workload which are summarized as temporal effort, mental effort and stress. These three
components of mental workload have been determined to be significantly correlated with
fatigue, for example, time (Aho, 2007), mental effort (Linsey M. Barker & Nussbaum, 2011),
and stress (Causse, et al., 2010). Many studies have determined a significant relationship
between mental demand and fatigue (Ada, et al., 2004; D. van der Linden, M. Frese, & S.
Sonnentag, 2003). The other widely used scale NASA-TLX developed by Hart and Staveland
(1988) includes two additional dimensions such as physical demand and performance to
assess workload. The multidimensional and complex natures of workload include many
elements that also significantly affect the development of fatigue (Hancock & Desmond,
2001). 2.3.3 Time Fatigue has been reported at the end of a regular working day, and fatigue
increase over time. Duration of work-tasks or amount of hours spent in occupation at the
workplace is one of the primary factors affecting fatigue significantly (El Falou, et al., 2003;
Jensen, 2003; Østensvik, Veiersted, & Nilsen, 2009). 36 Figure 2.6 Loss of strength with
fatigue Figure 2.6 demonstrates that time interacts with load hyperbolically to affect muscle
fatigue either peripheral or central, which has been well established throughout the
literature (Hill, Poole, & Smith, 2002; Monod & Scherrer, 1965; Poole, Ward, Gardner, &
Whipp, 1988; Vanhatalo, Fulford, DiMenna, & Jones, 2010). Does this relationship hold for
cognitive or total fatigue? 2.3.4 Rest breaks Breaks have been proven to be one sensitive
during the workday to reduce fatigue and other health consequences significantly. Breaks
can help to minimize fatigue by at least by introducing (1) reduced stress and promoted
enjoyment, (2) increased health awareness and facilitated behavior change, and (3)
enhanced workplace social interaction (W. C. Taylor et al., 2013). However, a clear
understanding of how and when these 37 breaks should be introduced has not been studied
enough. Is it the choice of individuals or is it assigned by the employers? The current
practice in industries and service sectors recommend pre-schedule rest breaks after two
hours, which may or may not be suitable with individuals’ preferences. Moreover, studies
show that micro breaks are more important to maintain performance and manage negative
health consequences, including fatigue (Dorion & Darveau, 2013; Henning, et al., 1997). In
addition to the recommended breaks, self-selected micro breaks could be effective to
manage fatigue (Tucker, 2003). Recent studies show that self-selected rest breaks improve
performance and reduce fatigue (Davy & Göbel, 2013). Because in many cases, for example,
professional drivers can detect fatigue and the time that they need to take a rest break
(Williamsonl, Friswelll, Grzebieta, & Olivier, 2013). The mixed findings regarding rest break
schedules, effective though, indicate that recommended pre-schedule breaks, self-selected
rest breaks or frequent micro breaks, could be efficient for managing fatigue (Arlinghaus et
al., 2012; Williamson & Friswell, 2013). Proper rest breaks between workdays and weekends
are as important as breaks within the workday (Hooff, et al., 2007). One of the first attempts
to define and understand fatigue in the workplace was developed primarily by focusing on
the recovery of fatigue (Eo Grandjean, 1968). Figure 2.7 illustrates the causes of fatigue,
which accumulates over time if not recovered respectably (Eo Grandjean, 1968). 38 Figure
2.7 Causes of fatigue by Grandjean's Picture reference: (Griffith & Mahadevan, 2011) 2.3.5
Gender and age The effect of gender has been observed to be significant in physical fatigue
(Linsey Marinn Barker, 2009; Billaut & Bishop, 2012; Kent-Braun, Ng, Doyle, & Towse, 2002;
Laurent et al., 2010). Working females experience substantially elevated levels of perceived
fatigue, when they have more responsibilities such as household-work, do not have time to
take exercise, and with other negative factors (T. Åkerstedt, et al., 2004; Karlqvist, Tornqvist,
Hagberg, Hagman, & Toomingas, 2002; Loge, Ekeberg, & Kaasa, 1998; Steele et al., 1998).
For an example, fatigue has been reported significantly higher by working women from the
Indian subcontinent (the study only included Pakistani, Indian and Bangladeshi). These
women are often responsible for more household work as compared to their spouse (Bhui
et al., 2011). Another example of women reporting fatigue significantly higher than men is
associated with the lower levels of education and 39 occupational status (Jason et al., 1999).
Similar results have also been observed in different age groups to affect physical fatigue
significantly (Bilodeau, Henderson, Nolta, Pursley, & Sandfort, 2001; Fell & Williams, 2008).
Nevertheless, mixed results have been reported for mental and total fatigue with respect to
age and gender (de Jong, Candel, Schouten, Huijer Abu-Saad, & Courtens, 2005). No
significant gender differences were observed in either mental or total fatigue, but for
physical fatigue, in healthy nursing population (Linsey Marinn Barker, 2009). 2.3.6 Ethnicity
A few studies have been published comparing ethnic groups with respect to fatigue (Dinos
et al., 2009). Moreover, the categorizations of ethnic group have not been performed
methodically to determine the effect of ethnicity alone on fatigue (Dinos, et al., 2009; Jason
La & et al., 1999; Njoku, Jason, & Torres-Harding, 2005). Studies have found a significant
difference between the ethnic minority and majority with respect to fatigue, which must not
be considered as the independent effect of ethnicity (Dinos, et al., 2009; Jason, et al., 1999;
Steele, et al., 1998). Nonetheless, the minority reported less fatigue when the studies are
controlled by demographics, including only education and age (Cordero, Loredo, Murray, &
Dimsdale, 2012). Studies have also reported no significant difference in ethnicity with
respect to fatigue (Bhui, et al., 2011; Buchwald, Manson, Pearlman, Umali, & Kith, 1996;
Yennurajalingam, Palmer, Zhang, Poulter, & Bruera, 2008). In contrast to ethnicity alone,
socioeconomic status, unemployment, and being classified as minority significantly affects
fatigue (R. R. Taylor, Jason, & Jahn, 2003). Moreover, fatigue studies comprising
demographic and ethnicity, very important 40 though, have not been researched enough to
reach to substantial conclusions (Di Milia et al., 2011; Noy, et al., 2011). 2.4 Fatigue
predictive models Many reliable models exist for localized muscle fatigue throughout the
literature. Unlike muscle fatigue, few models exist to measure physical and cognitive fatigue
resulting in total body fatigue. One of the first models to quantify total body fatigue for
healthy working populations was proposed by Babski-Reeves and Crumpton (1999).
Equation 2.1 illustrates the first model proposed to quantify the total body fatigue (Babski-
Reeves & Crumpton, 1999). (2.1) Where: Overall fatigue level Relative weighted value of
each fatigue indicator = Change in heart rate membership value Tone task reaction time
membership value Level of tiredness membership value Number of mental fatigue
symptoms reported membership value Number of physical fatigue symptoms reported
membership value And: i = participant number j = testing time k = testing session number
𝑖𝑗𝑘 = 1 𝑖𝑗𝑘 + 2 𝑖𝑗𝑘 + 3 𝑖𝑗𝑘 + 4 𝑖𝑗𝑘 + 5 𝑖𝑗𝑘 41 The model was also validated for work-tasks in
industrial (e.g. data entry operators and workers in manufacturing industries) and service
sectors (e.g. nurses) (Babski-Reeves & Crumpton, 1999; Babski-Reeves K., Crumpton-Young
L., Riley J., Nitcavic L., & Gentry H., 2000). The model could predict fatigue 52.5% accurately
for nursing work-tasks. Another model to assess total fatigue experienced by nurses in
healthcare industries is provided in Figure 2.8 (Linsey Marinn Barker, 2009). Both models by
Babski-Reeves (1999) and Barker (2009) are significantly task specific and both models
simply include task variables to quantify fatigue. Barker’s model is highly associated with the
impact of fatigue on performance, which is still equivocal and considerably task specific,
(Ackerman & Kanfer, 2009; van der Linden & Eling, 2006; D. van der Linden, M. Frese, & T. F.
Meijman, 2003; D. van der Linden, M. Frese, & S. Sonnentag, 2003), rather than what causes
fatigue and how it should be assessed (Linsey M. Barker & Nussbaum, 2011; Barker Steege &
Nussbaum, 2013). 42 Figure 2.8 Conceptual model of fatigue and performance in healthcare
workers Picture reference: (Linsey Marinn Barker, 2009). Another excellent model, Swedish
Occupational Fatigue Inventory (SOFI) described in Section 2.2.1.2 and Table 2.5 (E. Åhsberg,
et al., 2000; Elizabeth Åhsberg, et al., 1997) has been widely used to quantify fatigue
induced by physical work-task, mental work-task or both in the workplace (Barker Steege &
Nussbaum, 2013). The SOFI model by Åhsberg only assesses the current states of fatigue
levels without considering the cause of the development of fatigue, which is one of the
primary criteria to define or assess fatigue. Fatigue is highly complex and comprised of many
factors besides just the worktask. For example, sleep and variables associated with sleep
have been proven to be more effective in predicting fatigue than the variables associated
with the work-task itself 43 (James C. Miller, 2005; James C Miller & Eddy, 2008). Therefore,
numerous models to predict fatigue have been developed by utilizing sleep variables.
Because fatigue is complex and affected by many factors, including age, workrest break,
sleep deprivation, motivational factors, coping strategies, total time spent in occupation and
circadian disruptions (Gawron, French, & Funke, 2001), a comprehensive model should be
developed to assess fatigue. Few such models have been found throughout the literature.
One of the conceptual and comprehensive models is depicted in Figure 2.9 (Qiang, Lan, &
Looney, 2006). Figure 2.9 Bayesian network of fatigue variables Picture reference:
(McLauglin, 2007). Figure 2.10 depicts a recent theoretical model and it incorporates an
extensive list of factors that could potentially affect fatigue in the workplace (Di Milia, et al.,
2011). 44 This model includes both factors associated within the body and outside the body.
However, little has been discussed in the model about the workload, and the amount of
time spent in the work-task to affect fatigue, rather the model is highly focused on personal
traits, demographic and other job related factors (Di Milia, et al., 2011). Figure 2.10
Potential endogenous and exogenous variables that may be linked with fatigue. Picture
Reference: (Di Milia, et al., 2011) A recent review of models to predict fatigue in the
workplace only discovered models with sleep as the primary input (D. Dawson, et al., 2011),
which may predict fatigue for jobs with shift work but not regular daytime mentally
demanding jobs where other variables could be even more pertinent. 45 As the physically
demanding jobs are decreasing, mentally demanding jobs are also increasing (M. A. Boksem
& Tops, 2008; van der Ploeg, et al., 2013). Nevertheless, a model to predict fatigue induced
by mentally demanding work-tasks has yet to be created (M. A. Boksem & Tops, 2008).
Many models have been developed in the medical field for patients with chronic fatigue
syndrome due to different types of disease (B. Piper, 1989; Stein, et al., 1998). However,
generalization of these models to occupational ergonomics needs further investigation.
Moreover, none of these models include time (the running clock during the working day)
factor to predict fatigue; time spent in occupation has been proven to be one of the most
important contributing factors to the development of fatigue in the workplace (Bansevicius,
et al., 1997; Dembe, Erickson, Delbos, & Banks, 2005; Härmä, 2006; Schaufeli, Taris, & Van
Rhenen, 2008; Smith, Folkard, Tucker, & Macdonald, 1998; Van der Hulst, 2003). 2.4.1 Two-
step quantitative model to predict fatigue Most models currently existing within the
literature are inadequate to explain fatigue over time in the workplace due to at least the
two following reasons: 1. Comprehensiveness; not including all or a sufficient number of
factors that could predict fatigue in the workplace; and not explaining a significant amount
of variation. 2. Time (the running clock during the day); job-related fatigue increases over
time during the working day. Therefore, an interactive relationship between time and the
other factors that cause fatigue could substantially affect occupational fatigue, similar to the
significant hyperbolic relationship (Figure 46 2.6) between time and effort in neuromuscular
fatigue (Monod & Scherrer, 1965; Vanhatalo, et al., 2010). Figure 2.11 Factors that affect
fatigue (step one of the two-steps model) Figure 2.11 illustrates the first step of the
proposed two-steps model to address the limitations in the current models to predict
fatigue in the workplace. In the first step, a comprehensive list of factors that affect fatigue
in the workplace is identified. The variables to predict fatigue can be considered as
quantitative except ethnicity (Figure 2.11). The time in the model must be interpreted as a
running clock during the working 47 shift, which supposedly interacts with other factors in
the model to affect fatigue. In the second step, a quantitative mathematical relationship is
hypothesized to predict fatigue (equation (2.1) and Figure 2.12). The potential hyperbolic
relationship is depicted in Figure 2.12. Figure 2.12 Conceptual hyperbolic relationship of
time and fatigue load In addition to muscle fatigue, the hyperbolic relationship for overall
physical, cognitive or total fatigue has been conceptualized in many previous studies. In
comparison to lower intensity, the higher intensity of a factor must increase fatigue 48
quicker over time, which inherently indicates an interaction only relationship where main
effects of the individual factors are meaningless (Anna Dahlgren, et al., 2005). The
mathematical relationship of the resultant interaction for fatigue is given in equation (2.1).
(2.1) Where, x = Time spent in the workplace y = fatigue load = quantitative factors (e.g.
change in resting 49 CHAPTER III METHOD 3.1 Experimental Design An observational study
in the field was performed to evaluate fatigue in prolonged, mentally demanding work
tasks. However, the strategy of data collection has resulted in a repeated measure design of
experiment where participants were randomly selected from two populations (Indian and
Westerner), and each participant was measured over a four-hour time period. Ethnicity
(Eth) was considered as a betweensubjects factor and experimental clock time, or simply
time (T), was considered as a within-subjects factor. Task-independent and personal factors,
including the working shift (Sh); weekly exercise frequency (Ex); hours of daily sleep (Sl);
hours of rest after work (DR); weekly working hours in primary occupation (W); total weekly
working hours all of occupations (TW); and fatigue perceived at the end of a regular working
day (EDF) were also considered as between-subject factors. 3.1.1 Population model for the
experiment The population model provides the primary guidelines for statistical analysis of
variance. Therefore, the population means model in equation (3.1) was developed. (3.1)
Where: 𝑌𝑖𝑗𝑘 = + 𝛼𝑖 + 𝜀𝑘(𝑖) + τ𝑗 + 𝛼𝜏 𝑖𝑗 + 𝑒𝑖𝑗𝑘 50 i=1,2; j=1, 2,……, 9, 10; k=1, 2,……, 7, 8 𝑌
Response within ith group, at jth time point for the kth subject Overall mean 𝛼 Effect of i th
ethnic group subject to 𝛼 𝜀 Error associated with subjects nested in ethnic groups, ,
independent and identically distributed τ Effect of jth time point subject to τ 𝛼𝜏 The
interaction effect for the ith ethnic group and jth time point subject to 𝛼𝜏 𝛼𝜏 𝑒 Experimental
error, , independent and identically
Subjective measures of fatigue Two subjective instruments, the Modified Borg CR-10 scale (Borg Scale)
and the Swedish Occupational Fatigue Inventory (SOFI) were used to measure participants’ subjective
perceptions of fatigue. 3.3.1.1 Modified Borg CR-10 scale to measure fatigue Both the Rating of
Perceived Exertion (RPE) scale and the Category Ratio (CR10) scale have been widely used to measure
both perceived exertion and overall fatigue (E. Åhsberg, et al., 2000; G. Borg, 1970a). A modified Borg
CR-10 (modified because perceived overall fatigue was solicited instead of perceived exertion) scale was
used to measure perceived fatigue every 30 minutes over a four-hour study period. A total of 10
assessments were performed including the baseline measurements at the beginning of each two-hour
session before and after a short 15-minute break. The scales were 53 displayed as they appear in
APPENDIX B (Borg) and APPENDIX C (SOFI). Participants rated their perceived fatigue for specific body
parts presented in random order (APPENDIX E). Perceived fatigue was collected for (1) leg, (2) buttock,
(3) lower back, (4) upper back (5) shoulder- neck, (6) eyes, and (7) whole body. A total fatigue score for
each 30-minute block was calculated by adding fatigue ratings for each body part, including the whole
body (G. A. Borg, 1982; Loge, et al., 1998). (3.6) 3.3.1.2 Swedish Occupational Fatigue Inventory (SOFI)
The Swedish Occupational Fatigue Inventory (SOFI) used in this study is given in APPENDIX C (E. Åhsberg,
et al., 2000; Elizabeth Åhsberg, et al., 1997). The short version of SOFI was used, and participants
completed the survey every 30 minutes. A total multi-dimensional fatigue score for each 30-minute
block was calculated by adding the fatigue ratings for five dimensions of SOFI (E. Åhsberg, et al., 2000;
Loge, et al., 1998). (3.7) 3.3.2 Subjective measure of workload Subjective perceptions of workload were
measured using the NASA-TLX. While fatigue and workload are generally considered two distinctly
different concepts, they 54 have been found to be related in previous studies. A total workload score for
each 30- minute block was measured by adding the scores for six dimensions of NASA-TLX equation (3.8)
(Hart & Staveland, 1988; Loge, et al., 1998). Similar studies have not identified any significant difference
between weighted and un-weighted scores of NASA scores (DiDomenico, 2003; Ikuma, Nussbaum, &
Babski-Reeves, 2009). Therefore, simple un-weighted scores will be used to calculated total workload
measured by NASATLX. (3.8) 3.3.3 Objective measures of fatigue Two objective measures, (1) change in
heart rate (Duchon, Smith, Keran, & Koehler, 1997) and (2) saliva cortisol concentration (Rai, et al.,
2012), were collected. 3.3.3.1 Change in Heart rate (∆HR) A Polar RS 400 heart-rate monitor (Polar
Electro Oy, Professorintie 5, Fl-90440 Kempete, Finland; www.polar.fi) was used to measure heart rate
continuously at a sampling rate of 1Hz. Raw heart rate data was downloaded to the Polar Pro-Trainer 5
software (Polar Electro Oy, Professorintie 5, Fl-90440 Kempete, Finland; www.polar.fi) for analysis at a
later time. The heart-rate monitor was placed across the chest so that the sensor sits right of the
sternum. A wrist watch was worn on either hand or placed on the working desk to 55 minimize
interference, but close enough to the chest sensor for continuous heart rate monitoring. To start the
experiment, resting heart rate was calculated in a sitting position while participants were requested to
sit back and relax until they reached a steady state resting heart rate defined to be 2 consecutive heart
rate readings within 5 bpm. This procedure took 2 to 5 minutes. After recording resting heart rate, the
heart rate wrist watch clock was started to begin the experiment. Average heart rate was also calculated
during the steady state condition by collecting thee heart rate readings. Change in heart rate (HR) was
used in all analyses. To compute HR, task heart rate was averaged for each 30-minute block and the
resting heart rate was subtracted from the average, heart rate for the 30-minute block. 3.3.3.2 Saliva
cortisol concentration Six saliva samples; four samples during the experiment, one sample during early
morning (30 minutes after waking up) and another sample during a non-work day (between 2:00 and
3:00PM on a Sunday afternoon); were collected. The four samples collected during the experiment were
collected before and after each two-hour session. Samples were analyzed according to the ELISA
technique (Salimetrics, State College, PA). Participants were asked to chew a clinical cotton gum for a
minute to take the saliva sample, which was then stored in a test tube and kept in an ice box. Once the
experimental session was completed, the saliva samples were refrigerated at -100C until they were
needed for analysis. 56 3.3.3.2.1 Weighted saliva cortisol concentration In addition to raw saliva cortisol
concentration, normalized saliva cortisol concentration weighted by morning cortisol was also
computed. To eliminate individual differences, saliva cortisol concentrations were normalized by the
saliva cortisol concentration taken during early-morning according to equation (3.9). (3.9) 3.3.3.2.2 Data
cleaning method for saliva cortisol concentration to measure fatigue Two types of data manipulation,
Area Under the Curve with respect to ground (AUCG) and increase (AUCI), were performed to analyze
the cortisol concentrations in saliva samples (Fekedulegn et al., 2007) (Equation 3.10 and 3.11). These
two measures of salivary cortisol concentration were obtained by using the method developed by
Pruessner et al. (J. C. Pruessner, Kirschbaum, Meinlschmid, & Hellhammer, 2003). AUCG estimates total
cortisol secretion during the entire session and predicts the mean cortisol secretion, while AUCI
measures the sensitivity of the Hypothalamus-PituitaryAdrenal (HPA) axis activity over time (Edwards,
Clow, Evans, & Hucklebridge, 2001; Fekedulegn, et al., 2007; Schmidt-Reinwald et al., 1999). (3.10) 𝑜 𝑚𝑎
𝑖𝑧𝑒 𝑎 𝑖𝑣𝑎 𝐶𝑜 𝑡𝑖𝑠𝑜 𝐶𝑜𝑛𝑐𝑒𝑛𝑡 𝑎𝑡𝑖𝑜𝑛 𝑏𝑎𝑠𝑒 𝑜𝑛 𝑚𝑜 𝑛𝑖𝑛 𝑐𝑜 𝑡𝑖𝑠𝑜 , 𝐶 = 𝐸𝑎 𝑦 𝑜 𝑛𝑖𝑛 𝐶𝑜 𝑡𝑖𝑠𝑜 , 𝐶 𝑎 𝑖𝑣𝑎 𝐶𝑜 𝑡𝑖𝑠𝑜
𝐶𝑜𝑛𝑐𝑒𝑛𝑡 𝑎𝑡𝑖𝑜𝑛, 𝐶 𝐸𝑎 𝑦 𝑜 𝑛𝑖𝑛 𝐶𝑜 𝑡𝑖𝑠𝑜 , 𝐶 𝐴𝑈𝐶𝐺 = 𝑚(𝑖+1) + 𝑚𝑖 2 𝑡(𝑖) 𝑛 1 𝑖=1 57 (3.11) Equation
reference: (J. C. Pruessner, et al., 2003) 3.4 Participants Sixteen self-reported healthy participants with
no medical conditions (back pain, shoulder or neck pain, buttock pain, or headache) and 20/20 natural
or corrected eye vision volunteered for the study (descriptive statistics are presented in Table 3.2). No
other exclusion criteria were used. Eight Indian and eight Western participants were randomly selected
for the study. Four participants from each ethnicity were observed (completed the experiment) during
morning hours (between 8:00AM and 12:00PM (noon)). Another four participants from the same
ethnicity were observed during afternoon hours (between 1:00PM and 5:00PM). To aid in later analyses,
groupings for self-reported task-independent and lifestyle factors were created and used in later
analyses due to the small sample size. Logical groupings were made to test the effects of task-
independent and personal variables on perceived fatigue scores. The logical groupings are provided in
Table 3.3. Overall demographic statistics are provided in Table 3.2. The mean age of participants was
28.69 years . Mean daily hours of sleep were reported to be within a normal sleeping range ( ). Detailed
demographic information can be found from Table 3.2 to Table 3.5. In comparison to the Westerners,
Indian participants reported higher weekly working hours in the primary occupation as well as in all
occupations. End of the day fatigue on a regular working day was also observed to be 𝐴𝑈𝐶𝐼 = 𝐴𝑈𝐶𝐺 𝑚1
(𝑖) 𝑛 1 𝑖=1 58 higher for Indians than Westerners. Monday morning fatigue, weekly exercise frequency,
and hours of daily rest after work were reported to be similar by both ethnic groups. Table 3.2 Group
wise demographic statistics Variable Value Frequency Percent Variable Value Frequency Percent A 23 2
12.50 TW 35 1 6.25 24 1 6.25 44 1 6.25 25 3 18.75 48 1 6.25 26 1 6.25 50 3 18.75 29 1 6.25 54 1 6.25 30
2 12.5 56 2 12.50 31 3 18.75 60 2 12.50 32 1 6.25 64 1 6.25 35 1 6.25 70 3 18.75 39 1 6.25 74 1 6.25 Eth I
8 50.00 EDF 1 1 6.25 W 8 50.00 2 2 12.50 Sl 6.5 5 31.25 3 4 25.00 7.5 10 62.50 4 5 31.25 9.5 1 6.250 5 3
18.75 W 30 1 6.25 7 1 6.25 40 6 37.50 MMF 0 14 87.50 50 6 37.50 2 2 12.50 60 3 18.75 Ex 0 5 31.25 DR 1
1 6.25 2 1 6.25 2 7 43.75 3 6 37.50 3 8 50.00 4 4 25.00 A = Age of a participant in years, Sl = Hours of
daily sleep, W = Weekly working hours in primary occupations, TW = Total weekly working hours in all
occupation, EDF = End of the day fatigue, MMF = Monday morning fatigue, Ex = Weekly exercise
frequency and DR = Daily rest in hours 59 Table 3.3 Frequency table for logical groupings Variable
Grouping Frequency Percent 23-29 8 50 Age in years (A) 30 2 12.5 31-39 6 37.5 Ethnicity (Eth) I 8 50 W 8
50 Hours of daily sleep (Sl) 6.5 5 31.25 7.5 10 62.5 9.5 1 6.25 Weekly working hours in the primary
occupation (W) 30-40 7 43.75 50 6 37.5 60 3 18.75 Total weekly working hours in all occupations (TW)
35-48 3 18.75 50-56 4 25 56-74 9 56.25 Fatigue at the end of a regular working day (EDF) 1-2 3 18.75 3-4
9 56.25 5-7 4 25 Monday morning fatigue (MMF) 0 14 87.5 2 2 12.5 Weekly exercise frequency (Ex) 0 5
31.25 2-3 7 43.75 4 4 25 Daily rest after work (DR) 1-2 8 50 3 8 50 60 Table 3.4 Overall demographic
statistics Number of Subjects Mean Std Dev Min Max Age (years) 16 28.69 4.43 23 39 Sleep (hours) 16
7.31 0.73 6.5 9.5 Hours worked weekly 16 46.88 8.48 30 60 Total weekly working hours in all
occupations 16 56.94 10.51 35 74 End of the day fatigue 16 3.69 1.41 1 7 Monday morning fatigue 16
0.25 0.66 0 2 Weekly exercise frequency 16 2.25 1.61 0 4 Daily rest after work (hours) 16 2.44 0.61 1 3
Table 3.5 Demographic statistics by ethnicity and working shift Eth Variable N Mean Std Dev Mini mum
Maxi mum Sh Mean Std Dev Minim um Maxi mum I Age (year) 8 29.25 2.35 25 32 M 30.75 4.69 23 39
Sleep (hour) 8 7.00 0.50 6.5 7.5 7.50 0.87 6.5 9.5 Weekly working hours 8 50.00 8.71 40 60 43.75 8.62 30
60 Total weekly working hours 8 63.00 8.89 50 74 54.13 11.43 35 74 End of the day fatigue 8 4.38 1.33 3
7 3.75 1.40 2 7 Monday morning fatigue 8 0.25 0.67 0 2 0.50 0.87 0 2 Weekly Exercise frequency 8 2.13
1.70 0 4 2.13 1.70 0 4 Daily rest after work (hour) 8 2.25 0.67 1 3 2.50 0.50 2 3 W Age (year) 8 28.13 5.77
23 39 A 26.63 2.97 23 31 Sleep (hour) 8 7.63 0.79 6.5 9.5 7.13 0.49 6.5 7.5 Weekly working hours 8 43.75
7.00 30 50 50.00 7.12 40 60 Total weekly working hours 8 50.88 8.29 35 64 59.75 8.68 48 70 End of the
day fatigue 8 3.00 1.13 1 4 3.63 1.42 1 5 Monday morning fatigue 8 0.25 0.67 0 2 0.00 0.00 0 0 Weekly
Exercise frequency 8 2.38 1.50 0 4 2.38 1.50 0 4 Daily rest after work (hour) 8 2.63 0.49 2 3 2.38 0.70 1 3
Note: Eth=Ethnicity, I=Indian, W=Westerner, Sh=Working shift, M=Morning, A=Afternoon 61 Table 3.5
shows demographic statistics by ethnicity within a working shift, indicating a balanced design of
experiments with respect to both ethnicity and working shift. Most variables are comparable within
each ethnicity group by working shift. However, a few trends were observed. For example, weekly
working hours in primary occupations were observed to be higher for Indian participants (Morning and
afternoon ) as compared to western participants (Morning and afternoon ) in both working shifts.
Similar observations were also seen for total weekly working hours in all occupations. 3.5 Power analysis
Power analysis is given in Table 3.7. The lowest power obtained from the study was for the saliva
cortisol concentration for non-normalized data. However, normalized saliva cortisol concentration
provides power of more than 90% considering that fact that if the interactions are not obtained
significant. Strong power was obtained for the time variable. However, normalized cortisol produced
more power for ethnicity and time. 62 Table 3.6 Demographic statistics by ethnicity within a working
shift Indian Westerner Sh P Vari able N Mean Std Dev Mini mum Maxi mum Mean Std Dev Mini mum
Maxi mum M 4 Sl 40 7.25 0.44 6.5 7.5 7.75 1.10 6.5 9.5 W 40 45.00 8.77 40 60 42.50 8.40 30 50 TW 40
58.50 9.96 50 74 49.75 11.24 35 64 EDF 40 4.25 1.66 3 7 3.25 0.84 2 4 MMF 40 0.50 0.88 0 2 0.50 0.88 0
2 Ex 40 1.75 1.81 0 4 2.50 1.52 0 4 DR 40 2.25 0.44 2 3 2.75 0.44 2 3 A 40 29.50 2.32 26 32 32.00 5.99 23
39 A 4 Sl 40 6.75 0.44 6.5 7.5 7.50 0.00 7.5 7.5 W 40 55.00 5.06 50 60 45.00 5.06 40 50 TW 40 67.50 4.39
60 70 52.00 3.20 48 56 EDF 40 4.50 0.88 3 5 2.75 1.32 1 4 MMF 40 0.00 0.00 0 0 0.00 0.00 0 0 Ex 40 2.50
1.52 0 4 2.25 1.50 0 4 DR 40 2.25 0.84 1 3 2.50 0.51 2 3 A 40 29.00 2.38 25 31 24.25 0.84 23 25 Sh =
Working shift, M = Morning, A = Afternoon, P = Participants, A = Age of a participant in years, Sl = Hours
of daily sleep, W = Weekly working hours in primary occupations, TW = Total weekly working hours in all
occupation, EDF = End of the day fatigue, MMF = Monday morning fatigue, Ex = Weekly exercise
frequency and DR = Daily rest in hours 63 Table 3.7 Post-hoc power analysis DV Source Ethnicity Time
Borg 0.997 >0.999 SOFI 0.985 0.9950 ∆HR 0.290 >0.999 NASA 0.41 0.999 0.965 MAUCI >0.999 0.990
MAUCG >0.999 0.992 Borg = one-dimensional fatigue scores measured in Borg scale, SOFI =
multidimensional fatigue scores measured in Swedish Occupational Fatigue Inventory, NASA = workload
measured in NASA-TLX, ∆HR = change in heart rate (bit per minute), CRT=saliva cortisol concentration,
NCRT=Normalized saliva cortisol concentration by morning cortisol, AUCI= area under the curve with
respect to increase for salivary cortisol, AUCG= area under the curve with respect to ground for salivary
cortisol, MAUCI= area under the curve with respect to increase for normalized salivary cortisol, and
MAUCG= area under the curve with respect to increase for normalized salivary cortisol. 3.6 Procedure
Each participant was given a verbal and written description of the experiment and was required to
complete an Informed Consent document approved by the Institutional Review Board (IRB) for Research
Involving Human Subjects at Mississippi State University. Participants were asked to complete a
demographic questionnaire (APPENDIX A) after the informed consent procedure. The heart-rate monitor
was then attached according to manufacturer guidelines, and a resting heart rate assessment was
conducted. The first saliva sample and all baseline subjective assessments were collected 64 just prior to
the start of the first two hours of testing. At each 30-minute interval within each two-hour testing block,
the subjective fatigue and workload assessments were collected. After the end of the first two hours of
testing, a 15-minute break was provided, and all measures were collected. Procedures for the first-two-
hour test session were replicated for a second-two-hour testing session.
COPING MECHANISMS
Coping strategies among nurses in South-west

Ethiopia: descriptive, institution-based cross-sectional
study
Tesfaye, Tadesse Dagget.BMC Research Notes; London Vol. 11, (2018). DOI:10.1186/s13104-
018-3557-5
Objective
This study aimed to describe coping strategies for job stress among nurses working in Jimma Zone
public hospitals, South-west Ethiopia. The study conducted from March to April 2014 through census
using English version structured self-administered questionnaire.
Result
This study indicated percentage mean overall score of 65.07% for adaptive coping approach and
56.86% for a maladaptive approach. Nurses mostly used coping strategy were; just concentrating on
what they have to do, make a plan of action and following it, developing coworker/peer support, and
having a close friend to tell. While, coping strategy that least used among nurses were; do not want
to come to work when stressed, directly expressing anger on family or friends, trying to feel better by
taking drinks like tea, coffee, soft drinks more than usual and accept the situation because there is
nothing to do. In summary, an adaptive approach was dominant style; social support and plan-full
problem solving were the most preferred strategies. While escape-avoidance coping strategy least
used. Further researches need to be conducted to explore its predictors.
https://search.proquest.com/central/docview/2071820084/abstract/8310CF48AE0445B2PQ/3?accounti
d=35994
Introduction Coping has been described as any cognitive and/or behavioral eforts to manage, minimize,
or tolerate events that individuals perceive as potentially threatening to their well-being. It does not
imply success in dealing with situations, the responses to stressors can also be maladaptive. According
to Folkman and Lazarus transactional theories of stress, it places emphasis on subjective perceptions of
stressors, and individual diferences in ways of coping, viewing problems, past experience,
personalitytype, etc [1, 2]. All these may be important in informing and afecting the workplace–
individual stress interaction [3]. Te two forms of coping are problem-focused and emotion-focused
coping strategies. Problem-focused coping strategies are problem-solving tactics. Tese strategies
encompass eforts to defne the problem, generate alternative solutions, weigh the costs and benefts of
various actions, take actions to change what is modifable, and, if necessary, learn new skills. Emotion-
focused coping strategies are directed toward decreasing emotional distress. Tese tactics include eforts
like distancing, avoiding, selective attention, blaming, minimizing, wishful thinking, venting emotions,
seeking social support, exercising, and meditating. Emotion-focused coping is the more common form of
coping used when events are not change able [4]. A study in Malaysia in public hospital indicated six
most preferred coping mechanisms by nurses to reduce job stress were; to have a close friend to confne
in, compartmentalize work and home life, hobbies, leisure activities, recreation and turn to prayer or
spiritual thoughts, plan instead of responding to pressure, and building work-group norms of
cooperation, not competition. While, use of tranquilizers/drugs, leave a job for another and take it out
on family/friends were coping mechanisms never preferred by nurses in descending order. In summary
by theme, nurses coping mechanisms in a Open Access BMC Research Notes *Correspondence:
tadesse.dagget@yahoo.com; tadessed@bdu.edu.et Department of Adult Health Nursing, College of
Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia Tesfaye BMC Res Notes (2018)
11:421 Page 2 of 6 descending order were control, social support, escape, and symptom management
[5]. Studies have shown that majority of nurses prefer more active coping strategies/positive
reappraisal, plan-full problem solving and seeking social support and a few use avoidance coping
strategies like blame someone else for their problem, sleep more than usual and eat more [6–8]. Te
work setting is the main reason for job stress [9]. Job stress is one of the major psychosocial risks at
work and a great concern for many organizations and employees [10]. Little is known about the coping
strategies among nurses in our country Ethiopia especially in nurses working in Jimma Zone public
hospitals. Tis research has identifed coping mechanism implemented by nurses to reduce job stress in
Jimma zone public hospitals. Several investigations on the coping mechanism for job stress were done in
many developed countries and some African countries. However, research on how to cope job stress
among nurses working in hospitals in Ethiopia to the best knowledge of the investigator it is still
insufcient. Te aim of this study was to assess coping strategy among nurses working in Jimma Zone
public hospitals, South-west Ethiopia. Main text Methods and materials Study area and period Tis study
conducted in Jimma Zone, Oromia National Regional State, where its zonal city is Jimma that far 325 km
from Addis Ababa [11]. Tree public hospitals (Jimma University specialized hospital (JUSH), Shenen Gibe
and Limu Genet hospital) involved in the study. Te study was carried out from March to April 2014 in
these three public hospitals. Study design A cross-sectional study was conducted among nurses with
greater or equal to 6 months of work experience and those who were available at work at Jimma Zone
public hospitals during data collection period. Sample size A total of 433 nurses were available in the
study hospitals, among those only 73 were less than 6 months of experience and the rest 360 involved in
the study by a census. Data collection instrument English version structured self-administered
questionnaire developed through adaption from expanded nursing stress scale used for data collection
[12]. It contains three sections that suit the purpose of the study. Part-I consists of socio-demographic
questions. Part-II contains eighteen items on the coping mechanism used to measure coping with job
stress. Te items are divided into fve types of coping mechanisms (5 sub-scales). Tey are plan-full problem
solving (has 5 items), self-control mechanism (has 2 items), social support (has 3 items), symptom
management mechanism (has 3 items), and escape/avoidance mechanism (has 5 items). Respondents
requested to score each item rated on a four-point Likert item with a score ranging from 1 to 4 where ‘1’
“I never do this”, ‘2’ “I sometimes do this”, ‘3’ “I frequently do this” and ‘4’ “I always do this”. To identify
coping strategy, the total score for adaptive approach obtained by adding all the scores of 13 items and
their sum score range a minimum score of 13 and maximum of 52 which indicates the higher the score
the preferred coping strategy used by the nurse while for maladaptive approach the score of the 5 items
added and their sum score range a minimum score of 5 and maximum of 20 which indicates the higher
the score the preferred coping strategy used by the nurse. Te questionnaire was pretested at Woliso St.
Luke Hospital before the start of actual data collection and necessary comments and feedback taken and
incorporated. Overall Cronbach’s alpha score for overall adaptive coping measuring items 0.86,
maladaptive coping measuring items 0.76.
Quality of Nursing Care
The lived meaning of quality nursing care for practicing nurses was meeting human needs
through caring, empathetic, respectful interactions within which responsibility, intentionality,
and advocacy form an essential, integral foundation (Burhans, 2008).
What is good nursing care? The lived meaning of

quality nursing care for practicing nurses
Burhans, Linda Maas.East Carolina University, ProQuest Dissertations Publishing, 2008. 3303665.
https://search.proquest.com/central/docview/304367260/abstract/D25535D7FE894BADPQ/2?accou
ntid=35994
March 25, 2019

Abstract
TranslateAbstract
Healthcare quality in the United States of America (USA) is the subject of intense criticism.
Although quality nursing care is vital to patient outcomes and safety,
meaningful quality improvements have been disturbingly slow and incremental. Practicing nurses are
rarely involved in developing improvement programs and their
definitions of quality nursing care have not been known. The lived
meaning of quality nursing care for practicing nurses was unknown and not addressed in the
literature. A premise of this study was that effective efforts to improve quality nursing care must be
meaningful and relevant to nurses. It was proposed that uncovering the lived
meaning of quality nursing care would facilitate development of effective improvement approaches.
The purpose of this study was to uncover the lived meaning of quality nursing care for nurses
practicing in acute care hospitals. This lived meaning was revealed through analysis of practicing
nurse interviews using van Manen's (1990) hermeneutic phenomenology, a research approach
designed to explore and uncover the lived meaning of pragmatic experiences. The research
question asked: "What is the lived meaning of quality nursing care for practicing nurses in the USA?"
Participants were 12 nurses practicing on medical or surgical adult units at general or intermediate
levels of care within acute care hospitals who participated in semi-structured interviews. Emerging
themes were discovered through empirical and reflective analysis of audiotapes and transcripts.
The lived meaning of quality nursing care for practicing nurses was meeting human needs through
caring, empathetic, respectful interactions within which responsibility, intentionality, and advocacy
form an essential, integral foundation. The lived experience ofquality nursing care resided within
nurse-patient interactions. The lived meaning of quality nursing care for these practicing nurses was
within the art of nursing rather than the science of nursing.
Practicing nurses, managers, administrators, educators, researchers, and policy makers may use
these findings to further define the discipline of nursing and to facilitate practice changes, driving
improvements in the quality of nursing care. Future studies based on this understanding of the lived
meaning of quality nursing care could begin to address this focus in an effort to
improve qualitypatient care.
file:///C:/Users/May%20Therese/Downloads/What_is_good_nursing_care_The.pdf
Factors influencing nurse‐assessed quality nursing

care: A cross‐sectional study in hospitals
Liu, Ying; Aungsuroch, Yupin.Journal of Advanced Nursing; Oxford Vol. 74, Iss. 4, (Apr 2018):
935-945.DOI:10.1111/jan.13507
https://search.proquest.com/central/docview/2011999616/D25535D7FE894BADPQ/3?accountid=35
994
To propose a hypothesized theoretical model and apply it to examine the structural relationships
among work environment, patient‐to‐nurse ratio, job satisfaction, burnout, intention to leave
and quality nursing care.
Background
Improving quality nursing care is a first consideration in nursing management globally. A better
understanding of factors influencing quality nursing care can help hospital administrators implement
effective programmes to improve quality of services. Although certain bivariate correlations have
been found between selected factors and quality nursing care in different study models, no studies
have examined the relationships among work environment, patient‐to‐nurse ratio, job satisfaction,
burnout, intention to leave and quality nursing care in a more comprehensive theoretical model.
Design
A cross‐sectional survey.
Methods
The questionnaires were collected from 510 Chinese nurses in four Chinese tertiary hospitals in
January 2015. The validity and internal consistency reliability of research instruments were
evaluated. Structural equation modelling was used to test a theoretical model.
Results
The findings revealed that the data supported the theoretical model. Work environment had a large
total effect size on quality nursingcare. Burnout largely and directly influenced quality nursing care,
which was followed by work environment and patient‐to‐nurse ratio. Job satisfaction indirectly
affected quality nursing care through burnout.
Conclusions
This study shows how work environment past burnout and job satisfaction
influences quality nursing care. Apart from nurses’ work conditions of work environment and patient‐
to‐nurse ratio, hospital administrators should pay more attention to nurse outcomes ofjob satisfaction
and burnout when designing intervention programmes to improve quality nursing care.
Quality nursing care in the words of nurses

Burhans, Linda Maas; Alligood, Martha Raile.Journal of Advanced Nursing;
Oxford Vol. 66, Iss. 8, (Aug 2010): 1689. DOI:10.1111/j.1365-2648.2010.05344.x
TranslateAbstract
https://search.proquest.com/central/docview/580123732/D25535D7FE894BADPQ/4?accountid=359
94
This paper is a report of a study of the meaning of quality nursing care for practising nurses.
Healthcare quality continues to be a subject of intense criticism and debate.
Although quality nursing care is vital to patient outcomes and safety, meaningful improvements have
been disturbingly slow. Analysis of quality care literature reveals that practising nurses are rarely
involved in developing or defining improvement programs for quality nursing care. Therefore, two
major study premises were that qualitynursing care must be meaningful and relevant to nurses and
that uncovering their meaning of quality nursing care could facilitate more effective improvement
approaches. Using van Manen's hermeneutic phenomenology, meaning was revealed through
analysis ofinterviews to answer the research question 'What is the lived
meaning of quality nursing care for practising nurses?' Twelve nurses practising on medical or
surgical adult units at general or intermediate levels of care within acute care hospitals in the United
States of America were interviewed. Emerging themes were discovered through empirical and
reflective analysis of audiotapes and transcripts. The data were collected in 2008. The revealed lived
meaning of quality nursing care for practising nurses was meeting human needs through caring,
empathetic, respectful interactions within which responsibility, intentionality and advocacy form an
essential, integral foundation. Nurse managers could develop strategies that support nurses better in
identifying and delivering qualitynursing care reflective of responsibility, caring, intentionality,
empathy, respect and advocacy. Nurse educators could modify education curricula to model and
teach students the intrinsic qualities identified within these meanings of quality nursing care.
Patient perceptions of quality of nursing care as

evidenced by nurse caring behaviors
Reiss, Penny J.Loyola University Chicago, ProQuest Dissertations Publishing, 2005. 3174260.
https://search.proquest.com/central/docview/304990427/abstract/D25535D7FE894BADPQ/8?accou
ntid=35994
Lack of quality of care threatens patient safety and results in increased costs of health care. It is
critical for nursing to examine quality of care at the nurse-patient interaction level and gain an
understanding of patients' perceptions of both the interpersonal and technical
components of nursing care for a comprehensive representation of the consumer perspective. The
purposes of this study were to use a patient perspective to identify those nursing behaviors having
the highest correlation to quality of nursing care, to investigate differences in
ratings of quality of nursing care between patients without a nursing background and patients with
a nursing background (including basic technical skill), and examine for differences in
ratings of quality of nursing care based on age, educational level, gender, and
number of hospitalizations.
A retrospective, descriptive study design was used with a sample of two groups of patients recently
discharged from the hospital, patients with and patients without a nursing background. Four Midwest
hospitals participated. Two instruments were employed; a Quality of Nursing Care Visual Analog
Scale and Wolf's Caring Behaviors Inventory. Pearson's correlation coefficients, independent t-tests,
and ANOVA were used for data analysis.
One hundred, fifty subjects completed surveys; 75 patients with a nursing background and 80
patients without a nursing background. Findings demonstrated strong correlations between overall
QNCVAS scores and all subscales ratings of the CBI and total CBI scores. No significant
differences of ratings of either nurse caring behaviors or quality of nursing care between the two
subgroups were identified. No significant differences were found in any of the demographics.
Implications for future research include the use of a visual analog scale for
measuring quality of nursing care and the confirmation of specific nurse behaviors valued by patients
as promoting highest quality care for educational purposes.
Pls read this

file:///C:/Users/May%20Therese/Downloads/Patient_perceptions_of_quality.pdf
Identifying descriptions of quality nursing care shared

by nurse and patient in the acute care hospital
environment
Grimley, Karen A.Florida Atlantic University, ProQuest Dissertations Publishing, 2015. 10095876.
https://search.proquest.com/central/docview/1782319889/abstract/DF25C88628564E4FPQ/9?accou
ntid=35994
Abstract
TranslateAbstract
Nursing care is considered a primary predictor of patient assessment of the overall hospital
experience. Yet, quality nursing careremains difficult to define. Limited research about nurse or
patient perspectives on what constitutes quality nursing care in hospital settings prevents the
identification of a shared description or insight into their possible interrelationship. Research about
nurse and patient descriptions is needed to establish behaviors, attributes, and activities associated
with quality nursing care to improve the health and well-being of hospitalized patients.
The purpose of this qualitative study was to identify nurse and patient descriptions
of quality nursing care in the acute care hospital environment. Descriptions shared by nurse and
patient could add clarity to the term quality nursing care by naming aspects of the hospital
experience that are mutually recognized as quality nursing care. Findings from this study include 10
descriptions of qualitynursing care shared in varying degrees by nurse and patient in the hospital
setting. They include nursing vigilance, raising patient awareness, nurse approach to work, rapport,
caring behaviors, having enough time, staying one step ahead, nurses are knowledgeable, isolated
and ignored, and clinical safety. These descriptions can be used to explicate the
term quality nursing care, which could facilitate the identification of aspects of the nurse-patient
experience that influence patient well-being, satisfaction, and clinical outcomes.
PLS SEE
file:///C:/Users/May%20Therese/Downloads/Identifying_descriptions_of_qu.pdf

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CHAPTER II

REVIEW OF RELATED LITERATURE AND STUDIES

Nursing care in ICU

 Taking regular blood tests

Read more: http://www.healthtalk.org/peoples-experiences/intensive-care/intensive-care-patients-

Intensive care units (ICUs)

Who is cared for in ICU?

 complex spinal surgery

What to expect in ICU

Visiting is usually restricted to people the patient considers to be immediate family.

Patient and family support services

Speak to ICU staff if you would like to use interpreting services.

For an Australian patient in a public hospital in Western Australia:

 public patient – no cost to you unless advised otherwise

 Patients are monitored 24 hours a day.

Empowerment and autonomy among continuing care

Authority and autonomy of staff nurses providing

Intuition, autonomy, and level of clinical proficiency

An examination of leadership readiness and

Workplace empowerment and job performance in

Professional development among registered nurse to

This study used a non-experimental, cross-sectional design with a convenience sample of 96

Results from the PDSAM suggested a significant difference between

The Nurse and the Work Environment

The emotional well-being of the nurse within the multi-

March 25, 2019

Factors characterizing supportive nursing care units for

March 25, 2019

Fatigue and Work Environment

PORTUGUESE VERSION OF THE SWEDISH

March 25, 2019

Level of Fatigue and Nursing Care

Fatigue in the workplace

Human fatigue in prolonged mentally demanding

March 25, 2019

Fatigue and Quality Nursing Care

Coping strategies among nurses in South-west

Quality of Nursing Care

What is good nursing care? The lived meaning of

March 25, 2019

Factors influencing nurse‐assessed quality nursing

Quality nursing care in the words of nurses

Patient perceptions of quality of nursing care as

Pls read this

Identifying descriptions of quality nursing care shared

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