Characterizing Fatigue Experienced by Registered Nurses

Objective: The U.S. health care system requires critical nursing services around the clock, resulting in many nurses working overnight hours and having irregular shifts. One symptom commonly associated with the nursing workplace is fatigue, affecting up to 80% of Registered Nurses (RNs). Fatigue is problematic for RNs because it is associated with burnout, absenteeism, job-related injury and reduced job performance. Factors

known to contribute to fatigue are physiological (e.g. sleep disturbances, physical health and nutritional deficiencies), psychological (e.g. depression, anxiety, coping style), and situational (e.g. shiftwork and high work demands). Fatigue in turn negatively affects cognitive performance including memory, attention, and reaction time, as well as mood and quality of life. The pathophysiological mechanisms underlying fatigue are complex and not well understood. Hypothesized pathways include inflammation and autonomic dysregulation. The specific physiological, psychological and situational factors contributing to fatigue in RNs are unclear. Most studies in nurses look at fatigue in general, with few examining specific subtypes such as mental, physical, and emotional fatigue. Very few studies have examined fatigue in RNs longitudinally, nor have they explored the underlying pathophysiology. Little is known about the downstream effects of fatigue on nurses cognitive performance or on their ability to enjoy and participate in life outside of work. Thus, the objective of this study is to characterize fatigue experienced by RNs and to examine the physiologic, psychologic, and situational factors that contribute to fatigue and its subtypes.

AIMS: The primary AIM is to characterize the levels and types of fatigue experienced by RNs, and to examine the physiologic, psychologic and situational factors contributing to fatigue and its subtypes in RNs. The secondary AIM is to examine the relationship between fatigue with cognitive performance, mood, life satisfaction, and the ability to participate in social roles/activities in RNs and to assess changes in cognitive performance and mood over the course of three working days. The exploratory AIM is to explore molecular and clinical biomarkers associated with fatigue in a subset of RNs.

Study population: This study will occur in two parts. Phase I will recruit from a pool of approximately 1,275 RNs at the NIH Clinical Center, and we anticipate that 400 RNs will participate. Phase II will enroll up to 60 RNs, in order to obtain 40 RNs who complete all study timepoints.

Design: This study will utilize an adaptive design whereby a preliminary, anonymous cross-sectional surveyinvolving a large cohort of RNs will address the primary and secondary AIMs (Phase I). Phase II will utilize a prospective, repeated measures design to collect biomarkers of fatigue and health, along with more detailed psychologic, situational, and performance outcomes in a small subset of RNs (n = 40) at multiple time points including baseline (48+ hours after last working) and at the start and conclusion of three consecutive workdays. Phase II will address the primary and secondary AIMS in greater depth and over time, while addressing the exploratory AIMs of the study.

Outcome measures: The primary outcome is fatigue, using the Multidimensional Fatigue Symptom Inventory- Short Form (MFSI-SF) and Occupational Fatigue Exhaustion Recovery (OFER) scale used to: (1) determine the levels and types (general, physical, emotional, mental, acute and chronic) of fatigue experienced by RNs (Phase I), (2) examine whether fatigue and its subtypes change over time (Phase II); and (3) determine which physiologic (sleep disturbance, physical health, nutritional status), psychologic (depression, anxiety, self-efficacy, coping style), and situational (job type, work hours, work demands, professional quality of life, outside demands) factors contribute to fatigue in RNs. Secondary outcomes include downstream performance outcomes believed to be related to fatigue including NIH toolbox measures of cognitive performance, Profile of Mood States (POMS), and PROMIS measures of life satisfaction and the ability to perform social roles/activities. Exploratory factors that potentially influence fatigue (MFSI-SF) will be examined in Phase II including markers of autonomic function (orthostatic blood pressure (BP) and inflammation (hs-CRP, TNF-alpha, IL-6, IL1-beta, and GlycA).