Introduction/ Background Fatigue is real and it hurts

Introduction/ Background
Fatigue is real and it hurts. In that it can be disabling to its sufferer as well as have negative implications for the institution and the community if left unchecked. According to Dave (2017), “fatigue is a common dilemma”. In a study done it was estimated that physical fatigue accounted for 20-60% and mental fatigue 40-80% of the 20% of Americans who claimed to have experience fatigue intensely enough that they were unable to lead a normal life (Dave 2017).
People who complain of fatigue use words such as weary, tired, exhausted, malaise, listless, lack of energy and feeling run down (Dave 2017). It is also known that there are several conditions or disease processes that can cause an individual to feel fatigue (Lewis and Wessely 1992, p. 93) such as anemia, malignancies, HIV and other serious infections, cardiac arrythmias, chronic obstructive pulmonary diseases, multiple sclerosis, autoimmune disorders, thyroid problems, Parkinson’s disease (Wilson, Morgan, Magin, and Drie, 2014).

Furthermore, fatigue has negative implications not only to the sufferer but also to the institution and to patient outcome/ experience. According to Rosenberg (2014) and Caruso (2012), fatigue in the workplace can be very costly and dangerous; costing the institution approximately $2,000 to $10,000 per employee per annum as a result of workload and staffing imbalances: understaffing leading to absenteeism, decrease in effectiveness at work, increase in worker turn over which may be a result of disability, death or resigning to take a less demanding job schedule. Furthermore, Caruso (2012) added that risks can also extend to the community when the tired nurse commutes home and meets into a motor-vehicle accident or makes a medication error.
Fatigue can have such an impact on the body so much so that “Multiple studies have found that performance in a person who has been awake for 17 hours or more resembles that of someone with alcohol intoxication” (Caruso 2012). Sleep disturbances from long hours and shift work is deemed the major contributory factor to effects of fatigue: it reduces immunologic functioning, increase risks for depression, injury, heart problems, gastrointestinal disorders and cancers (Caruso 2012). “Sleep deprivation has been long recognised as an unmet public health challenge” (Steve et. al 2012). A 2010 study was conducted which revealed that “the percentage of American healthcare workers who reported 6 or fewer hours of sleep per day (too little, according to sleep experts) increased from 28% in the mid-1980s to 32% in the mid-2000s. So, it’s likely that a growing number of nurses aren’t getting enough sleep” says Caruso (2012).
Utilizing the Walker and Avant techniques (2011), this paper seeks to highlight the aims and purpose of the fatigue analysis, to explore the various uses of fatigue and identify the defining attributes and assess for a commonality. Model cases, borderline cases as well as a contrary case will be constructed to illustrate the different scenarios that fatigue embodies. Lastly, antecedents and consequences will be identified, empirical referents defined and the implication of the concept for nursing research (Thompson 2018) in Jamaica.
In undertaking the analysis of the concept ‘fatigue’, several research articles, scholarly journals and internet search engines were reviewed. The concept fatigue has been frequently utilized in healthcare, sociology, psychology, engineering and other disciplines.
Aims and Purpose of the Analysis of Fatigue Determined
Fatigue, as indicated in several sources, is a major hazard to the wellbeing of the individual, the industry and the community. As the various literatures sought to bring greater insight on the phenomena of fatigue, it was observed that there are several instruments or tools available to measure the impact of sleep deprivation on fatigue (Åkerstedt, 2004), as well as the precursors to fatigue based of sociodemographic associations and population norms (Dittner, Wesseley ; Brown, 2004). Furthermore, because fatigue can be a symptom of a disease process, the purpose and aim of this paper is therefore to explore the concept fatigue to determine how well the concept is understood, assess measures used to differentiate fatigue from that caused by an underlying condition as a as well as to assess the applicability and practicality of the various measures/ tools used in early fatigue detection within various institutions or disciplines.
Uses of the Concept Fatigue
Fatigue is a term that was first coined in the1690s from the French word ‘fatiguer which means to ‘to tire’, in Latin ‘fatigare’ meant ‘to weary or tire out’. It was not until 1719 that the term was associated to the feeling of weariness from exertion’ that was attributed to labors of military persons (Online Etymology Dictionary).
Fatigue, according to the Concise Oxford Dictionary 11th edition (2008), is “extreme tiredness resulting from mental or physical exertion or illness; a lessoning of one’s response to or enthusiasm for something; caused from overexposure”.
According to the Free Dictionary.com, “fatigue is defined as physical or mental exhaustion that can be triggered by stress, medication, overwork, or mental or physical illness or disease. It is the body’s way of signaling its need for rest and sleep. However, when fatigue persist beyond normal sleepiness it is usually a sign that something is amiss”.
Physical fatigue as defines by the Free Dictionary.com involves the feeling of a marked lack of energy involving muscle weakness, slowed movements as well as a decrease in central nervous system reactions. Mental fatigue, a consequent of persistent physical fatigue can lead to difficulty concentrating, feeling of mental fuzziness, and even memory loss.

According to the American College of Occupational and Environmental Medicine, fatigue is “the body’s response to sleep loss or to prolonged physical or mental exertion”, (Rosenberg 2014).

According to Mechanical engineering (2008), fatigue is “the process of localized permanent structural change occurring in a material subjected to conditions that produce fluctuating stresses and strains at some point or points and may culminate in cracks or complete fracture after a sufficient amount of fluctuations”.
In sociology, fatigue is defined as “complex, representing simultaneously a physiological, psychological and social phenomena”, (Loriol 2017).

In psychology, fatigue can refer to a subjective symptom of malaise and aversion to activity or to objectively impaired performance. It has both physical and mental aspects”, (Sharp &Wilks, 2002).

In further analysis of the concept ‘fatigue’, other terms were used to describe the phenomena such as compassion fatigue. Compassion fatigue, a term coined in 1992 by Carla Joinson, is a consequent of overpowering, invasive stress that can begin to dominate us and interfere with our ability to function, hence we become angry, ineffective, apathetic and depressed”, (Carlson 2013).
Determining the defining Attributes
Having reviewed several literatures analyzing the concept fatigue it was possible to identify the commonalities that existed. McKenna (1997) said that,
The characteristics of the concept that occurs again and again represent the hallmark of what Walker ;Avant (1995) referred to as the defining attributes of the concept. In essence, the defining attributes distinguishes the concept from related or similar concepts. Hence it is argued that it is better to have three or four defining attributes that characterizes the concept well than to have many that are tangentially related to the concept.
It is therefore under this guidance that the following defining attributes for fatigue was selected:
Mental exhaustion/ Poor clinical judgement
Lack of motivation
Physical tiredness/weariness
Medical problems ensue: heart disease, stomach ulcers etc.

Model, Borderline and Contrary Cases
“According to McKenna (1997), developing a model and additional cases is valuable in clarifying abstract concepts such as those encountered in nursing” (Xyrichis and Ream, 2007). To illustrate and bring some clarity to the concept of fatigue the model, a borderline and a contrary case has been developed.

Model case
“A model case is an example of the concept that exhibits all of its defining attributes and qualities” (Reed, 2014). Reed (2014) further stated in a citing Walker and Avant (2011, p.163), description of a model case as ‘a pure case of the concept, a paradigmatic example, or a pure exemplar’.
Jessica, a 30 year old charge nurse, is working in the busy Emergency Department at the Kingston Public Hospital. Over the past few months Jessica has been working countless extra shifts due to dreaded staff shortages. Since then Jessica has been having stomach problems and occasional tension headaches and found herself to be more impatient and apathetic than usual but feels unable to control it as she often times feels overwhelmed. Jessica is on her first day off having worked 4 consecutive 12-hour shift and was called in to cover a shift as they could not find anyone else. Though feeling tired, Jessica was compelled to accept it as she felt that the department was depending on her. Jessica half way through the shift is now beginning to feel very weary and having difficulty concentrating. Jessica was asked to co-sign a Morphine order and instead of doing her normal due diligence co-signed without checking. About 5 minutes later she hears ‘code blue, patient in room 2 not breathing!’ Later Jessica realises, it was the same patient’s (elderly lady) drug she signed off on who received a dose of 10 mg IV stat as oppose to a titrated dose. Now Jessica is frustrated, angry and depressed for making such an error.
A borderline Case
“According to Walker and Avant (2011), a borderline case has many of the same elements as a model case however one or more of the defining attributes differs in some way. It is closely connected to the case, but has some dissimilarity that makes it inherently distinguishable from the concept being studied” (Xyrichus and Ream, 2007). The following is a borderline case of fatigue derived from the initial model case.

Jessica, a 30-year-old, is a charge nurse working in the busy Emergency Department at the Kingston Public Hospital has been working 4 consecutive 8-8pm shifts. Today Jessica is off and she received a call from her manager to cover a shift as she was next in line. Jessica feeling very tired having worked such long and busy shifts decided to forego the extra shift so she could get some time to rest as she was still feeling tired, though she had slept the night.

Contrary Case
According to Walker and Avant (2005), the contrary case of a conceptual model is a clear example of what the concept is not, (Brush, Kirk, Gultekin, Baiardi, 2012). Below, a contrary case is developed.

Jessica, a 30-year-old charge Nurse, is working in the busy ED at KPH and loves going to work. She is on a set day shift schedule where she works 3 days on and 3 days off with a full quota of staff on each shift. When the department is very busy, Jessica is able to call in additional staffing to cover the shifts or liaise-on with other departments to get patients moving quickly through the department. As a result, work is not overwhelming. When off from work, Jessica goes scuba diving with her friends, does yoga daily and maintains a healthy diet.

Antecedents and Consequences identified
“Walker and Avant (2005) describes antecedents as events or incidents that must occur prior to the occurrence of a concept, while consequences are events that occurs as a result of it” (Xyrichus and Ream, 2007). Therefore, identifying antecedents and consequences can shed some light on the social context in which the concept is used thereby helping to refine the defining attributes, as according to Walker and Avant (2005), an attribute cannot be an antecedent and a consequence at the same time (Xyrichus and Ream, 2007).See Figure 1 for illustration.

right5991(Attributes)
Self
Depressed/Angry
Difficulty concentrating
Poor clinical judgement
Feeling run-down/ tired
Lack of motivation
Medical problems arise
Increased absenteeism/resignation
00(Attributes)
Self
Depressed/Angry
Difficulty concentrating
Poor clinical judgement
Feeling run-down/ tired
Lack of motivation
Medical problems arise
Increased absenteeism/resignation
1887051669194(Consequences)
Community
Increased drug errors/ Accidents
Client dissatisfaction
00(Consequences)
Community
Increased drug errors/ Accidents
Client dissatisfaction
17294091391478002156322850900center324099Fatigued
Staff
0Fatigued
Staff
3309730881270(Antecedents)
Prolonged disruption in circadian rhythm
Demanding job/ long work hours
(Antecedents)
Prolonged disruption in circadian rhythm
Demanding job/ long work hours

28326514616200
2136913247429(Consequences)
Institution
COST
00(Consequences)
Institution
COST

19281914886700
Figure 1: illustrates the vicious cycle of fatigue and its impact on the individual, community and the institution.

Figure 1, summarizes the antecedents, attributes and consequences of fatigue on the individual, the community and the institution. It illustrates how certain factors such as alteration in the circadian rhythm due to lack of insufficient sleep and rotating shifts and overwork, can negatively impact the performance of an individual and how fatigue, when sets in, can be not only costly to the institution but also endangering to the staff, patients and patients’ experience. The individual/ nurse in knowledge of their errors/performance can become more depressed, angry which can in turn magnify the symptoms of fatigue on the individual. This can be greatly challenging for the nurse as their first mandate is to do no harm and many, if not all, have chosen their career path because they want to relieve suffering and make a difference (Carlson, 2013).

Empirical Referents
Empirical referents according to Lui, Avant, Aungsuroch, Zang, and Jiang (2014), “are classes or categories of actual phenomena that by their existence or presence demonstrate the occurrence of the concept itself”. This is very useful as by analysing the empirical referents, one can validate, not only the existence of the concept identified but also its significance in future research. Walker and Avant (2005) says empirical referents for the defining attributes is the final step in concept analysis (Xyrichis ; Ream 2007).
There is no doubt that fatigue exist in the real world. Clark (2008), a sociologist, in an article exploring accounts of researched fatigue with Qualitative research engagement, titled his article, ‘We’re Overresearched Here!’. Secondly, Graves (2009) declares that a growing number of scientific evidences demonstrate negative effects of fatigue on human performance. Thirdly, there are several tools or instruments that have been developed in various disciplines such as, Neurology, ‘The Fatigue Severity Scale used to test fatigue in two chronic illnesses: Systemic Lupus Erythematous and Multiple Sclerosis’, (Krupp, LaRocca, Muir-Nash & Steinberg, 1989). Furthermore, Alertometer used to “mitigate and detect driver drowsiness and fatigue using an integrated human factors and computer vision approach (Hammond & Zhang, 2008) and Fatigue Countermeasure Feasibility Study (FCMFS) to evaluate its feasibility in improving sleep duration and quality while reducing daytime sleepiness and patient errors (Scott, Hofmeister, Rogness &Rogers, 2010) was also developed. Lastly, a Fatigue Assessment Instrument was developed to describe psychometric properties and distinguish normal fatigue from fatigue related to medical disorders (Schwartz, Jandorf & Krupp, 1993). In addition, to measure/tools and research, there are also several literatures suggesting there are different types of fatigue: compassion fatigue (Carlson, 2013), central fatigue and peripheral fatigue (O’Connell ;Stokes, 2014), and chronic fatigue syndrome (Fukuda, 1994). Lastly, there are many nursing journals such as the ENA Connections and Journal of Emergency Nursing has highlighted several articles on fatigue or the consequences of it as well as conferences that have been held discussing the fatigue phenomena.
Implication for Nursing Research
Clark (2008), says that fatigue is a concept that has been over-researched. However, in spite of the fact that there is vast amount of information about the topic by various disciplines including nursing, there are no clear theories associated with the concept of fatigue. Secondly, though there are several tools developed to measure fatigue, they are not universally applicable or agreed on or acceptable as a result of their limitation. For example, the Numeric Rating Scale is said to be limited in defining how “functional capabilities relate to the numeric associated with it”, (O’Connell & Stokes 2014).

Thirdly, on reviewing the various definitions of fatigue, it was noted that there are disagreements regarding antecedents such as previous exertion leading to fatigue. For instance, O’Connell and Stokes (2014) was one who defined fatigue as a “state characterized by weariness unrelated to previous exertion…”. In essence, it can be argued that “fatigue is hard to define”, (O’Connell & Stokes, 2014) and complex (Hopwood, Nanjing, Donnellan &Shiatsu, 2010).
However, “Ream and Richardson (1996) in a large-scale concept analysis review of fatigue literature, proposed a clarified definition for the otherwise amorphous concept. The authors suggested ‘fatigue as a subjective, unpleasant symptom which incorporates total body feelings ranging from tiredness to exhaustion creating an unrelenting overall condition which interferes with an individual’s ability to function to their normal capacity” (O’Connell ;Stokes, 2014). With this discovery of a potentially universally accepted definition of fatigue, healthcare workers can now move forward in developing theories and instruments/ tools applicable to the health profession to help bring awareness and acceptance of the fatigue reality and its impact on healthcare on a whole.

Reference
Åkerstedt, T., Knutsson, A., Westerholm, P., Theorell, T., Alfredsson, L., ; Kecklund, G.
(2004). Mental fatigue, work and sleep. Journal of psychosomatic Research, 57(5), 427-433.

Brush, B. L., Kirk, K., Gultekin, L., ; Baiardi, J. M. (2011, July). Overcoming: A concept
analysis. In Nursing forum (Vol. 46, No. 3, pp. 160-168). Malden, USA: Blackwell Publishing Inc.
Carlson, Kathleen E. Compassion: Are You Satisfied or Fatigued? ENA Connections
(November 2013, Vol 37, Issue 10, pp 8-9)
Caruso, Claire C. “Better sleep: Antidote to on-the-job fatigue.” American Nurse Today 7.5
(2012).
Clark, T. (2008). We’re Over-Researched Here!’ Exploring Accounts of Research Fatigue
within Qualitative Research Engagements. Sociology, 42(5), 953-970.
Coetzee, S. ; Klopper, H. (2010). Compassion Fatigue with Nursing Practice: A concept
Analysis. Nursing and Health Science. 12 (2), 235-243
Davis, Charles P. Doerr. (2017, Nov. 09) Steven. Fatigue, Treatment and Causes. Retrieved
from www.emedicinehealth.com/fatigue/article_em.htm#what_is_fatigue
Dittner, A. J., Wessely, S. C., ; Brown, R. G. (2004). The assessment of fatigue: a practical
guide for clinicians and researchers. Journal of psychosomatic research, 56(2), 157-170.

Flynn-Evans, E. E., Arsintescu, L., Gregory, K., Mulligan, J., Nowinski, J., ; Feary, M.
(2018). Sleep and neurobehavioral performance vary by work start time during non-traditional day shifts. Sleep health.
Graves, K., ; Simmons, D. (2009). Reexamining fatigue: implications for nursing
practice. Critical care nursing quarterly, 32(2), 112-115.
Haraldsson, P. O., ; Akerstedt, T. (2001). Drowsiness–greater traffic hazard than alcohol.
Causes, risks and treatment. Lakartidningen, 98(25), 3018-3023.
Holleran, Renee S. How tired are we? Journal of Emergency Nursing (July 2012, Vol. 38,
No 4. pp 318).

Krupp, L. B., LaRocca, N. G., Muir-Nash, J., ; Steinberg, A. D. (1989). The fatigue severity
scale: application to patients with multiple sclerosis and systemic lupus erythematosus. Archives of neurology, 46(10), 1121-1123.
Lerman, S. E., Eskin, E., Flower, D. J., George, E. C., Gerson, B., Hartenbaum, N., … ;
Moore-Ede, M. (2012). Fatigue risk management in the workplace. Journal of Occupational and Environmental Medicine, 54(2), 231-258.
Loriol, M. (2017). A sociological stance on fatigue and tiredness: social inequalities, norms
and representations. Neurophysiologie Clinique/Clinical Neurophysiology, 47(2), 87-94.

McKenna, Hugh M. (1997). Determining defining Attributes. Routledge Essentials for
Nursing: Building Theory Through Concept Analysis. pp 62. New York, NY. Taylor ; Francis Group
O’Connell, Caroline. Stokes, Emma K. (2014). Fatigue. A Comprehensive Guide to Geriatric
Rehabilitation, (3rd Ed). pp.453
Online Etymology Dictionary, Retrieved September 25, 2018 from
http://www.etymonline.com/serach?q=fatigue
Reed, J. (2014). eHealth: a concept analysis from a nursing perspective. Can J Nurs
Inform, 9(1-2).
Rosenberg, K. (2014). The Joint Commission Addresses Health Care Worker Fatigue. AJN
The American Journal of Nursing, 114(7), 17.
Scott, L. D., Hofmeister, N., Rogness, N., & Rogers, A. E. (2010). An interventional
approach for patient and nurse safety: a fatigue countermeasures feasibility study. Nursing research, 59(4), 250-258. +
Sharpe, M., & Wilks, D. (2002). Fatigue. BMJ?: British Medical Journal, 325(7362), 480–
483.

Skinner, N., & Dorrian, J. (2015). A work-life perspective on sleep and fatigue—looking
beyond shift workers. Industrial health, 53(5), 417-426
Thompson, Cathy J. (2018, March 27). Commonly Used Concept Analysis Methods in
Nursing: An Introduction to Walker and Avant’s eight step Method. Retrieved from http://nursingeducationexpert.com/concept-analysis-methods-walker-avant/.

Weinstein, Sharon M (2016, July 14). Nurse fatigue takes toll on patient care. Retrieved from
https://www.reflectionsonnursingleadership.org/features/more-features/Vol41_1_nurse-fatigue-takes-toll-on-patient-care
What is fatigue (2008 September 10). Mechanical Engineering. Retrieved on September 27,
2018 from mech-engineer.blogspot.com/2008/09/what-is-fatigue.