Leadership through crisis: fighting the fatigue pandemic in healthcare during COVID-19, Whelehan et al, 2021

[Andy]

COVID-19 presents many challenges to healthcare systems internationally, none more so than the significant reporting among healthcare workers (HCWs) of occupational fatigue and burnout or Long COVID related symptoms. Consensus on the extent of HCW fatigue during the pandemic remains largely unknown, as levels of Long COVID related fatigue in HCWs appears to be on the rise. What is known is that, among current levels, impacts of fatigue on HCW well-being and performance is likely. Developing strategies to mitigate fatigue are the responsibilities of all healthcare system stakeholders. Leadership that goes beyond organisational efforts of mitigating fatigue through mandated working hour limits alone are needed. A process to facilitate identification, mitigation and prevention of fatigue is likely to be best suited in this regard. This might involve development of operational systems modelled off successful industries, such as aviation, for performance optimisation. These system-based designs provide the foundation for systematic yet innovative approaches to enable effective design of macro-level to micro-level interventions for fatigue mitigation. Shifts in organisational culture have occurred in healthcare since the onset of the pandemic, with increasing agility and embracing of innovation. Creating a culture whereby we recognise and support people in being malleable through a pandemic and beyond is at the level of leadership. Leveraging this cultural shift allows an opportunity for organisational change. One focus of such a leverage within systems could be the incorporation of the evidence-based practical recommendations informed by the authors of this paper.

Open access, https://bmjleader.bmj.com/content/early/2021/02/22/leader-2020-000419

An important characteristic of Long COVID fatigue which is similar to cardinal features of ME/CFS is postexertional malaise (PEM), where there is an inability to produce sufficient energy on demand.12 Previous epidemics such as SARS, H1N1 and Ebola saw large proportions meet ME/CFS diagnostic criteria as a result of virus contraction.13 Additionally, higher incidences of ME/CFS have been reported in HCWs14 compared with the general population.

 

[Hutan]

The abstract suggests the authors fundamentally misunderstand what Long Covid is.

Creating a culture whereby we recognise and support people in being malleable through a pandemic and beyond is at the level of leadership.

It looks as though they don't understand what 'malleable' means either. I hope they meant something more like 'flexible'. It is a very odd choice in that sentence - how could the editors and peer reviewers have let it through?

Malleable (google dictionary)

 

[Trish]

I have read the whole article. The sections about ME/CFS surprised me how good they are, with PEM explained, energy envelopes, pacing, and heart rate monitoring included, and the importance of not setting unrealistic goals, etc. Then I saw they had advice from Nicola Clague-Baker, who is one of @PhysiosforME.
It talks separately about fatigue caused by work stresses and long hours and lack of sleep leading to burn-out. Maybe there's too much emphasis on resilience training for the sufferer, but they do also talk about the importance of good management practices to reduce workplace stress and exhaustion.

 

[Hutan]

Fair enough. Good on them for getting some advice, and choosing who they get advice from well.

Previous epidemics such as SARS, H1N1 and Ebola saw large proportions meet ME/CFS diagnostic criteria as a result of virus contraction.

But, if they were writing about an Ebola outbreak, would they talk about managing both the fatigue that the medical staff experienced from working long, emotionally demanding shifts and the post-Ebola syndrome that those who contracted Ebola and survived might develop in the same paper? They are such different topics. And would they use a title 'fighting the fatigue pandemic' - as if Long Covid is only fatigue, and burnout and Long Covid are part of a single 'fatigue pandemic'.

Adjuncts
Beyond the remit of this editorial but worth noting is that while fatigue stemming from COVID-19 shares parallels with aspects of ME/CFS, it has been cautioned that recommendations should not be generalised across the two conditions. To date, there is no evidence base for or against any pharmacological or non-pharmacological interventions for Long COVID related fatigue.31 Instead, an individualised approach to fatigue reflecting energy conservation techniques, appropriate nutrition and paced activity engagement has been recommended,32 prompting an interdisciplinary approach.

There's this 'adjunct' which looks, to me, as though the authors have misunderstood good advice (e.g. not to confuse Long Covid with 'fatigue') and have come up with something almost the opposite of what I imagine they were told by Nicola. They have said that recommendations for ME/CFS should not be applied to Long Covid. And they recommend 'paced activity engagement' that sounds a lot like GET to me, and the good old 'interdisciplinary approach' which inevitably involves a psychologist and mindfulness.

 

[Trish]

I agree the rest of the article is not good, and I also think it's a serious mistake to write about post viral long Covid and possible parallels with ME/CFS in the same article as a long section on burn out, which is very likely to lead to readers thinking both groups of sufferers have the same sort of fatigue, and can be treated at work in the same way.

 

[Jonathan Edwards]

Whether or not the authors have got input from people with some understanding the authors themselves clearly have none. To mix health care worker burnout with Long Covid is ridiculous.

I may still not fully understand ME/CFS but from my own experience of post-viral fatigue suggests that there are two completely different scenarios.

1. I would really like to go out and do stuff today but BAM if I do I feel dreadful and my body refuses to go.
2. I really can't cope with doing any more of this, even though I know I can. I've had enough.

And who wants a 'new culture'. We just want reliable information and service provision. Presumably the 'evidence base' the authors talk of is no evidence base at all since there isn't any as far as I know.

 

[Invisible Woman]

I agree the rest of the article is not good, and I also think it's a serious mistake to write about post viral long Covid and possible parallels with ME/CFS in the same article as a long section on burn out, which is very likely to lead to readers thinking both groups of sufferers have the same sort of fatigue, and can be treated at work in the same way.

Exactly. This leads back to a reluctance to understand and acknowledge that not all fatigue is the same & won't respond in the same way to similar treatments.

What they could have looked at (& I haven't waded through the whole thing) is if workers who are at risk of burnout through excessive hours worked are any more likely to develop long covid than counterparts who are working as usual & how does that compare to members of any other profession?

When I was first ill my diagnosing consultant commented that certain professions seemed more likely to develop ME in his experience. He included health care workers and teachers not necessarily because of stress, burnout & their ability to cope but simply because they routinely come into contact with a wider number of people. This was also true of my own work where some weeks I might spend almost every day on a different client site, surrounded by different people.

His thinking was, for all we know, pwME are just unfortunate that they are exposed to two or more different pathogens in too short a time frame & that overwhelms the body's ability to recover normally.

 

[Hutan]

His thinking was, for all we know, pwME are just unfortunate that they are exposed to two or more different pathogens in too short a time frame & that overwhelms the body's ability to recover normally.

When I was 10, I had a year off school with something that was diagnosed as ME, and then I recovered. I don't know what caused it, but I wasn't under any sort of stress then.

When I was 16, I had glandular fever (presumably EBV) and shingles - at the same time. I had shingles blisters around half of my torso. I had a week or so off school, and then went back, and soon after, to a school camp, with no ill-effect, and no ME/CFS. At the time, I wasn't emotionally stressed, but I was working very hard on lots of things.

And then, when I was 40 something, I developed ME/CFS, along with my two children, immediately after what seemed to be a flu with gastrointestinal symptoms and a heat wave and being shut up inside a house with a container load of personal effects that had been treated with methyl bromide - but none of us were under emotional stress or working too hard.

What to make of all that? I don't know. But, if I have a genetic susceptibility and 'two or more different pathogens in too short a time frame' and working hard are risk factors, why didn't ME/CFS develop when I was 16? (Obviously n=1, and maybe I don't have ME/CFS at all.)

 

[Invisible Woman]

What to make of all that? I don't know. But, if I have a genetic susceptibility and 'two or more different pathogens in too short a time frame' and working hard are risk factors, why didn't ME/CFS develop when I was 16? (Obviously n=1, and maybe I don't have ME/CFS at all.)

It's a fair point.

Maybe your body was "primed" by previous exposure to infection?

Maybe it's not just that there were multiple exposures of any pathogen at the same time but it's how those pathogens affect the body and the cumulative effect they have?. Maybe previous exposure to something that means that some process in the body reacts in a certain way?

Maybe none of the above. He just found it interesting that many of his patients worked in jobs where staff regularly mixed with higher numbers of people than the average office worker.

It has always seemed to me that multiple exposures at the same time, perhaps when there has been previous exposure to something else has been just as likely, if not more so than burn out.

As for not having ME/CFS .... who knows? Maybe I don't either. If we don't know precisely what it is, how do I know for sure what I have is it. It's just the most likely diagnosis. For now at least.

One thing for sure is behavioural questionnaires don't get us any closer to understanding much about anything. Except perhaps what they tell us about the thoughts and attitude of the people who rely on them so heavily & how they choose to interpret them.

 

[Mithriel]

In the late 80s I was a member of a local ME group. One woman there had developed ME after she had gone down 2 viruses at once. I think it was meningitis and something else. Having 2 infections to fight was definitely seen as being a risk factor for ME then according to doctors.

 

[Wyva]

As a matter of fact, mine may have started with a double infection too. I had a really bad viral throat infection, by bad I don't mean the severity but that it kept coming and going for a month and it was incredibly annoying. Than a while later I developed the EBV infection, and with its longer incubation period, it was probably already in my body during the throat infection.

There was this very detailed New York Times article about the connection between ME/CFS and long covid and in that article Nancy Klimas mentioned her theory that maybe herpesviruses are involved in a two-phase process when they trigger ME/CFS, meaning that something happens to the body first that "distracts" the immune system and herpesviruses already present in the body use that opportunity to launch an attack. I don't know if this is the case, but it made me think.