As we enter the latter half of 2020, an uneasy feeling pervades the corridors of hospitals and clinics across the world. While many systems have emerged relatively intact from the first wave of the global covid-19 pandemic, few are unscathed, and the challenges will inevitably have taken a toll on those who work within healthcare.
Clinicians are likely to be tired and battle weary. Yet instead of much-needed rest and recuperation, the second wave has already arrived in many parts of the world, bringing further anxiety and concern over what is to come. Well before covid-19, healthcare staff were already familiar with the personal consequences of fatigue on wellbeing and performance. It would surely surprise few to learn that fatigue is associated with decreased productivity, increased medical error, and myriad long-term health effects.
Furthermore, for many years, the NHS has faced challenges around recruitment and retention of its medical workforce. Previous surveys of doctors conducted by the General Medical Council (GMC) provide an insight into the problems that the NHS faces. [1,2] The 2019 survey revealed that trainees and trainers alike rated the intensity of their work as either “heavy” or “very heavy” with high workloads, rota gaps, and the lack of a supportive work environment all contributing to this feeling of burnout.
Given these issues, optimising physician wellbeing—including attempts to better understand work intensity and fatigue—demand the attention of employers and policymakers as recently highlighted in the GMC report “Caring for Doctors, Caring for Patients.”  In reality though, the focus on wellbeing is too often limited to the identification of occupational burnout. This presents a problem as established burnout represents an advanced stage of impaired occupational wellbeing. By the time it has occurred, effects on function are likely to be manifest and the costs already substantial to both the sufferer and the system. A shift of focus to the identification and monitoring of “burnout precursors” may prove more useful and more effective at improving clinicians’ working lives.
We hypothesise that one such precursor may be found in the concept of “Need for Recovery” (NFR), which provides an assessment of the time taken to recover from the physical and psychological effects of work. An indirect measure of work intensity and fatigue, increased NFR is associated with progression to occupational burnout and might serve as an “early warning” indicator. Originally developed and validated in the Netherlands, eleven “yes” or “no” questions are summated providing a score of 0-100, where 100 is the highest attainable NFR.  Despite obvious relevance to those working on the healthcare front line, NFR has not previously been investigated among UK doctors. In order to confirm the utility of the scale, we began by undertaking a single centre study.  This confirmed the high acceptability of the survey in an Emergency Department (ED) setting. Subsequently, we gained the support of the newly formed UK Trainee Emergency Research Network (TERN) to plan and deliver the largest UK healthcare population study of NFR to date of UK and Ireland Emergency Department doctors in July 2019. 
The results were eye-opening. With previous baseline NFR scores reported in the literature of between 36-44, the median NFR score amongst over four-thousand ED doctors was 70, higher than previously reported. We also identified some seemingly modifiable risk factors for increased NFR. If targeted by employers, NFR might be reduced and wellbeing improved as a result. Among our respondents, difficulty accessing annual and study leave significantly increased scores. We also found that an increased proportion of antisocial working increased scores in a linear relationship. This suggests that any reduction in antisocial shifts might result in direct improvements in NFR and prove protective against the development of burnout. Even where this cannot be achieved, acknowledgement of a problem and the provision of rest facilities may help to mitigate this. The UK Emergency Medicine Trainees Association Rest and Rota Charter aims to establish an improved culture where trainees and organisations are mutually responsible for improving working lives. 
Whatever the next six months may bring, the job of those on the front line is unlikely to get easier. With further, as yet unknown challenges ahead, now is the time to take action to optimise wellbeing. Crucially, this means extending thinking beyond burnout. During stakeholder engagement for our research, clinicians reported feeling “burned out with burnout inventories” and while there seems to be little appetite for more of the same, NFR might be different. We seem to have struck on an issue familiar to many respondents and interest has blossomed, with NFR now being evaluated in other populations such as Advanced Care Practitioners. Specifically, providers must now focus on aspects of job sustainability such as maintenance of rotas and work intensity to improve wellbeing. Ready access to annual and study leave can have a positive impact on staff recovery between shifts and this must therefore remain a priority, even during challenging times.
Laura Cottey is a Research Fellow in Emergency Medicine and the Chief Investigator of the Trainee-led evaluation of inter-shift recovery in the Emergency Department (TIRED study).
Blair Graham is a Lecturer in Urgent & Emergency Care at the University of Plymouth and a Royal College of Emergency Medicine Doctoral Research Fellow
- General Medical Council. Inital findings report 2018 [Internet]. 2018. Available from: https://www.gmc-uk.org/-/media/documents/dc11391-nts-2018-initial-findings-report_pdf-75268532.pdf
- General Medical Council. National training surveys 2019: Initial findings report [Internet]. General Medical Council; 2019. Available from: https://www.gmc-uk.org/-/media/gmc-site-images/about/national-training-surveys-initial-findings-report-20190705_2.pdf?la=en&hash=8455783A3C4DE2CC55A38ACB9ACF5D0B391744B0
- West M, Coia D. Caring for Doctors, Caring for Patients [Internet]. General Medical Council; Available from: https://www.gmc-uk.org/-/media/documents/caring-for-doctors-caring-for-patients_pdf-80706341.pdf?la=en&hash=F80FFD44FE517E62DBB28C308400B9D133726450
- van Veldhoven M. Measurement quality and validity of the ‘need for recovery scale’. Occup Environ Med. 2003 Jun 1;60(>90001):3i–9.
- Graham B, Cottey L, Smith JE, Mills M, Latour JM. Measuring ‘Need for Recovery’ as an indicator of staff well-being in the emergency department: a survey study. Emerg Med J. 2020 Sep;37(9):555–61.
- Graham B, Cottey L. Current projects: TIRED [Internet]. 2018. Available from: https://www.rcemlearning.co.uk/foamed/current-projects-tired/
- Emergency Medicine Trainees Association. Rest and Rota charter [Internet]. 2020. Available from: https://www.emtraineesassociation.co.uk/rest-rota-charter