Authors: Blair Graham, Laura Cottey / Codes: SLO10 / Published: 28/08/2018


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Emergency Medicine is tough.How does working in the ED affect you? Do you often feel tired following a shift or on your days off? Do you love working in one of the most dynamic specialties out there, but worry about the risk of developing burnout or health problems as a result of work intensity?  Are you anxious that fatigue could lead to mistakes or impact the quality of care you are able to offer patients?

We know that these are pressing concerns for many trainees, and that they may impact retention and resilience of a talented group of staff. This is a major problem, not least for patients, but also for those of us who become the future leaders of our specialty. As such, developing evidence-based strategies to ensure retention of clinicians has been highlighted as a top research priority in Emergency Medicine2. Existing data derived from national EMTA surveys report recurrent concerns related to rotas and workload3, 4, but there are other factors aside.  Many organisations – for example, Employers, Trade Unions, Professional Bodies – rightly have a stake in monitoring fatigue and improving wellbeing, but each has their own agenda and perspective. As trainees we must be empowered to directly report the lived experience of issues affecting us. All too often, generic burnout inventories are used to provide a retrospective impression of how work affects our wellbeing. But these have a major limitation – they simply identify and categorise problems after they have occurred, at a point when interventions are complex, costly, and likely less effective. Instead, we propose developing a more proactive means of monitoring work intensity, fatigue and wellbeing so that interventions can be put in place before it is too late. In essence, our vision is to develop and validate an ‘Early Warning Score’ to forecast trainee dissatisfaction and burnout.

TERN has committed to supporting research that can help us try and understand how the concept of ‘Need for Recovery’ may act as a precursor to trainee dissatisfaction and burnout, identify and learn from excellent working practices where they already exist, and effect the case for change where they do not.

What is the ‘Need for Recovery’

The concept of ‘need for recovery’ refers to the perceived need to recover from the physiological and psychological demands of a working day. Where increased need for recovery is not identified or acted upon, the effects can be cumulative. We hypothesise that increased need for recovery occurs before the development of long-term health problems or features of burnout such as depersonalisation, emotional exhaustion, and reduced personal accomplishment.

The ‘need for recovery’ scale (NFRS) is a validated questionnaire originally developed in the Netherlands, to assess how work demands affect inter-shift recovery.5 It features eleven items requiring a dichotomous (‘yes’/’no’) response, takes only a few minutes to complete, and shows high acceptability amongst surveyed populations. Responses are summated to provide an NFRS of 0-100, with ‘0’ representing the least attainable need for recovery and ‘100’ representing the highest need. The instrument has good reliability (Chronbach α=0.82) and has been validated in two large cross-sectional studies (n=80, 870), where norms within the Dutch general population have been generated. 7,8  Subsequent smaller studies have indicated norms in a range of health- and non-health related occupations.8-13

Table 1: NFRS International Comparisons by Occupation and compared to ‘whole population’ average of Dutch Validation Study. 7

Occupation Bus drivers Merchant Sailors


Nurses Whole Population Nurses Paramedics Miners
n 930 332 128 12038 922 53 80
NFRS 27.2 36.4 36.4 38 39.4 43.6 55.2

The first study to evaluate the NFR in an ED setting has recently been conducted in the South of England. Permanent staff (n=209) were invited to participate in an online NFR survey during January 2018. Additional items explored personal (n=4), work-pattern (n=14) and wellbeing/burnout (n=5) characteristics. The response rate of 85.1% across all staff groups indicates excellent acceptability.  Results were straightforward to interpret, easy to understand, and revealed some important and statistically significant associations based on some key occupational and demographic characteristics. These findings need to be confirmed in a wider population of ED staff from across the UK.

What is the research question and specific aims of this project?


What is the baseline need for recovery (NFR) score among ED doctors in the UK and which factors influence NFR?


  • Conduct a national study to characterise the baseline NFR score in ED doctors across the UK.
  • Determine whether there are any associations and differences between NFR scores and demographic, occupational, personal wellbeing, rota characteristics, or geographical region variables.

How will the study work?

The survey will be conducted through an online survey platform and will be open to all doctors working within a UK ED.  In addition general information will be anonymously recorded by the TERN study representative looking at rota patterns, staffing, sickness absence and organisational factors.

Our initial work was conducted in all occupations working within the ED, unfortunately it is not feasible to replicate this on a national scale through this study but we are working with other occupational research groups to ensure this study is useable for all.

What will this study add for patients? 

Fatigue is well evidenced to increase the risk of human error occurring. Emergency Medicine is an inherently high-risk occupation and errors resulting from staff fatigue are likely to result in excess morbidity and mortality for patients. This study has the potential to aid patient safety by providing individuals and employers with an indication of who is most at risk of increased NFR score, whether disparities exist between different staff groups, departments, and localities, and whether increased need for recovery is a predictor of future occupational burnout. We hope this information will stimulate national and local change to improve the working lives of staff in UK EDs that will in turn impact positively on patient care. Although not the focus of this initial study, the relationship between NFR and patient satisfaction and the incidence of clinical errors may be possible.

What will this study add for clinicians? 

This research aims to evaluate the NFR experienced by UK ED doctors, in the first instance, and compare this to established population norms. This will allow the work intensity encountered by ED staff to be compared meaningfully to other occupations, such as those in Table 1. Once nationwide data collection is complete, it may be possible to understand characteristics indicating increased need for recovery such as rota pattern, staffing gaps and demographics. It is envisaged that practical recommendations and suggestions for improving working lives may result, the effectiveness of which can be monitored using serial evaluations of the NFR survey.

What is the timeline for this project?

Once the survey is launched (current aim April/May 2019) it will be publicised by local TERN members, see details below to sign up, and will be open for a period of a month. We will aim to publish our results by late summer 2019.

How do I get involved?

We are now looking for interested trainees to be a departmental lead for this study or interested departments to register an interest. To register please go to this link 

Full training and support will be provided to those interested.


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