In the wake of the COVID apocalypse that flogged the already dead horses of Australian critical care, exhausted CICM examiners (just before dramatically collapsing like Pheidippides) created Question 8 from the first paper of 2022, which asked the candidates to "implement a strategy to mitigate fatigue in the medical workforce". It is the absolute apex of irony that this question was posed to senior ICU trainees who had just experienced two of the most gruelling years of their career, during which many reported no administrative attention whatsoever to their burnout and fatigue, apart from some nauseating cooing sounds made by state politicians. For example, the reader is reminded how, over 2020-2022, the Victorian Health Service declared a "Code Brown" prohibiting healthcare staff from taking leave. Moreover, the question phrasing ("mitigate fatigue in the medical workforce") neglects the probably more important matter of the nursing workforce, which in the author's experience was the main rate-limiting step in maintaining patient access to critical care services.
Anyway. The question is not "how has the system neglected you", it is "if you were in charge in the last few years, what would you have done in my place", as the reader is also reminded that many of the examiners are senior members of the medical workforce, often directors of Intensive Care units, with influence over rostering and leave allocation.
What follows is a series of attempts to join the fragmented pieces of information on this subject floating around the internet, where they are often present in the form of local policies and guidelines rather than peer-reviewed publications. Probably the most detailed and useful publication available for this topic is the 2020 review by Bywood et al (for the ISCCR), as it seems to cover all the important points, and even though the size (69 pages) might repel some readers, it is well structured and therefore rather easy to follow. Also, an excellent example of a fatigue management system exists in Queensland Health, the AMA has what they consider to be a "minimum standard", and somebody else's professional college has a good guideline.
Of the CICM documents, none is specifically relevant to this subject. The least irrelevant document is probably IC-5, Statement on the Health and Wellbeing of Fellows and Trainees. There, the onus is squarely upon the Fellows and Trainees, who are instructed to "attend to their own health and wellbeing" and to "develop long-term health and well-being management strategies which reflect the evolving nature of the working life cycle". That's at least better than the Victorian government "WorkSafe" resource website for employers, which at one stage had a page on preventing and managing the risk of employee fatigue during the pandemic, but the URL is dead and the death message is "Sorry, it looks like something went wrong". Fatigue management guidelines from 2007 are still available on the NSW Health website, however. Each jurisdiction seems to have its own approach, which is often available as an obsolete PDF on some server somewhere, and the reader is encouraged to find their local version, if only to laugh at it resentfully through their sweaty N95 mask.
To define fatigue is usually a good starting point for CICM exam answers. For this, one would require a work-related definition. A good example is this quick from safeworkaustralia.gov.au:
Fatigue is a state of mental and/or physical exhaustion which reduces a person’s ability to perform work safely and effectively
Good, because it focuses on what fatigue does, not on what it is. The decreased function of staff members due to a lack of energy is obviously not something easily defined or measured in a way that would be consistent across different cultures and work environments, so it would probably be better to leave it at this. If one insists on complicating things, Frone & Tidwell (2015) have a whole paper on the measurement and definition of work fatigue, which they divide into physical emotional and mental.
At a basic level, fatigue is determined by:
The following organisation-level changes can be made to minimise the risk factors for the development of fatigue:
This is where, faced with the realities of some sort of Desperate Times, the institution is forced to conclude that the workload is what it is, there's no funding to fix the leaky environment, and the roster is borked beyond all recognition. In short, fatigue will happen. The only thing you can do now is ameliorate its effects. Unfortunately, these strategies are not especially evidence-based. Bywood et al lists the following:
The Canadian Royal Colleges, in their 2013 statement, suggested that fatigue management is something that should be individualised, rather than being imposed from above in the shape of mandatory maximum working hours or holiday leave. The risk of fatigue varies among individuals. Personalised assessment of risk from fatigue should be undertaken. Unfortunately, the Canadian recommendations stopped short of spelling out exactly how to do this, and so the details of the implementation are left to the imagination of the reader. Still, a few indivdual-level interventions could be helpful:
Fatigue in other industries (transportation, aviation) is seen as an occupational hazard and is discussed in those terms, in the same way as one might discuss a frayed electrical cable or a gas leak. Instead, for some reason in medicine fatigue is instead seen as some sort of personal challenge to be overcome. Taylor et al (2016), exploring this topic with medical and surgical residents, found that it was conceptualised as inescapable, manageable, surmountable and even necessary for future practice. The authors were forced to conclude that any fatigue management programs that treat workforce fatigue as a hazard would come up against this barrier, i.e. the medical workforce would still perceive being overworked as some kind of a virtue, a part of professional self-discipline.
This section is modelled on the excellent Queensland Health guidelines: