Lessons Learned and Mitigation Strategies
BY IMELDA WONG
COVID-19 and Worker Fatigue
The declaration of coronavirus disease 2019 (COVID-19) as a public health emergency in the United States immediately changed the way we work and live, and intensified feelings of stress and uncertainty about the future. New routines and behaviors such as adhering to stay-at-home orders, wearing masks, and social distancing, along with frequent messaging about handwashing, cleaning, and not touching our faces, are constant reminders of our “new normal” and have been shown to increase anxiety. Exposure to an abundance of news coverage, some of which is conflicting or has changed over time, has fueled feelings of uncertainty and fear. The closure of many businesses has led to job loss and financial instability for millions for an undetermined period. Essential service occupations—some of which might not have been previously recognized for exposure to infectious diseases—are now perceived as more dangerous due to the increased infection risk associated with working among the general public. Worries about the health and well- being of ourselves and loved ones have further affected our emotional health and added to fatigue. New terms such as “caution fatigue” and “quarantine fatigue” have emerged to describe the weariness we feel about our new restrictive circumstances as a result of the COVID-19 pandemic.
SLEEP, STRESS, AND FATIGUE
Fatigue in workplace settings is commonly associated with nonstandard work schedules such as shift work, long work hours, and the resulting poor sleep or sleep loss from these arrangements. However, it can also be attributed to many other occupational, individual-level, and lifestyle factors such as work demands, age, and health behaviors. The effects of fatigue include slower reaction times, reduced attention or concentration, limited short-term memory, and impaired judgment. Fatigue, in combination with time pressures and stress, can result in deliberate or accidental omission of critical work procedures, with implications for fatigue-related incidents. All of this can increase the risk for safety- critical events that have the potential to affect workers as well as their coworkers, families, and the general public (read more in the
NIOSH Science Blog
). Recognizing the sources of fatigue can allow for targeted, effective mitigation strategies.  During stressful times, sleep problems are common and sensitivity to sleep disruption increases the likelihood of chronic insomnia. Insomnia is a major risk factor for post-traumatic stress disorder (PTSD) when people are exposed to major stressors. This, in turn, is associated with an increase in sleep disruption, which can create a spiral of stress, mental health issues, and sleep impairment. A recent study published in
Brain, Behavior, and Immunity
reported that PTSD symptoms were evident after the COVID-19 outbreak among Wuhan, China, residents and persisted for several months. A survey of British residents published as a preprint in
medRxiv
found that worries and adversities related to COVID-19, including contracting the disease, financial difficulty, loss of paid work, difficulties acquiring medication, difficulties accessing food, and threats to personal safety, were associated with lower quality sleep. With each additional adverse event, the risk for poor sleep increased by 20 percent.  Especially during these times, it is important to remember that fatigue may be a symptom of depression or other mental health conditions, and sleep impairment and reduced sleep quality can exacerbate existing mental health issues. 
HOW DID WORK CHANGE DURING COVID-19?
When COVID-19 was declared a public health emergency in the U.S., more than 55 million workers were in jobs designated as essential to maintain critical infrastructure. Some organizations added overnight shifts to accommodate physical distancing requirements while keeping up levels of production or service. Many workplaces operated with reduced staff, which led to greater work intensity and work demands for individual workers. While the pandemic provided insurmountable challenges never before faced, some industries—those that traditionally encounter emergency situations, for example—were arguably better prepared. In other industries, employees who are not normally considered frontline workers, such as grocery clerks or delivery drivers, lacked training and resources to manage stress, long work hours, increased work demands, and fatigue. 
Stress and Fatigue Among Healthcare Workers
Millions of healthcare workers on the front lines of the pandemic response put themselves at risk of exposure to SARS-CoV-2, the virus that causes COVID-19, while caring for the influx of COVID-19 patients. As the pandemic progresses, healthcare workers are reporting an overall surge in new cases of depression, anxiety, and insomnia as well as an exacerbation of existing mental health issues due to increased risk of COVID-19 disease exposure and transmission, limited resources and personal protective equipment, overwhelming workload, longer shifts, disruptions to sleep, process inefficiencies, overall lack of preparedness and response, insufficient training, and concerns about financial instability. Healthcare workers concerned about the potential spread of the virus to family members felt a loss of family support as they opted to not live at home or chose to separate themselves from others while living at home. The combination of workplace and personal issues and changes in living situations all had a greater effect on stress, well- being, and poor sleep quality among healthcare workers compared to other professions.
The closure of businesses and concerns about exposures led to a scarcity of places for truck drivers to pull over for rest stops.
The lack of physical and temporal work boundaries has resulted in blurred lines between work and home life.
Strains on the Supply Chain
Our supply chain came under extreme pressures due to the panic buying of consumer goods such as toilet paper, hand sanitizer, and cleaning products, which rely on a vast chain of trucking and delivery networks. In response to the pandemic, and the designation of truck drivers and support personnel as essential critical infrastructure workers, hours-of-service regulations were amended to allow more time to transport emergency or critical supplies to avoid situations in which drivers would be too fatigued to operate their rigs safely.  A survey of American truck drivers during the early stages of the national emergency (PDF) found that the transport loads shifted from long-haul to more short-haul deliveries to meet regional supply demands. With the decrease in traffic congestion due to stay-at-home orders and fewer commuters, commercial drivers were able to increase their driving speeds and hours of service while keeping within regulatory limits. Longer delivery times were attributed to extra time needed to load and unload trailers and maintain recommended COVID-19 mitigation practices. In addition, the closure of many businesses and concerns about potential exposures led to a scarcity of places to pull over for rest stops. This raised concerns that drivers would be pushed to operate longer, forgo rest breaks, and park in unsafe or unsecure locations if they ran out of available hours—all of which adds to considerable worries about fatigue among truck drivers who haul essential goods in our supply chain. 
Work-from-Home Challenges
Stay-at-home orders and social-distancing requirements prompted many businesses to quickly adopt work-from-home options for their employees where feasible. It’s been estimated that almost 40 percent of jobs in the U.S. can be done at home, although it is possible that considerably more people were working from home during the pandemic. Surveys of home-based workers conducted by Gallup found that almost all felt that COVID-19 caused a “great deal” or “fair amount” of disruption in their lives. The lack of physical and temporal work boundaries has resulted in blurred lines between work and home life, longer workdays, and fragmented focus time. Numerous home-based workers have struggled with learning to use new technologies, adjusting to new routines, and experiencing workplace isolation. Many juggle childcare responsibilities, including home- schooling, with their work. While gender differences were not formally examined, some studies suggest mothers are at greater risk than fathers for burnout and fatigue based on differences in typical childcare duties.  As many of us know from experience, makeshift offices have cropped up in nontypical workspaces (for example, in dining rooms, garages, or under the stairs) to accommodate working from home, and these setups are not all ergonomically friendly. Often, small spaces are used by a number of family members, making it difficult for workers to concentrate with constant noise in the background. All of these factors are major contributors to stress and fatigue. 
WHAT COULD WE EXPECT WITH RETURNING TO “BUSINESS AS USUAL”?
When we think about the work environment during the COVID-19 pandemic, we cannot overlook the number of people who have lost their jobs or have been furloughed. The U.S. Bureau of Labor Statistics estimates that the largest job losses occurred in the service industry, and the International Labor Organization forecasts the greatest economic impacts will be for those employed in accommodation and food services, manufacturing, and wholesale and retail trade. These labor-intensive sectors employ millions of often low-paid workers for whom a loss of income can be devastating. Unemployed workers or those in precarious work situations are at high risk for increased stress, unhealthy behaviors, intensified mental health conditions, and other threats to health and well-being. 
For some businesses, pandemic shutdowns escalated the pressure to compensate for economic gaps and created an incentive to increase work intensity or hours of work. The reopening of the economy saw an initial uptick in employment, with 40 percent attributed to part-time workers who would have preferred full-time employment but were working part time because either their hours were reduced or they were unable to find full-time jobs. Because of this, there may be more workers employed in multiple jobs, either in several part-time jobs or as part of the gig economy, to make ends meet. For these workers, this may mean more time at work or in between jobs, which may be used to run errands, attend to household responsibilities, or commute between jobs. This type of schedule results in more time awake and added stress, with ultimate effects on fatigue. 
WHAT CAN EMPLOYERS DO TO MITIGATE EMPLOYEE FATIGUE? 
Previous studies reported adverse psychological reactions among healthcare workers following the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak and indicated a potential for long-term psychological implications and fatigue. Lessons learned from SARS and COVID-19 suggest that strategies to prevent occupational stress and fatigue could include structured training on large-scale disasters, increased staffing, collaborative efforts, and adapted human-resources policies such as alternate paid time off options. Psychological support systems and organizational measures such as social distancing and good ventilation reduced workers’ anxiety, depression, stress, and insomnia upon returning to work. Improving awareness of fatigue and communicating with managers regarding the importance of timely intervention may also reduce the risk for fatigue-related incidents.  Providing effective, targeted fatigue mitigation strategies requires identifying contributing sources of fatigue. Different messaging techniques with considerations for language level and delivery methods (for example, infographics or online training) should be tailored to the workforce population. In times of crises, employees need a clear plan from leadership to set expectations, adjust resources, and help workers feel connected and involved to reduce stress and fatigue. These unusual times require some creativity in redesigning or shifting workloads in ways that may not have been considered before. Some organizations are seeking to prevent burnout and reduce fatigue among workers by capping overtime hours, scheduling email- and meeting-free periods to allow for uninterrupted focus time, and encouraging workers to take time off.  Other tips to mitigate employee fatigue include: 
  • Provide information for workers on the consequences of sleep deprivation and resources to assist them in preventing and managing fatigue. NIOSH offers a number of free resources through its website.
  • Create a procedure that does not punish workers for reporting when they, or their coworkers, are too fatigued to work safely. Build it into team comradery as an example of how management and staff can support each other.
  • Develop processes to relieve a worker who is too fatigued to work safely.
  • Allow staff enough time to organize their off-duty obligations and get sufficient rest and recovery.
  • Schedule at least 11 hours off between shifts (each 24-hour period) and one full day of rest per seven days for adequate sleep and recovery.
  • Avoid scheduling staff to be working for more than 12 hours, if possible.
  • Formalize and encourage regularly scheduled breaks in clean and safe areas where social distancing can be maintained. Recognize the need for additional time for increased hand hygiene and safely putting on and taking off masks or required PPE.
As we adjust to returning to “business as usual,” our communities will see the number of new COVID-19 cases rise and fall. This will impact operating procedures and require frequent assessment of emerging concerns. Flexibility and creativity are needed to help everyone through these times. 
WHAT CAN WORKERS DO TO MANAGE FATIGUE?  
Many companies are opting to extend work-from-home options for their employees. For some workers, this may mean continued blurring of work-life boundaries, disruptions to regular routines, and limited access to daylight and exercise. In times of quarantine or activity restrictions, we lose many of our natural cues to maintain optimal health and get a good night’s sleep. These include biological, social, and environmental regulators such as the light we are exposed to, mealtimes, exercise, and social events. Binge eating and other unhealthy behaviors are natural reactions during times of stress. Lack of a regular daily routine as commonly dictated by work or school responsibilities can lead to sleep difficulties and additional health risks. During these difficult times, it’s important to engage in regular routines that include scheduled wake/sleep times and healthy rest breaks to maintain optimal health, well-being, and a strong immune system.  For those who continue to work from home, setting physical and temporal boundaries is important to create a separation between work and home life. In addition, to help stave off fatigue, workers should try to take breaks that include stretching or walking around a bit and getting exposure to fresh air and natural light. Experts recommend dedicating time (two to three hours, if possible) without interruptions to concentrate on one task because multi-tasking is difficult for the mind and can lead to fatigue and burnout.  In times of common stress, it is also normal for individuals to feel a greater need to communicate with each other. Social interaction may be challenging while maintaining social distancing, but is found to diminish stress, and social support can further improve sleep quality. Studies from Wuhan found that good social support, social capital, and a sense of belonging reduced anxiety and fostered better sleep and self-efficacy during COVID-19 and return to work. Healthy behaviors to maintain optimal functioning of the central nervous system and immune system to control stress and boost immunity have been shown to reduce workers’ anxiety, depression, stress, and insomnia upon returning to work. These strategies can include enhanced personal hygiene (such as frequent handwashing and wearing masks) and utilizing psychological support systems among coworkers, family, and friends. Under regular circumstances, adults need seven to nine hours of sleep per night. During stressful times or greater work demands, some people may need more. The following tips can help improve sleep:
  • You’ll sleep better if your room is comfortable, dark, cool, and quiet.
  • At least five hours before bedtime, avoid certain foods and drinks (such as alcohol, nicotine, caffeine, or heavy meals) that can make falling asleep difficult.
  • Reduce exposure to sunlight and bright lights and block blue light on electronic devices 1.5 hours prior to bedtime to facilitate falling asleep.
  • Create a routine to unwind and relax approximately 1.5 hours before bed.
  • Before you begin working a long stretch of shifts, try “banking your sleep”—sleeping extra hours than you normally do.
  • After you’ve worked a long stretch of shifts, remember it may take several days of extended sleep before you begin to feel recovered. Give yourself time to recover.
  • If you are having a difficult time falling asleep or staying asleep for seven to nine hours and it is significantly interfering with your daily activities, it may be wise to seek the help of a healthcare provider.
Ensure that the workers under your care know what to do if they feel too tired to work safely:
  • Use a buddy system at work so workers can check in with each other to ensure that everyone is coping with work demands and is working safely.
  • Help workers learn to spot the signs and symptoms of fatigue (for example, yawning, difficulty keeping eyes open, inability to concentrate, unusual errors in judgment, lack of energy, more withdrawn than usual) in themselves and their coworkers, and take steps to mitigate fatigue-related injury or error.
  • If your employer has a formal program to help manage fatigue on the job, provide information about the program and ensure that the workforce fully understands the employer’s policies and procedures for helping employees manage fatigue.
  • Urge workers not to work if their fatigue threatens their safety or the safety of others. Workers should report to a manager when they feel too tired to work safely.
WE’RE IN THIS TOGETHER
The only certain thing during these uncertain times is the need to work together to navigate through uncharted territories. Recognizing that worker fatigue can be attributed to a variety of sources stemming from individual concerns, changes in work routines and schedules, and varying degrees of stress due to adversities related to COVID-19 can aid in the development of targeted, efficient mitigation strategies. A holistic approach with shared responsibility and open communication among employers and employees is needed to ensure worker safety, health, and well-being and a successful return to regular operations. As the economy reopens, addressing changes in work hours and routines, organizational practices, and the physical and psychosocial work environment due to COVID-19 will help mitigate worker fatigue and can support healthy behaviors and practices as workers adjust to the new normal.  
IMELDA WONG, PhD, is coordinator of the NIOSH Center for Work and Fatigue Research.
Disclaimer:
The findings and conclusions in this report are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention/the Agency for Toxic Substances and Disease Registry.  Send feedback to The Synergist.
Husam Cakaloglu/Getty Images, deliris/Adobe Stock, SelectStock/Getty Images, Chansom Pantip/Getty Images, Pixfly/Getty Images, DragonImages/Getty Images
NIOSH RESOURCES
(Available in Several Languages)
OTHER RESOURCES
American Transportation Research Institute and the OOIDA Foundation: “COVID-19 Impacts on the Trucking Industry” (PDF, April 2020).
Brain, Behavior, and Immunity
: “A Longitudinal Study on the Mental Health of General Population During the COVID-19 Epidemic in China” (July 2020). Gallup: “How Leaders Are Responding to COVID-19 Workplace Disruption” (April 2020).
medRxiv
: “Are Adversities and Worries During the COVID-19 Pandemic Related to Sleep Quality? Longitudinal Analyses of 45,000 U.K. Adults” (2020).