Andrew Tagg. Take a break?, Don't Forget the Bubbles, 2020. Available at:
We spend a large proportion of our lives at work so it is important that we pay attention to our own wellbeing. A casual stroll through Twitter may reveal any number of wellbeing initiatives – from early morning yoga classes, through communal choirs, to meditation mornings. Whilst, subjectively, many of these appear to work, there is clearly a need for a better measure of wellbeing. Enter the NFR.
What is the NFR?
The Need For Recovery scale measures that subjective feeling of the need to take a break and recuperate from the emotional and physical demands of a day at work.
Originally derived from a sample of 68775 shift workers in the Netherlands, it is comprised of eleven dichotomous Yes/No questions.
In the emergency department, there are a number of extrinsic factors that might impact on our Need For Recovery. These include departmental crowding, lack of resources, and ambulances queuing out of the door. The assumption is that the daily accumulation of such tiring shifts, without a restorative break, can impact on our long-term health and increased occupational stress.
In order to look at how we are doing now, it might be worth taking a snapshot of the adult and paediatric emergency department workforce. PERUKI and TERN combined their might to do just this.
Cottey L, Roberts T, Graham B Trainee Emergency Research Network (TERN) and Paediatric Emergency Research in the UK and Ireland (PERUKI), et al. Need for recovery amongst emergency physicians in the UK and Ireland: a cross-sectional surveyBMJ Open 2020;10:e041485. doi: 10.1136/bmjopen-2020-041485
This study was coordinated through the Trainee Emergency Research Networks (TERN) of UK and of Ireland and Paediatric Emergency Research in UK and Ireland (PERUKI).
A total of 4247 emergency physicians* from 112 emergency departments completed the survey.
For the purposes of this study an emergency physician was defined as any doctor working within the ED, be they seasoned veterans or post-graduate year one doctors completing their six-month term in emergency medicine.
Participants were invited to take part in an online version of the Need For Recovery instrument. Although developed for industry it has been piloted in Emergency Department staff. Graham et al. (2020) trialed the survey in a single ED and achieved an 80.3% response rate (168/209). These subjects had to complete the 11 point NFR survey as well as an additional 32 questions. This larger survey upped the ante and added 44 items to the NFR. The quality of the web-based survey was maximized using the CHERRIES checklist.
Snapshot data was collected over a six-week period from 3rd June 2019, long before anybody had even heard of SARS-CoV-2.
Before we look at the Need For Recovery it is interesting to look at the demographic data.
3445 (83.5%) survey respondents worked full time. 609 (14.7%) worked less than or equal to 80% full time equivalents.
2886 (70.3%) worked more than one in four weekends with a shocking 1479 (36%) working every other weekend!
36.2% worked for, at most, four consecutive days, with the majority working between five and seven days in a row. 13.5% (554) had been rostered on for eight days straight.
Emergency physicians score higher than paediatricians, miners, paramedics, everyday folk, nurses, merchant sailors and truck drivers
The median NFR score (remember you want it to be as low as possible) was 70.0 (with 95% confidence intervals ranging between 62.0 and 78.0). It appeared to be higher in the more junior cohort – those that had been in the department for less than a year. This group scored an average of 72.7 with an upper limit of 90.9. Those who had spent more time in the job seemed better at recovery with a median NFR of 63.6. Those lucky individuals that had made a career of emergency medicine and had spent over ten years in post had the lowest score of all, 54.5.
As one might expect, higher scores were associated with a full-time work commitment, a burdensome weekend roster, and a higher number of consecutive days worked.
Lower scores were found in consultants and those that worked less than full time. The ability to access study leave and annual leave was also associated with lower scores. Luckily for those of us who have pursued a career in paediatric emergency medicine, this appeared to be associated with a lower NFR score too.
The authors conclude that there are three modifiable risk factors related to a higher NFR – access to annual leave, to study leave, and the proportion of out of hours work. Non-modifiable factors included things like male gender, seniority, generally good physical health, and working in a Paeds ED.
Risk of bias
So far we have reported the facts, as presented but let’s get a little nerdy, as Ken Milne would say, and look at the paper using Burns and Kho (2015) assessment guide for survey reports.
Was a clear research question posed?
Yes – the researchers wanted to look at Need For Recovery scores in a cohort of doctors working in emergency departments throughout the United Kingdom and Ireland.
Was the target population defined?
Yes but… – the target population was defined as any registered doctor who had a fixed contract position (i.e. not a locum) in an emergency department in the UK and Ireland.
There are 183 Type 1 Emergency Departments in England alone. These are consultant-led, 24 hours a day, 7 days a week, 365 days a year services. The authors asserted that they wanted to have over 50% of their respondents from Type 1 centres but this data is not clear in the data presented. Are the majority of respondents from centres that do not have good consultant support?
According to 2018 data, 26% of advertised UK EM consultant places are unfilled. I would be interested to know if individual departmental data could be pulled out and benchmarked against the national average.
Was a systematic approach used to develop the questionnaire?
Yes – the technique was clearly outlined in the methods.
Was the questionnaire tested?
Yes – the questionnaire developed was very similar to that used by Graham et al. The only key difference being around some of the ancillary questions, rather than those analysed in this paper
Were they administered in such a way that response and non-response bias was limited?
Yes – it was distributed in an appropriate way.
Was the response rate reported?
No – though all principal investigators should be applauded for the large number of surveys completed, it is not clear what the denominator is. How many emergency physicians, as defined by the study group) were working during the six week period? Were those doctors who did not even attempt to complete the survey just too exhausted to do so?
Each site PI did provide an best-guess estimate of the number of potential respondents (accounting for sick leave, sabbaticals, annual leave etc.). This number was then used as the departmental denominator, with each site aiming for a 70% response rate. The actual response rate is not mentioned in the paper.
Were the results clearly and transparently reported?
Sort of – there were actually 5107 unique visits to the survey site but only 4247 eligible for analysis. The NFR scores were then calculated as long as a minimum of 8 of the 11 questions were answered. The authors do not mention how they handled the missing data. If only 8/11 answers were provided, how would the addition of 3 further data points affect the results?
The demographic data was clearly reported, barring a few items, as described above, and the rest of the results were presented neatly.
Although I agree with the majority of the authors conclusions I am not so sure I would agree with the assertion that NFR score is unrelated to hours worked. It would seem from the data provided in table 2. those working less than full-time had a lower score.
Where to from here?
The ability to bounce back after a hard day at work is a marker of our general wellbeing. Whilst not everyone can swap over to working in PEM, these data from Cottey et al. would suggest that there are modifiable factors that would improve one’s ability to recover. Interestingly, none of these are within the junior doctors’ locus of control – access to study or annual leave, and better rostering. They are fully in the hands of others. This lack of autonomy can also lead to a lack of motivation.
The term, Need for Recovery, suggests that the onus is on the individual as if they were an elite athlete resting between races. It is not. It is the system that needs to change.
The authors note, in their limitations, that this is just a data snapshot, taken at one moment in time. There is little, in the medical sphere, to benchmark this data against. A similar survey could be carried out, in a different setting, in different geography or at a different time. Are these ratings typical of all areas of the hospital in the NHS or is it just the NHS? Do different craft groups score as highly? Are Need for Recovery scores as high in Australia and New Zealand (Editors note: I’ll work on that one) or are they a product of just working in the ED, regardless of the temperature outside? Are these scores a product of the time? The survey was carried out in the Northern hemisphere summer of 2019. What would those scores be like now, in a COVID ravaged world?
One more thing
There is one non-modifiable risk factor that we have not discussed – gender. Male and female respondents were equal in number but men had a much lower NFR than women – 65.6% (CI 60.8 – 66.5) vs 72.7% (70.5 – 75). But, women are much more likely to be the primary caregiver, you might argue. And you would be right, but even if this is taken into account, women seem to have a higher need for recovery. This seems to hold true in other studies that have looked at gender differences and fatigue.
Burns KE, Kho ME. How to assess a survey report: a guide for readers and peer reviewers. Cmaj. 2015 Apr 7;187(6):E198-205.
Eysenbach, G., 2004. Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). Journal of medical Internet research, 6(3), p.e34.
Graham B, Cottey L, Smith JE, et al Measuring ‘Need for Recovery’ as an indicator of staff well-being in the emergency department: a survey study. Emerg Med J Published Online First: 2020. doi: 10.1136/emermed-2019-208797
Van Veldhoven, M.J.P.M. and Broersen, S., 2003. Measurement quality and validity of the “need for recovery scale”. Occupational and environmental medicine, 60(suppl 1), pp.i3-i9.
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Wood, M., 2005. Bootstrapped confidence intervals as an approach to statistical inference. Organizational Research Methods, 8(4), pp.454-470.