Fatigue: Biomedicine, Health & Behavior

ISSN: 2164-1846 (Print) 2164-1862 (Online) Journal homepage: http://www.tandfonline.com/loi/rftg20

In-depth review of five fatigue measures in shift

workers

Knar Sagherian & Jeanne Geiger Brown

To cite this article: Knar Sagherian & Jeanne Geiger Brown (2016): In-depth review of
five fatigue measures in shift workers, Fatigue: Biomedicine, Health & Behavior, DOI:
10.1080/21641846.2015.1124521

To link to this article: http://dx.doi.org/10.1080/21641846.2015.1124521

Published online: 19 Jan 2016.

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 Fatigue: Biomedicine, Health & Behavior, 2016
http://dx.doi.org/10.1080/21641846.2015.1124521

In-depth review of five fatigue measures in shift workers

Knar Sagherian* and Jeanne Geiger Brown

School of Nursing, University of Maryland, Baltimore, MD, USA

(Received 4 October 2015; accepted 22 November 2015)
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Background: Occupational fatigue is commonly reported in shift-working

populations. In the literature, there are several well-known fatigue measures that
are regularly used to assess either general or specific aspects of employee
fatigue. Purpose: The purpose of this paper was to provide an in-depth review
of five fatigue instruments frequently used in occupational science over the past
two decades. These instruments are: the Checklist Individual Strength, the
Fatigue Assessment Scale, the Need for Recovery, the Occupational Fatigue
Exhaustion Recovery, and the Swedish Occupational Fatigue Inventory scales.
We describe each instrument in detail, including how it was developed and
validated, how it can be obtained, psychometric data, and its use in occupational
studies. Conclusion: These instruments provide an understanding of fatigue
either as a unidimensional or multidimensional construct. Overall, the five
measures are brief (10–20 items), user-friendly, and have minimal respondent and
administrative burden. They are reliable and valid based on the psychometric
studies in the working population. Each measure has the potential to be utilized as
a surveillance tool in monitoring employee fatigue and ensuring workplace safety.
Selecting one or combination of these measures depends on the researcher’s
conceptual and operational definitions of fatigue, and the study objectives.
Keywords: fatigue; instrument; occupation; reliability; validity; worker

Introduction
Fatigue is a common occurrence in occupational settings when physical and psychoso-
cial work demands are high, and when compressed work schedules and shift rotations
are part of the job.[1–5] If unrelieved and prolonged, work-related fatigue interferes
with work performance and increases the risk of accidents, musculoskeletal injuries
and errors.[6–8] Fatigued workers are also at risk for developing stress-related illnesses
[9–13] and be absent from work.[14–16] Outside the work environment, fatigue in
addition to sleepiness, threatens the safety of the public during commute times.[17–20]
Fatigue is conceptualized as either a unidimensional or multidimensional construct.
As well, it can be presented in terms of acute states or chronic traits. As there is no con-
sensus on one definition of fatigue, occupational researchers may have difficulty in
selecting an instrument to measure this construct. Unidimensional definitions are
synonymous to feelings of weariness, tiredness, lack of energy or decreased functional

*Corresponding author. Email: knar.sagherian@umaryland.edu

© 2016 IACFS/ME
 2 K. Sagherian and J. Geiger Brown

capacity.[21] Examples of multidimensional definitions include: “a temporary physio-

logical state of incapacitation, a decrease in work performance and subjective feelings
of lassitude or tiredness” [21]; “an overwhelming sense of tiredness, lack of energy, and
a feeling of exhaustion associated with impaired physical and/or cognitive functioning”
[22]; “a subjective phenomenon that is connected with the desire to rest and is associ-
ated with unpleasant psychological and physiological sensations” [17]; and “a subjec-
tive sensation with emotional, behavioral, and cognitive components”.[23]
Workers can have acute fatigue, chronic fatigue or both. Acute fatigue is short lived
and reversible in nature and related to daily work activities. It resolves with adequate
rest and sleep, and participating in leisure activities. In chronic fatigue, recovery is
uncertain, even when practicing these fatigue countermeasures, and maintaining
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normal daily physical activities become difficult.[23] Chronically fatigued workers

experience negative emotions, decreased motivation and interest, and difficulty in con-
centration and commitment to work in addition to reduced physical performance.
[23–26]
Currently, there is no gold standard for measuring subjective fatigue in workers.
Fatigue instruments that are developed for working populations or adapted from
patient-reported measures vary based on the conceptual and operational definitions
of their authors. They are either unidimensional measures addressing overall/total
fatigue [27–29] or multidimensional with certain aspects addressed such as motivation,
sleepiness, physical activity, and concentration.[30,31]
Understanding the dimensions and states of fatigue are important when selecting an
instrument in occupational research. A researcher might consider using a state measure
when the exposure of interest is work activities short-term and the response is con-
sidered to be an acute event (i.e. acute fatigue). On the other hand, a trait measure
might be more appropriate when a worker is exposed to work stressors over a longer
period, and the response is more enduring (i.e. chronic fatigue).
This paper provides a comprehensive review of five commonly used fatigue instru-
ments in occupational science over the past two decades. The work-related fatigue
instruments are presented in alphabetical order: (1) Checklist Individual Strength, (2)
Fatigue Assessment Scale, (3) Need for Recovery Scale, (4) Occupational Fatigue
Exhaustion Recovery, and (5) Swedish Occupational Fatigue Inventory. For each
instrument we describe the intent of the measure (aspect of fatigue measured and
recall period) and its content (number of items and response options). We also give
examples of studies where this was used. Then we describe administration, scoring,
respondent and administrative burden, as well as the availability of the instrument in
translated versions. Finally, we provide psychometric information including history
of how the instrument was developed and then data on reliability and validity. In
Table 1, we introduce the five scales that measure either acute or chronic fatigue
from a unidimensional or multidimensional perspective. This presentation is intended
to guide the researcher in selecting among them.

Checklist Individual Strength (CIS) questionnaire

Description
Purpose: To measure chronic (prolonged) fatigue.
Content: The CIS is a multidimensional instrument measuring chronic fatigue. Chronic
fatigue is considered irreversible and not task-specific, wherein compensatory
 Fatigue: Biomedicine, Health & Behavior 3

Table 1. The dimensionality and different states of fatigue measured by the 5 scales.
Instrument Acute or chronic fatigue Number of dimensions
Checklist individual Chronic fatigue Four dimensions:
strength
1. Subjective feeling of
fatigue/fatigue severity
2. Concentration
3. Motivation
4. Physical activity

Fatigue Assessment Scale Chronic fatigue One dimension

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Need for recovery Acute fatigue One dimension

Occupational fatigue Acute fatigue, Chronic Each subscale indicates one
exhaustion recovery fatigue, intershift recovery dimension
Swedish Occupational Neither acute nor chronic Five dimensions:
Fatigue Inventory
1. Lack of energy
2. Physical exertion
3. Physical discomfort
4. Lack of motivation
5. Sleepiness

mechanisms that were used in reducing temporary fatigue states become ineffective.
This instrument consists of four dimensions: subjective feeling of fatigue/fatigue sever-
ity (8 items), concentration (5 items), motivation (4 items), and physical activity (3
items). Twenty statements are administered (e.g. physically I feel in a good shape)
and participants are asked to indicate their relevant fatigue experiences.
Number of items: 20 items.
Response options: Each statement has a 7-point semantic differential response scale
from 1 (yes that is true) to 7 (no that is not true).
Recall period for items: In the past 2 weeks.
Examples of use: In 1994, the CIS was developed for patients with chronic fatigue syn-
drome [32] and applied afterwards in other patient populations like multiple sclerosis [33]
and rheumatoid arthritis.[34] In 1998, the first occupational use of the CIS was in the
National Maastricht Cohort study that aimed to measure employee fatigue in the
Dutch general workforce.[35] Since then, the CIS was used in different working popu-
lations (Table 2) such as police officers, healthcare workers, pilots, and teachers.[36–39]

Practical application
How to obtain: The CIS with its scoring instructions is published in the “Fatigue among
working people: validity of a questionnaire measure” article.[23] It is also available at
the Radbound University Nijmegan Medical Center (e-mail: nkcv@umcn.nl) in Neth-
erlands. The CIS can be obtained at no cost from the developer: Jan HMM Vercoulen
(email: j.vercoulen@mps.umcn.nl).
Method of administration: Self-administered computerized and paper-and-pencil
formats.
 4 K. Sagherian and J. Geiger Brown

Table 2. Citations for instruments in Web of Science Core Collection (1985–2015).

Citation is an
Times occupational
Measure Seminal articles cited studya Workforce type
Checklist Beurskens et al. 182 91 Police officers, aging workers,
individual [23] postpartum working
strength women, airline pilots,
overweight/obese workers,
white collar employees,
forest operators, workers
with common mental
disorders, nurses,
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physicians, teachers,
employees with chronic
disease, onshore and
offshore workers, army,
seafarers, military aviation
shift workers, rescue
workers, industrial workers,
fire fighters, fatigues
employees, nuclear power
plant operators, truck
drivers, and sheep farmers
Bultmann et al. [30] 112 65 Postpartum working women,
white collar, nurses,
teachers, employees with
chronic diseases, enterprise
workers, physicians,
firefighters, policemen,
mariners, rescue workers,
bus drivers, workers with
mental health problems,
veterinarians, shift workers,
and ambulance personnel
Fatigue Michielsen et al., 110 17 Nurses, construction workers,
Assessment [48] office employees, teachers,
Scale administrative staff, pilots,
faculty members, and
military aviation shift
workers.
Need for De Croon et al., 32 27 Nurses, healthcare providers,
recovery [28] office employees, industrial
workers, seafarers,
production workers,
employees with hearing
impairment, and ambulance
personnel
Van Veldhoven et 71 58 Airline pilots, computer
al., [29]. workers, construction
workers, supervisors,
bricklayers, vocational
employees, hospital staff,
fire fighters, office staff,
employees with hearing
impairment, nurses,
firefighters, and pastors

(Continued)
 Fatigue: Biomedicine, Health & Behavior 5

Table 2. Continued.
Citation is an
Times occupational
Measure Seminal articles cited studya Workforce type
Occupational Winwood et al., 42 32 Emergency healthcare
Fatigue [24] workers, athletes, nurses,
Exhaustion emergency medicine
Recovery clinicians, workers with
chronically ill conditions,
general employees/workers,
student workers, advanced
manufacturing technology
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operators, police officers,

and seafarers
Winwood et al., 20 18 Nurses, school teachers, adult
[25] workers, student workers,
and fire fighters
Swedish Ahsberg et al., [57] 40 21 Preschool personnel, workers
Occupational (construction, transport,
Fatigue hospitality, health, trade and
Inventory industry), drivers, AMT
operators, shift workers,
nurses, production staff,
white collar, assembly plant
Ahsberg [31] 46 23 Nurses, homecare workers,
teachers, school employees,
drivers (freight transport
vehicles, taxis,
ambulances), radiology
residents, shift workers,
seafarers, maritime craft
operations, assembly plants,
and visual display terminal
workers
a
The instrument was used to measure fatigue in a working populations.

Scoring and interpretation: The items 1, 3, 4, 9, 10, 13, 14, 16, 17, 18, and 19 are
reversed scored. Subscale scores are obtained by summing their corresponding items.
An overall total fatigue score represents the summation of the four subscales. Possible
scores range from 20 to 140 where higher scores indicate a higher level of fatigue, con-
centration problems, reduced motivation, and less physical activity or functioning. Indi-
viduals who score greater than 76 on the CIS are at high risk for sickness-related
absence from work.
Respondent burden: not reported, may take 4–5 minutes.
Administrative burden: not reported, easy to score, takes 5–6 minutes manually.
Translations/adaptations: The CIS (Dutch version) has been translated and validated in
Japanese, Portuguese, Turkish, Persian, Chinese, English, Korean, and Polish languages.

Psychometric information
Method of development: Originally, the CIS consisted of 24 items that was developed in
collaboration with 2 major hospitals in Netherlands. It was designed to measure several
 6 K. Sagherian and J. Geiger Brown

aspects of fatigue and administered to a sample of 298 patients suffering from unex-
plained chronic fatigue. In principal component analysis (PCA), four factors were
obtained and four items were removed because of weak correlations. The final subscale
accounted for 67.7% of the variance. The Cronbach’s alpha coefficient for the CIS in
the patient population was 0.90, with coefficients of 0.83–0.92 for its subscales. The
Gutman split-half reliability coefficient was 0.92.[32]
Acceptability: The items are easy to understand. There is no reported information about
the patterns of missing data or floor/ceiling effects from the psychometric studies.
Reliability: In a sample of 351 Dutch general workers, De Vries et al. [40] found a
reliability coefficient of 0.96 for the CIS-total scale and 0.87–0.96 for its subscales.
In test–retest reliability, the Japanese CIS version reported an intraclass correlation
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coefficient (ICC) of 0.82 after 3 days of follow-up.[41]

Validity: In divergent validity, the CIS as hypothesized was able to discriminate
between fatigued and non-fatigued subgroups of workers. In convergent validity, the
CIS-total had a moderate correlation of 0.62 with the Maslach Burnout Inventory
(MBI)-Emotional Exhaustion subscale in a group of employees with possible mental
fatigue.[23] Construct validity was further supported in another Dutch study where
the CIS-total had moderate-to-strong correlations with the MBI-Emotional Exhaustion
(r = 0.67), World Health Organization Quality of Life (WHOQOL)-energy and fatigue
(r = 0.71), fatigue scale (r = 0.78) and NFR (r = 0.66) scales.[40] Based on ROC ana-
lyses (specificity = 90%, sensitivity = 73%), a CIS cut-off point of ≥76 has been estab-
lished where fatigued employees with CIS scores of 76 and more are at risk for
sickness-related absence or work disability.[30]

Fatigue Assessment Scale (FAS)

Description
Purpose: To measure chronic fatigue.
Content: The FAS is a unidimensional instrument consisting of 10 items. The items
addressing physical (5 items) and mental fatigue (5 items) are selected from the
Energy and Fatigue subscale-WHOQOL (2), the CIS (5), and the Fatigue Scale (2).
One additional item was added to the scale (item 9: mentally I feel exhausted). The
FAS does not differentiate between physical and mental fatigue states and considers
it one overall fatigue construct.
Number of items: 10 items.
Response options: 5-point Likert scale (1 = Never to 5 = Always).
Recall period for items: No time reference (how an individual usually feels).
Examples of use: Developed in 2002, the FAS has been used in occupational groups
(Table 2) like military aviation shift workers, pilots, and nurses.[42–44] Also, it has
been frequently used in patients with sarcoidosis, stroke, and cancer.[45–47]

Practical application
How to obtain: The FAS is published in the original article “Psychometric qualities of a
brief self-rated fatigue measure-the Fatigue Assessment Scale”.[48] In order to use the
scale, researchers must contact the primary author: Helen J. Michielsen (email: h.j.
michielsen@kub.nl).
Method of administration: Self-administered paper-and-pencil and computerized formats.
 Fatigue: Biomedicine, Health & Behavior 7

Scoring and interpretation: Items 4 and 10 are reverse coded. A total fatigue score
ranging from 10 to 50 is obtained by summing all the items in the scale. Higher
scores indicate more of the construct (i.e. higher chronic fatigue levels).
Respondent burden: not reported, may take 2–3 minutes.
Administrative burden: not reported, easy to score and takes around 1 minute manually.
Translations/adaptations: The FAS exists in Dutch and English versions.

Psychometric information
Method of development: At the first stage, 40 items from 4 instruments (CIS, Fatigue
Scale-FS, MBI-Emotional Exhaustion (EE) subscale, and the Energy and Fatigue subscale
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from the WHOQOL) were compiled. For content validity, semantic analyses were used to
guide the selection process of the items from this item pool. Nine meaningful groups were
identified and an additional semantic group was added in order to address both physical and
mental aspects of fatigue equally.[48] In each group, the items with the highest factor load-
ings were selected.[27,48] The FAS consisted of 10 items with a reliability coefficient of
0.87 during its initial psychometric testing in workers. At the final stage, the loading on one
factor indicated the unidimensionality of the construct which explained 48.0% of the var-
iance. In Mokken analysis, the scalability coefficient was moderate (H = 0.47).[27]
Acceptability: The items are easy to read and understand. There is no reported information
on missing data and floor/ceiling effects on any of the items in the psychometric studies.
Reliability: The Cronbach’s alpha is 0.90 in the working population.[48]
Validity: For convergent validity, the correlations between the FAS and the other
fatigue (CIS, WHOQOL-EF and FS) subscales after correcting for overlap were mod-
erate to strong (0.60–0.76). In divergent validity, a Pearson r of 0.65 was found
between the FAS and the CES-depression scales. Although PCA showed two factor
loadings, four depression items loaded on both factors. Divergent validity was sup-
ported by the –0.38 correlation with the emotional stability scale. The factor structure
was clearly delineated with two separate factors representing the constructs. Only two
FAS items had gender bias; however, they did not influence the total score of the scale
and no further modifications were warranted.[48]

Need for Recovery Scale (NFR)

Description
Purpose: To measure short-term work-related fatigue (i.e. acute fatigue). This type of
fatigue arises in the last hours of work or immediately afterwards and indicates the need
for recovery.
Content: The NFR subscale is part of the “Experience and Evaluation of Work” (VBBA
in Dutch) questionnaire indicating early onset of fatigue. The scale is unidimensional in
nature consisting of 11 dichotomous statements (e.g. I find it difficult to relax at the end
of a working day). The items focus on the duration and th e severity of symptoms
reflecting work efforts during work hours.
Number of items: 11 items.
Response options: Dichotomous (yes/no).
Recall period for items: Refers to the end of a working day (end-of-shift).
Examples of use: Since its development in 1994, the NFR has been used in various occupations
like healthcare providers, office employees and industrial workers (Table 2).[49–51]
 8 K. Sagherian and J. Geiger Brown

Practical application
How to obtain: The NFR scale is published in the paper “Measuring quality and validity
of the Need for Recovery scale”.[29] Being part of the Experience and Evaluation of
Work (VBBA in Dutch) Questionnaire, permission to use the scale must be granted
by the Dutch Stichting Kwaliteitsbevordering Bedrijfsgezondheidszorg (SKB) research
institute.
Method of administration: Self-reported survey in paper-and-pencil and computerized
formats.
Scoring and interpretation: Nine of the statements are worded as unfavorable situ-
ations, and only item 4 (after the evening meal, I generally feel in good shape) that
is worded as a favorable situation is reverse scored while scoring the scale. A total
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score is calculated by summing the positive responses on the 11 items and transforming
it on a scale from 0 to 100. Higher scores indicate more complaints of fatigue and
greater need for recovery after work.
Respondent burden: not reported, may take 2–3 minutes.
Administrative burden: not reported, easy to score and takes less than 1 minute
manually.
Translations/adaptations: The NFR scale exists in Dutch, English (UK), Italian, and
Brazilian–Portuguese languages.

Psychometric information
Method of development: Initially, the authors analyzed 50 instruments in the field of
psychosocial workload and stress, and identified common concepts that were later
used in constructing the VBBA Questionnaire that includes the NFR subscale. Detailed
information regarding the development of the VBBA questionnaire is not reported in
English. The conceptual development of the NFR is based on the Effort-Recovery
model developed by TF Meijman and colleagues.[52] Work produces efforts manifest-
ing through emotional, cognitive and behavioral symptoms. At the end of a working
shift, the need to recuperate from work induced effort (fatigue) is captured by the
NFR scale. The unidimensionality of the NFR is supported by Loevinger’s H = 0.46
(0.40–0.50 is moderate) in Mokken analysis.[29] A higher value of 0.54 (≥0.50 is
strong) was reported in a study of Dutch general workers indicating higher measure-
ment reliability.[40] The scale had reliability coefficients of 0.87 and 0.86 during its
construction and replication stages.[29]
Acceptability: The items are easy to read and understand. We were unable to find infor-
mation reporting on missing data in the psychometric studies.
Reliability: In a national sample of 68, 775 Dutch workers, the Cronbach’s alpha was
0.88 and 0.81–0.92 when divided in 45 smaller subgroups.[29] In test–retest reliability,
the ICC after two years for truck drivers and nurses were 0.68 and 0.80. The NFR’s
stability over time was evident in stable working conditions only.[28] Validity: The
NFR has good content and convergent validity supported by the strong correlations
(0.66 and 0.71) with the CIS-subjective fatigue subscale in two large Dutch studies.
[29] Also, the NFR had moderate to strong correlations with the CIS (0.42–0.66)
and FAS (0.79) scales.[40] It has predictive validity from predicting future sickness-
related absences from work.[29] A cut-off point of >54 indicates an increased risk
for sickness-related work absence based on psychological complaints.[53] The validity
of the NFR was further tested by comparing the need for recovery at the individual and
 Fatigue: Biomedicine, Health & Behavior 9

department levels with 10 psychosocial job characteristics. The data at the department
level were constructed by averaging the individual scores in each department. At the
individual level, 27.0% of the variability in need for recovery was explained by 10 psy-
chosocial job factors. At the department level, the explained variance was 33.0%. With
an increase in department size (i.e. number of employees per department), the explained
variability in NFR increased from 45.0% to 54.0%. These findings indicate that the
NFR was able to detect departmental level fatigue where employees share work experi-
ences or are influenced by the shared perceptions of work-related fatigue.[29]
Ability to detect change: The scale was found to be sensitive in detecting fatigue related
to changes in truck drivers’ increased working hours. The effect size between baseline
and after two years was 0.40 (medium to large).[28]
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Occupational Fatigue Exhaustion Recovery Scale (OFER 15)

Description
Purpose: To measure acute and chronic fatigue, and intershift recovery.
Content: The OFER 15 consists of 3 subscales: acute fatigue (5 items), chronic fatigue
(5 items) and intershift recovery (5 items). The dimensionality of fatigue as a construct
is not reported; however, each subscale represents one dimension or a certain aspect of
fatigue itself. The conceptualization of fatigue and the mediating role of recovery have
a theoretical basis derived from allostatic load. The theory is based on neurophysiolo-
gical responses to external stressors (e.g. work).
Number of items: 15 items.
Response options: 7-point Likert scale from strongly disagree (0) to strongly agree (6).
Recall period for items: In the last few months.
Examples of use: The final version of the OFER-15 was published in 2006. Since then,
it has been used frequently in healthcare working population (Table 2).

Practical application
How to obtain: The OFER 15 and the scoring instructions are obtained by contacting the
primary developer Dr. Peter Winwood via email: peter.winwood@unisa.edu.au. There is a
cost associated with using the scale. Other translated versions are available with the author.
Method of administration: Self-administered survey through paper-and-pencil and
computerized formats.
Scoring and interpretation: The items 9, 10, 11, 13, and 15 are reverse coded. The sum
in each subscale is divided by 30 and multiplied by 100. The scores range from 0 to 100
where high scores/percentages indicate more of the measured construct.
Respondent burden: not reported, may take 3–5 minutes.
Administrative burden: not reported, easy to score and takes 3–4 minutes manually.
Translations/adaptations: The OFER 15 is available in French, Estonian, Iranian,
Chinese, Mandarin and Serbian versions.

Psychometric information
Method of development: Based on allostatic load theory and after a thorough review of
the fatigue literature and the existing instruments, 30 items with face validity were
chosen in constructing the OFER scale. The measure included both positive and negative
 10 K. Sagherian and J. Geiger Brown

worded items. The OFER with its 30 items was tested in 2 pilot studies of male quarry
workers and female nurses. The chronic fatigue (CF) subscale had good convergent validity
with both the CIS (r = 0.53) and Maslach Burnout Inventory (r = 0.69) scales. The number
of the items were reduced by PCA to 20 and validated in a large study of 770 Australian
nurses. Three factors were identified were similar to the pilot findings. Three items were
removed because they were below the item-factor correlation cut point of 0.52.
The three-factor solution explained 59.0% of variance. Cronbach’s alpha for the
subscales were 0.75–0.93. In confirmatory factor analysis (CFA), the fit indices
improved after removing two more items and yielded satisfactory fit to the data. The
convergent and discriminant validity of the OFER subscales were supported by both
the direction and significance of the correlations with other validated instruments in
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the study (e.g. Nottingham Health profile-NHP, Experience and Evaluation of

Work). In test–retest after two months, the ICCs were 0.62–0.84.[24] The refined
measure included 15 items that was further validated in 510 Australian nurses.[25]
Acceptability: The items are easy to read and understand. We were unable to find infor-
mation reporting on patterns of missing data and floor/ceiling effects on the items.
Reliability: The OFER 15 subscales were reliable with Cronbach’s alpha of 0.84–0.89.
In test–retest reliability, the ICCs after 2 months were 0.61–0.64.[25]
Validity: In CFA, the 15-item OFER had good model fit to data. The fit indices were
chi-square (χ 2 = 216.63), Tucker–Lewis index (TLI = 0.96), goodness-of-fit index
(GFI = 0.95), cumulative fit index (CFI = 0.97) and root mean square error of approxi-
mation (RMSEA = 0.05). It has strong convergent and discriminant validity supported
by Pearson correlations and linear regression analyses with selected NHP subscales and
average pre- and post-shift fatigue scores. In structural equation modeling, recovery
was found to be a partial mediator between acute and chronic fatigue in both the
large sample and in subgroup analyses.[25]

Swedish Occupational Fatigue Inventory (SOFI)

Description
Purpose: To measure perceived fatigue.
Content: The SOFI provides a measure of an individual’s perception of fatigue related
to work. Perceived fatigue is related to performing work-related tasks where specific
tasks differ in the kind of demand they impose on the individual. It is a multidimen-
sional instrument where symptoms (e.g. passive, drained, or yawning) address lack
of energy (4 items), physical exertion (4 items), physical discomfort (4 items), lack
of motivation (4 items), and sleepiness (4 items).
Number of items: 20 items.
Response options: 7-point scale from 0 (not at all) to 6 (to a very high degree).
Recall period for items: depending on the purpose of the study: now, in the last 10
minutes or when most tired.
Examples of use: After the SOFI was revised in 2000, it has been used in research both
as occupational (e.g. radiology residents, teachers) (Table 2) [54,55] and patient-
reported fatigue measure (e.g. patients with multiple sclerosis).[56]

Practical application
How to obtain: The SOFI 20 with the scoring instructions is published as an appendix
in the “Dimensions of fatigue in different working populations” article.[31] Permission
 Fatigue: Biomedicine, Health & Behavior 11

in using the instrument is not reported; however, it is advisable to contact the developer
Elizabeth Ahsberg. National Institute for Working Life, Solna, Sweden. Email: eliza-
beth.ahsberg@niwl.se.
Method of administration: Self-administered in paper-and-pencil and computerized
formats.
Scoring and interpretation: A mean score for each subscale consisting of four items is
calculated. Higher mean scores indicate greater degree of lack of energy, physical exer-
tion, physical discomfort, decreased motivation, and sleepiness.
Respondent burden: not reported, may take 2–3 minutes.
Administrative burden: not reported, easy to score and takes 4–5 minutes manually.
Translations/adaptations: In addition to Swedish, the SOFI 20 is translated to Spanish,
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Chinese, Persian, Danish, Icelandic, and English languages.

Psychometric information
Method of development: 172 items were extracted from the fatigue literature, diction-
aries, and in-depth interviews of 10 workers on fatigue perceptions related to work.
Based on content validity, the number of the items was reduced to 95 after a thorough
review by the research team. The instrument was administered to 705 Swedish respon-
dents from different occupations (e.g. bus drivers, teachers, medical personnel, fire
fighters) for further testing. In exploratory factor analysis, 50 items were excluded
and the number decreased to 45. Five factors were extracted explaining a total of
59.6% of variance. In CFA, the items were decreased to 25 in order to have an accep-
table model fit. The Cronbach’s alphas for the subscales ranged from 0.77 (physical
exertions) to 0.91 (lack of energy). The hypothesized model was not influenced by
gender, age, residential area or quality of perceived fatigue.[57] The proposed five-
factor model was validated in 597 workers from five different occupations: teachers,
firemen, cashiers, bus drivers, and locomotive engineers. The revised model had 20
statements with 1 general nested dimension (lack of energy) and 4 specific dimensions
of perceived fatigue.[31]
Acceptability: The items are easy to read and understand. There was no information on
missing data and floor/ceiling effects of the items in the psychometric studies.
Reliability: The reliability coefficients for the five subscales were satisfactory ranging
from 0.81 to 0.92.[31]
Validity: In construct validity, the CFA showed based on a revised model of 20 items
and five dimensions good fit to the data. The SOFI 20 was able to discriminate per-
ceived fatigue between teachers, firemen, and locomotive engineers. For convergent
validity, lack of energy and sleepiness subscales had Pearson correlations greater
than 0.40 with the overall fatigue measured by the Category Ratio (CR 10) scale. More-
over, the SOFI explained 43.0% of variability in overall fatigue indicating that the
instruments were measuring certain aspects of fatigue. The greatest variability in
overall fatigue by the SOFI was found in firemen (Adjust. R 2 = 0.57) and bus drivers
(Adjust. R 2 = 0.52).[31]

Discussion
The five fatigue measures described in this paper are brief, user-friendly, provide clear
instructions, and do not require training prior to use. The items are easily understood,
and most ratings are measured on 5 or 7-point Likert scales, providing adequate
 12 K. Sagherian and J. Geiger Brown

Table 3. Reliability and validity of the five fatigue instruments in the workforce
Reliability Validity
Cronbach’s Test– Face/
Measures alpha retest content Construct Criterion
Checklist Individual 0.87–0.96 Yes Convergent Predictive
Strength divergent
Fatigue Assessment 0.90 Yes Convergent
Scale divergent
Need for recovery 0.88 0.68 Yes Convergent Predictive
Occupational Fatigue 0.84–0.89 0.61– Yes Convergent
Exhaustion Recovery 0.64 divergent CFA
Swedish Occupational 0.81–0.92 Yes Convergent
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Fatigue Inventory divergent CFA

CFA, confirmatory factor analysis.

variability in the respondents’ scores. Four instruments have short recall periods (e.g.
referring to now, in the last 10 minutes or past 2 weeks), [23,29,31,48] hence favoring
greater precision in participant responses. The OFER 15 has the longest recall period
referring to the past few months. The potential for recall bias does exist; however,
the degree and direction of this biasing effect is not known. The instruments have
minimal administration burden as the scoring is easy and requires little time.
The psychometric properties of the five instruments have been established in the
working population through classical test theory. The NFR, OFER 15, and SOFI 20
were specifically developed for workers and validated in different occupational
groups. Moreover, the NFR is valid both at the individual and the departmental level
in indicating work-related fatigue and predicting future sickness-related absences. Orig-
inally developed for chronic diseases, the CIS was adapted and used in the working
population with great success. The FAS addresses both physical and mental fatigue
where the items were selected from three different fatigue instruments used both in
clinical and working subgroups. All five instruments had good reliability coefficients
of >0.80. In terms of construct validity, each instrument was tested through different
approaches and yielded satisfactory findings. The most common methods were confir-
matory and exploratory factor analyses, followed by convergent and divergent validity
(Table 3). The OFER 15 and FAS items are reported to be free of gender bias.
Some of the above studies do report theoretical frameworks guiding their proposed
fatigue definitions and instrument development. The NFR is based on the Effort-Recov-
ery conceptual model commonly used in fatigue/recovery research. The OFER 15
defines fatigue and the progression from acute to chronic states through neurophysio-
logic mechanisms known as allostasis and allostatic load theory.
To date, the dimensionality of fatigue remains debatable among researchers thus
leading to the use of both unidimensional and multidimensional measures in occu-
pational research. As indicated in Table 1, the CIS and the SOFI 20 cover physical, cog-
nitive, and psychological dimensions of fatigue, while the OFER 15 focuses on the state
and trait aspects of the fatigue. The NFR and the FAS are unidimensional measures of
acute and chronic fatigue commonly administered in occupational settings. These
instruments are equally important as they offer an understanding of general or specific
aspects of fatigue. They provide clear but different definitions of fatigue, and have been
tested in various working populations. There is good evidence for their psychometric
 Fatigue: Biomedicine, Health & Behavior 13

properties both in terms of validity and reliability; however, more studies are needed in
testing the stability of the instruments over time.
With this paper we aimed to assist researchers by providing detailed information
about several reliable and valid fatigue measures, which can help them in selecting
measures according to their own conceptual and operational definitions, and research
objectives. In addition, these measures can be utilized as possible surveillance tools
in occupational settings to monitor employee fatigue and ensure workplace safety.

Disclosure statement
No potential conflict of interest was reported by the authors.
Downloaded by [University of California, San Diego] at 00:23 27 January 2016

Notes on contributors
Knar Sagherian RN, is a Doctoral candidate, School of Nursing, University of Maryland, Bal-
timore, MD, USA.
Jeanne Geiger Brown RN, PhD, is an Associate Professor, School of Nursing, University of
Maryland, Baltimore, MD, USA.

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