Lengthy shifts and decision fatigue in out-of-hours primary care: a qualitative study

Abstract

Rationale: demands on healthcare workers are high: services are stretched, shifts are long and healthcare professionals (HCPs) regularly work lengthy periods without a break. Spending time continuously ‘on task’ changes decision-making in predictable ways, as described by the ‘decision fatigue’ phenomenon where decision-makers progressively shift towards making less cognitively effortful decisions as the time worked without a break increases. This phenomenon has been observed repeatedly in large quantitative observational studies, however, individual healthcare workers' experiences have not been explored.

Aims: this qualitative study aimed to explore general practitioners' (GPs) and advanced nurse practitioners' (ANPs) experiences of working for lengthy periods in an out-of-hours primary care service in the UK. This included exploration of self-perceived changes in decision-making throughout a work shift, and mitigating strategies used to avoid changes in decision-making over time.

Design: semi-structured interviews were conducted online. An inductive thematic analysis was carried out to identify salient issues articulated by participants.

Setting and participants: the interview sample (n = 10) comprised ANPs (n = 5) and GPs (n = 5) who regularly worked within the out-of-hours primary care service across a regional National Health Service (NHS) health board.

Results: HCPs (GPs and ANPs) provided insights into their experiences during lengthy shifts and the impact of prolonged periods of work on clinical decision-making. Four main themes were identified and developed: (1) HCPs are aware of decision fatigue effects over the course of a shift; (2) Multiple factors help and hinder stable decision-making quality; (3) HCPs deliberately use strategies to help keep the quality of their decision-making stable; and (4) HCPs are aware of contextual changes, likely related to the decision fatigue phenomenon.

Conclusions: the findings of this study underscore the intricate interplay of personal, social and systemic factors in decision-making quality and highlight HCPs' deliberate efforts to mitigate decision fatigue's effects in practice.

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Identifiers

ORCID for Daniel Powell: orcid.org/0000-0003-4995-6057

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