Physicians work within a complex health system and face many challenges. This article offers strategies doctors may consider to mitigate the effects of fatigue, with a focus on hospital settings and in-patient care.
Every physician recognizes that, at one point or another, fatigue has influenced their ability to function. Human resource shortages, on-call duties, long hours, caring for multiple patients at once, sleepless nights, and interrupted sleep have long been a part of practising medicine.
Studies demonstrate that fatigue can adversely affect physician performance.1-5 To reduce the impact of fatigue, systemic approaches that target scheduling and impose duty-hour restrictions have been used along with self-care measures like micro-breaks and naps.6
It is also worth considering how standardizing team practices can help create a safety net for times when fatigue is inevitable. Using structured team communication processes may foster a shared understanding of the current state of affairs, promote a consideration of issues from different perspectives, and foster critical thinking to promote team situational awareness at critical times like shift changes, before the start of procedures, when dealing with an emergency, and during handovers in care.
Situational awareness refers to a person's perception and understanding of the dynamic information that is present in the environment. It involves keeping track of what is happening and includes anticipating what might need to be done.
Staying on top of matters in constant evolution can be challenging for fatigued physicians. In clinics or hospitals, huddles may foster and maintain situational awareness. Scheduled huddles are typically held at the beginning of a shift and help create a predictable routine. Aimed at addressing general administrative and logistical matters affecting a care unit, they allow all team members to discuss issues such as patient load and its impact on capacity, problems anticipated during the shift, and bed and staff availability. Unscheduled huddles can be called at any time by any team member to respond to an evolving situation that requires the team to rethink its care plan and enhance the ongoing safety of care, for individual patients and the entire unit alike.
An obstetrical unit covered by a single obstetrician is getting increasingly busy over a weekend. Individual nurses call on the obstetrician for advice. The charge nurse knows the obstetrician well and notices she is having difficulty concentrating and making decisions. The charge nurse calls for an unscheduled huddle with the obstetrician, all nurses, and a midwife to triage and prioritize all the clinical needs. This helpful input from colleagues allows the obstetrician to slow down, rebuild her situational awareness, and focus her attention on high priority areas.
Briefings bring key team members together before a procedure or event. Geared to discussing clinical care about to be provided, they promote team situational awareness and highlight potential critical situations. Briefings ensure all team members have a common understanding, or shared mental model, of what is about to happen and an opportunity to ask questions. It gives them the clarity necessary to do their jobs effectively and successfully.
Briefings may employ a checklist before initiating the procedure. The Surgical Safety Checklist (SSCL) is an example of such a tool. It serves as a forcing function that minimizes the likelihood that a critical step may be forgotten as a result of fatigue. When paired with debriefs, the strategy can prove to be a powerful learning activity. For more information, see the CMPA Good Practices section on team communication.
An anaesthesiologist has been up for 26 hours. He is called to start a trauma case in the operating room. Before the first incision, the team pauses and reviews the SSCL. This leads the anaesthesiologist to realize he has not checked for blood availability, and allows him to do so before starting the procedure.
Structured communication establishes a norm for how teams communicate. This increases the likelihood that team members will convey information correctly, efficiently, and effectively. Several structured communication approaches for handovers in care have been described in the literature.7 Whatever the tool, their value stems from the clarity they can generate, especially as it pertains to the following:
- assignment of responsibilities and tasks
- creation of contingency plans
- creation of shared mental models
- minimization of the likelihood that critical information might be omitted from a discussion
When information is conveyed to obtain a decision, tools such as SBAR (Situation, Background, Assessment, and Recommendation) can help focus the speaker on formulating a clear, concise message and prime the listener to listen for key elements of that message.
A child is admitted late in the evening with diabetic ketoacidosis. He is on an intravenous insulin regimen and his admission potassium level of 3.5 has remained the same. His nurse wakes the junior resident to obtain an order for supplemental potassium. Rather than saying, “I wanted to let you know that his potassium is 3.5,” which might lead a drowsy resident to say “ok” and return to sleep, the nurse increases the likelihood of a correct assessment by saying:
Situation: “I’m calling about David Jones who was just admitted with DKA.”
Background: “His admission potassium was 3.5, he currently has 40 meq/L of potassium in his IV, but his potassium level just came back at 3.5 again.”
Assessment: “I’m worried he is not receiving enough potassium”
Recommendation: “Should we increase his potassium supplementation?”
Cross-monitoring and speaking up
Fatigue may lead to mistakes, poor judgment, or missing an important detail, all of which could result in a patient safety incident (accident in Québec). In such cases, cross-monitoring and speaking up are two additional team practices that, among others, can mitigate the risks associated with fatigue.
Cross-monitoring is the practice of being mindful of what others are doing. The goal is to avoid a patient safety incident. Cross-monitoring is not supervision and does not imply accountability or authority of one team member over another. Rather, it is an approach to teamwork that places a shared value of patient safety at the core of practice through observing others’ work and looking out for them.
At 03h30, an experienced surgeon, performing his third emergency surgery of the night, calls for an instrument. The scrub nurse identifies that this instrument should not yet be needed because a required step in the surgery has not yet been completed. Rather than providing the instrument, she politely asks the surgeon whether he would like another instrument first, in order to complete the step she identified as being required next. He thanks her for her comment and attention, stating that he was “already three steps ahead in his mind” and that she had correctly identified a potential risk.
Tired individuals often cannot recognize they are about to commit an error until it is too late. While individuals may be blind to their risk of error, co-workers might see and hear things differently and identify an otherwise unappreciated risk. Speaking up is about saying something about a risk that seems unappreciated or under-appreciated by another provider.
Several approaches may be used to promote speaking up.8 It can, for example, be done rapidly in three successive, escalating steps summarized by the acronym CUS.9
C - "I'm concerned"
U - "I'm uncomfortable" or "This is unsafe"
S - "This is a safety issue" or "I am scared"
If a concern is acknowledged when it is first raised, there is no need to continue with the subsequent statements. If the situation is not addressed, the speaker can escalate to the next step in the approach.
Alternatively, a five-step process can be used:
- get the person’s attention
- state your concern
- state the problem as you see it
- propose a solution
- obtain agreement on the next steps
While the aim of speaking up is to acknowledge a potential risk and identify a corrective measure, it could lead to confrontation with a tired and irritable colleague. To create and maintain a culture of speaking up, it is crucial that both parties strive for a supportive, calm, non-judgmental, and non-punitive conversation.
The bottom line
Fatigue, an omnipresent human condition, can contribute to the loss of situational awareness. While self-care is a good starting point to mitigate the impact of fatigue on individual performance, systematic and standardized approaches to teamwork and communication should also be considered to help mitigate risks to patient safety.
A physician who realizes that their level of fatigue may impact the quality of their care should take appropriate steps to protect patient safety, either by asking for help or by deferring non-urgent care. Nevertheless, leveraging the power of huddles, briefings, and cross-monitoring and speaking up may help introduce an additional safety net and help teams build a culture of safety.
Visit the CMPA’s Physician wellness section for helpful resources on managing stress and staying well. If you are facing a medico-legal difficulty, contact us to speak with a CMPA physician advisor.
Schaefer EW, Williams M, Zee PC. Sleep and circadian misalignment for the hospitalist: a review. J Hosp Med. 2012 [cited on 2021 May 11];7:489-96. DOI: 10.1002/jhm.1903
Mansukhani MP, Kolla BP, Surani S, et al. Sleep deprivation in resident physicians, work hour limitations, and related outcomes: a systematic review of the literature. Postgrad Med. 2012 [cited on 2021 May 11];124 :241-9. DOI: 10.3810/pgm.2012.07.2583
Parry DA, Oeppen RS, Amin MSA, et al. Sleep: Its importance and the effects of deprivation on surgeons and other healthcare professionals. Br J Oral Maxillofacial Surg. 2018 [cited on 2021 May 11];56(8):663-6. DOI: 10.1016/j.bjoms.2018.08.001
Weinger MB, Ancoli-Israel S. Sleep deprivation and clinical performance. JAMA. 2002 [cited on 2021 May 11];287(8): 955-7. DOI: 10.1001/jama.287.8.955
Trockel MT, Menon NK, Rowe SG, et al. Assessment of Physician Sleep and Wellness, burnout and clinically significant medical errors, JAMA Network Open, 2020;3(12):e2028111
Wong LR, Flynn-Evans E, Ruskin KJ. Fatigue risk management: the impact of anesthesiology residents’ work schedules on job performance and a review of potential countermeasures. Anesth Analg. 2018 [cited on 2021 May 11];126:1340-8. DOI: 10.1213/ANE.0000000000002548
Desmedt M, Ulenaers D, Grosemans J, et al. Clinical handover and handoff in healthcare : a systematic review of systematic reviews. Int J Qual Health Care. 2020 [cited on 2021 May 11];33(1):1-24. DOI: 10.1093/intqhc/mzaa170
Brindley PG, Reynolds SF. Improving verbal communication in critical care medicine. J Crit Care. 2011 [cited on 2021 May 11];26(2):155-9. DOI: 10.1016/j.jcrc.2011.03.004.
Canadian Patient Safety Institute. CPSI;2011. The Patient Safety Education Program, Module 4: Teamwork: Being an Effective Team Member [revised 2017; cited on 2021 Apr 21]. Available from: https://www.patientsafetyinstitute.ca/en/education/PatientSafetyEducationProgram/PatientSafetyEducationCurriculum/Documents/Module%2004%20-%20Teamwork.pdf#search=CUS