Lengthy Shifts and Decision Fatigue in Out-of-Hours Primary Care: A Qualitative Study

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.