Long before “burnout” became an occupational epidemic, its precursor “fatigue” held a grip on healthcare professionals struggling to maintain their energy during lengthy and difficult shifts.
“Healthcare has always been a high-stress, fast-paced environment, so fatigue has always been a latent hazard,” says Associate Professor Mustafa Ozkaynak, PhD of the University of Colorado College of Nursing. “In the longer term, fatigue leads to burnout, but in the shorter term it contributes to impaired clinical judgment and increased frequency in medical errors.”
Dr. Ozkaynak, whose research centers on healthcare, technology, and workflow, notes that fatigue is a complex -- and likely unavoidable – phenomenon.
Recently, Ozkaynak and a team of professors, researchers and clinicians associated with the University of Colorado Anschutz Medical Campus were awarded a two-year, $372,034 grant from the National Library of Medicine (part of the National Institutes of Health). Specifically, Ozkaynak and his team will study the multidimensional effects of fatigue on decision-making in pediatric emergency departments.
The project could benefit the broader field of healthcare where fatigue is increasingly widespread and problematic.
“Additional stressors were already in place in healthcare, but the workflows got even more complicated because of COVID-19,” Ozkaynak says, alluding to scheduling, staffing and other issues associated with the pandemic. “Clinicians had to do more workarounds and shortcuts. With fatigued cognition, these workarounds get more challenging and it’s easier to make mistakes.”
About the Project
Over the course of two years, Ozkaynak and his team will collect data and build “foundational knowledge” that could help health information technology vendors develop tools or “adaptive clinical decision support systems” that anticipate and adapt to fatigue.
As part of the project, Ozkaynak and his team also will build a prototype system that will be tested among 20 clinicians in simulation settings. Ultimately, Ozkaynak believes that these tools could minimize fatigue’s effect on clinicians and patients.
“Reducing fatigue is almost impossible,” Ozkaynak says. “There are a lot of solutions – such as drinking coffee, getting more sleep and recruiting more people, but they’re not always possible. And if they’re not always possible, then it’s important to make sure the tools and the technology we use can adapt.”
Ozkaynak, who joined CU College of Nursing in 2013, holds a PhD in Industrial Systems and Engineering from the University of Wisconsin Madison.
The project’s team consists of Dr. Rakish Mistry, a professor of pediatrics-emergency medicine from the University of Colorado School of Medicine, Paul Cook, PhD, Professor and Chair of CU College of Nursing’s Family & Population Health Division and Dr. Sarah Schmidt, Assistant Professor, Pediatrics-Emergency Med at CU Medical School. Mistry and Schmidt are both affiliated with Children’s Hospital Colorado.
A statistician also will be staffed for the project to help design and structure metrics and data-collection methodologies to inform the findings.
Ozkaynak acknowledges that part of the challenge with measuring fatigue is that the symptoms can be insidious. Indeed, a clinician could experience fatigue without even knowing. Although participants in the study will be queried on their fatigue levels regularly, the investigators will also study how fatigue influences clinicians’ interaction with technology.
“Maybe the way they use the mouse is a little slower than usual,” he says. “Perhaps they make more typographical errors and increase the use of the backspace or delete buttons on their keyboards.”
The project specifically focuses on antibiotic prescriptions -- leveraging the results from a 2014 study that found that clinicians prescribe more antibiotics than necessary when they are fatigued.
As a co-investigator and psychologist in the project, Dr. Cook says he’ll focus on how clinicians’ thinking changes when they experience fatigue. In 2018, Cook co-developed the “Two Minds Theory,” which proposes that people’s behavior is largely determined by factors outside their conscious awareness.
For example, Cook says a nurse might go through a daily routine operating mainly by habit – using what could be called “the intuitive mind.” However, when something unexpected occurs and more critical thinking is necessary, that nurse might slip into the more deliberate “narrative mind.”
“Most of the time, the intuitive mind is really good at making clinical decisions,” Cook says. “It works fast. It is good at multitasking, and it gets better as a nurse develops expertise. But when someone gets tired, the intuitive mind gets less efficient. Their thinking might be drawn into the more trivial aspects of the situation and they don’t perform as well.”
Evidence suggests that health information technology intended to improve efficiencies and ease clinical support decisions may inadvertently exacerbate fatigue and worsen outcomes. Cook says programming prompts and reminders that are commonly incorporated into technology systems won’t necessarily help clinicians’ performance when they are fatigued.
“The intuitive mind sees electronic prompts as one more annoyance,” Cook says. “A more effective approach might be to slow down the pace of interaction with the system, provide less information rather than more and to have fewer buttons and prompts.”
Ozkaynak agrees that if technology is not designed well, it can contribute to fatigue. Healthcare professionals and students increasingly depend on technology to improve patient outcomes.
“The question is how can we design better systems so that clinicians can perform at their best,” he says.
Potential to Improve Healthcare
As another co-investigator associated with the study, Dr. Mistry says he’s enthusiastic about the project’s overarching goal to make health IT tools more conducive to emergency care and more clinician-focused.
“The methods uncovered in this study could help clinicians rather than increasing the cognitive burden,” Mistry says.
Ozkaynak believes results of this research project could benefit other disciplines in healthcare outside of the emergency pediatric setting.
“Over time, this proposal will improve both clinicians’ wellbeing and their performance level in challenging work conditions, thereby maximizing patient outcomes,” he says.