The issue of fatigue has been long-standing in the profession of surgery. Typically the term has been associated with performance decrement, and in particular, focus has been on mitigating fatigue to prevent error-making. Emerging fields of fatigue research is beginning to explore the motivational components, and how fatigue and performance relationships are much more complex. This research uses surgery as a case study example of how a dysfunctional profession, with high-stake outcomes, can culminate in complex understandings between causes and effects of fatigue. It also proposes a significant change in paradigm to that of what is required to survive with fatigue or to thrive in work and life.
This is a mixed-methods research approach being primarily explored through a post-positivist lens. It is informed by the Medical Research Council Framework for Complex Interventions. Initially, a narrative and systematic review were conducted to identify the impact of sleep deprivation on aspects of surgical performance. Thereafter, a single-site observational study, exploring the impact of on-call models of sleep and performance outcomes, in surgeons was completed. An exploration of clinical decision-making, as an aspect of non-technical performance, ensued through four methods: a review of the literature, an exploratory survey study of variables influencing clinical decision-making, a validation of a simulated scenario of clinical decision-making, and a pilot exploration of the impact of cognitive load on decision-making outcomes. Following this, three qualitative studies were conducted on a single-site cohort, informed by a thematic analysis, identifying the phenomena of fatigue, thriving, and the confounding role of the COVID-19 pandemic in surgery. These thematic findings informed the design and validation of an extensive survey study design which sought to establish trends between health, well-being, lifestyle, work, and performance outcomes. Triangulated findings merged with theoretical underpinning of the COM-B model of behaviour change, culminating in the design of an individualised behaviour-change intervention. This was piloted and tested for feasibility in a single-site. Finally, collected data informed the design of a theory exploring the relationship between fatigue, performance, and thriving, and the required prerequisites to optimise performance. Cohorts of physiotherapists were used to explore comparisons of the outcomes of this research to healthcare professionals and systems as a whole.
The literature based on fatigue in surgery is conflicted. While more studies identified no impact on simulated or real-life performance, decrement was higher in studies with cognitive performance requirements. Systematic findings suggest a decrement in technical performance of 11.9%-32% in validated simulated scenarios. These findings were verified by the observational study, which also identified that both current workflow and on-call models predispose surgeons to early onset sleep. In exploring the ramifications of clinical decision-making, a validated clinical decision making assessment method identified that intuitive decision-making processes are predominantly influenced by practitioner and disease-related factors, and the deployment of greater risk-taking in decision-making was associated with those surgeons who then reported higher cognitive load. The self-identified causes and effects of fatigue were numerous, and included both work and non-work related factors for surgeons. The presence of COVID-19 added additional stressors, but resulted in contrasting levels of fatigue between surgeons. Trends in survey findings identified a symbiotic relationship between self-identified health, well-being, and performance, which was influenced by a myriad of lifestyle factors including sleep, stress and physical activity. In addition the work factors of culture and resource also influenced performance outcomes. There are opportunities for thriving in surgery. Surgeons perceived fatigue and sleep deprivation to be the main inhibitor to them thriving in work, but the theoretical objective synthesis identified that both states can co-occur, as long as there is a higher level of recovery processes, psychological capital, and psychological skill use. The use of a behaviour-change intervention which identified two phases, education and coaching, proved to be a feasible way to enable greater access to thriving states. These findings have comparisons to other context-specific healthcare professions, such as physiotherapy, where similar issues of fatigue and sleep deprivation exist.
A fundamental shift in understanding of fatigue in surgery has been provided, with triangulating evidence suggesting the impact of the state on all aspects of surgical performance. The primary responsibility for performance optimisation lies with the individual themselves, but environmental restructuring to facilitate performance optimisation, particularly through biomathematical modelling of work-life and positive cultures will likely sustain behavioural efforts. There is oftentimes a focus on negative performance domains, and the impact of current environmental and cultural restrictions on surgical performance. This thesis provides legitimate and warranted need for further exploration of the positive aspects of performance, and how the roles of three variables in particular recovery processes, psychological capital, and psychological skills utilisation may influence the relationship between performance in fatigued surgeons who survive or those who thrive .||en