Coping With Decision Fatigue In (And Out) Of The Emergency Department.
Author: Cristiana Theodoli
Ask anyone who has worked with me and they'll tell you of my lists. As the department gets busier and busier I rely more and more on a trusty - if never-ending - list of tasks to do. As a classic type A personality I am organised, impatient and decisive, and though there are many negative traits that come with being highly strung, they can also be an advantage when working in an Emergency Department (ED).
Lately however, I have been noticing my decisiveness disappear after a busy shift. I get home and find myself unable to make simple decisions. As my partner tries to involve me in choosing what to eat, watch or do I just cannot engage my brain enough to pick anything and I end up sitting there staring at him, AMT 0/4, wondering if this is what the onset of dementia feels like.
Decision fatigue – and as in my case the resulting Decision Paralysis - is a feeling that many of my colleagues will recognise. From clinical support workers to consultants, nurses to junior doctors we have all felt depleted and drained by the end of a heavy shift. Psychologist Roy Baumeister, who carried out seminal research into the topic, hypothesised that we all have a limited supply of decision-making stamina which depletes during our day¹. This leads to a coping mechanism described as effort avoidance, evidenced by research in which participants with depleted decision-making abilities were less likely to make concrete plans².
Decision fatigue is especially marked in clinicians working in ED, likely linked to the frequency and complexity of the decision-making involved in our field of practice³. Similarly research on critical care nurses linked decision fatigue to decreased ability to maintain attention, decreased ability to engage in problem solving and increased difficulties in processing and retaining clinical information⁴.
The impact of decision fatigue is also felt on the quality of our decisions during the length of a shift. One famous study carried out with Israeli judges sitting in parole board hearings found that, when accounting for other variables, favourable rulings dropped from 65% to almost 0% as the day went on, only to return to the initial levels after a break⁵.
Many of the strategies I could find online to deal with decision fatigue however are very much based on a 9-5, Monday to Friday lifestyle and impossible to apply in the unpredictable and often chaotic environment of emergency medicine and nursing. “Scheduling important decisions at the start of the day” just doesn't cut it when the standby phone warns of a major trauma coming our way at 5am on a Saturday morning.
So here are a few suggestions on how to cope with decision fatigue on and off shift. As well as saving time, these tips reduce the cognitive load of having to consider different options, hopefully minimising decision fatigue, preventing decision paralysis and helping to keep our minds alert.
Standardise the decision-making process and minimise draining activities.
There is a reason we have prescription charts, checklists and algorithms coming out of our ears in ED. They minimise mistakes and standardise the decision-making process. Similarly create your own checklists and algorithms for your way of working and living.
If anyone comes into a cubicle on oxygen make it a rule to recheck their SpO2 within a half hour, it saves the time spent wondering “should I recheck it now or give it a little longer?”. Create a checklist of items you'll need on shift and keep them all together, mine include trauma shears, tape, pens +++, chewing gum and lip balm. The one shift I had to change into scrubs I felt lost due to the lack of pockets!
Similarly, outwith work, if you do a large weekly shop make it a rule to always go the day before a run of shifts so you don't have to worry about running out of anything while exhausted. Set up your shopping list in the order you walk through the store to minimise diversions. Save time by having a running shopping list on your phone to add to as items are close to running out or meal ideas pop into your head so as to not have to try and decide all in the one go. Other options are planning your weekly meals in advance or always eat the same meal when on shift.
The advantages of regular breaks.
This is probably common sense, yet every shift you still see staff delaying or at times even skipping breaks. While we all need to refuel, regular breaks are not just beneficial for our physical health but give our minds a chance to reset. Like the Israeli judges, whose parole board approvals returned to baseline after a lunch break⁵, our breaks are vital in terms of being able to make unbiased decisions.
Don't start the decision-making process until you can act on it.
Tackle problems as they come up, there is no point in trying to figure out how to log roll a trauma patient for a CT scan when there aren't enough people around if they still haven't had a full A-E assessment. Pre-planning is great, but worrying about problems you can't tackle yet is a big cognitive drain. As well as a 'defensive pessimism' that anticipates possible issues, a key part of the cognitive process of expert trauma physicians is handling uncertainty by acknowledging it and being prepared to reassess the situation as things evolve⁶. Don't get bogged down by potential obstacles if there isn't anything you can do to prevent them but be prepared to tackle them when they present themselves.
Use a binary matrix.
This one is especially useful for those AMT 0/4 moments. When faced with “What should we watch tonight?” after a heavy shift the amount of choices feel overwhelming. Tackle it with a binary approach where you only have one of two choices to make at a time. “Film or TV Series.” “Comedy or Drama.” “1hr long or 20min”. And as the binary choices go on watch the options shrink to a manageable size.
Set up a waking up and going to sleep routine.
Especially important for us shift workers, having waking up and sleep time routines help to promote a better quality of sleep. If you teach your body “this is what I always do before I go to sleep” it will eventually be conditioned to know that shower-brushing teeth-stretching-reading-sleep is the standard sequence so when you start the sequence at 10am instead of midnight it will know that sleep time is coming. Similarly if the waking up routine is alarm-check social media-coffee-shower-getting dressed, starting the routine at 6pm when on a nightshift will alert the body that it's time to get going. Will it solve all your shift related sleep problems? Probably not, but it will likely help your mind to start switching off or on as needed.
Some of these may sound like common sense, yet I found these specific tips work for me. As I don't expect they would necessarily work for everyone though, I am keen to hear how others cope with decision fatigue!
¹ Stewart, A. F., Ferriero, D. M., Josephson, S. A., Lowenstein, D. H., Messing, R. O., Oksenberg, J. R., Johnston, S. C. and Hauser, S. L. (2012). Fighting decision fatigue. Ann Neurol., 71: A5-A15. 10.1002/ana.23531
² Hallgeir, S., and Baumeister, R.F. (2018). The Future and the Will: Planning requires self-control, and ego depletion leads to planning aversion. Journal of Experimental Social Psychology. Volume 76. 127-141. https://doi.org/10.1016/j.jesp.2018.01.005
³ Cheng, Y. H., Roach, G. D. and Petrilli, R. M. (2014). Clinical Fatigue Management Strategies. Emerg Med Australas, 26: 640-644. 10.1111/1742-6723.12319
⁴ Tian, F., and Exline, M. (2017). Reduced clinical recall and attentiveness due to decision fatigue (Conference abstract only). American Journal of Respiratory and Critical Care Medicine, 195, 1. https://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2017.195.1_MeetingAbstracts.A7153
⁵ Danziger, S., Levav, J., and Avnaim-Pesso, L. (2011). Extraneous factors in judicial decisions. Proceedings of the National Academy of Sciences, 108(17), 6889–6892. http://dx.doi.org/10.1073/pnas.1018033108
⁶ White, M.R., Braund, H., Howes, D., Egan, R., Gegenfurtner, A., van Merrienboer, J.J.G. And Szulewski, A. (2018). Getting Inside the Expert's Head: An Analysis of Physician Cognitive Processes During Trauma Resuscitations. Ann Emerg Med. 2018 Sep;72(3):289-298. https://doi.org/10.1016/j.annemergmed.2018.03.00D