The Impact of Personal Protective Equipment on Cognitive and Emotional Aspects of Health Care Work.

OBJECTIVE: Personal protective equipment (PPE) is critical to the safety of health professionals and vital to clinical practice. However, there is little known about the cognitive and emotional impact of PPE on health professionals' performance, comfort, and well-being. METHODS: A mixed-method, cross-sectional, observational study was adopted. An online survey consisting of 5-point Likert scale questions and free-text comments canvassed the opinions of patient-facing health professionals. RESULTS: An overall negative impact of PPE on health professionals' ability to carry out work was found from 185 responses from medicine, nursing, and allied health disciplines, including increased fatigue, poor communication, and feeling uncomfortable. CONCLUSIONS: There are significant negative impacts of PPE on health professionals' ability to carry out work, impairing communication, task efficiency, and comfort. Personal protective equipment is an essential infection control practice requiring further research, design, and testing to overcome challenges.

Clinical decision making in physical therapy - Exploring the 'heuristic' in clinical practice.

Clinical decision-making (CDM) plays an integral role in the work of a physical therapist and has ramifications for patient outcomes and experience. Rational decision-making - acting in a manner that helps us achieve our goals - is influenced by cognitive, emotional, and social variables. The dual process theory helps us understand how clinicians make what they perceive to be rational decisions. Within dual process is the use of cognitive decisional shortcuts, commonly referred to as 'heuristics,' which are either developed through experience or the use of fast and frugal trees (FFT). The use of heuristics in physical therapy practice has yet to be explored. This paper aims to describe this subset of physical therapy decision-making and to identify the typical cognitive biases - the error in heuristic-driven decision making - inherent in this style of reasoning. Common heuristics and their related biases are described and illustrated with vignettes, including the anchoring, availability, confirmatory, and representative heuristics. The authors conclude by proposing interventions to optimize physical therapists' awareness of their use of heuristics in clinical decision-making and to identify and minimize the influence of potential bias.

Sleepy Surgeons: A Multi-Method Assessment of Sleep Deprivation and Performance in Surgery.

BACKGROUND: Minimum rest is mandated in high stake industries such as aviation. The current system of healthcare provision permits on-call surgeons to work in sleep deprived states when performing procedures. Fatigue has been demonstrated to negatively affect performance. This study aimed to explore measurements of sleep deprivation and their impact on simulated performance. METHODS: This was a single site study conducted between September 2019 and February 2020. Surgical trainee and consultants were conveniently sampled from a single site. All testing was done between 7 AM and 9 AM. Participants completed electroencephalogram testing using a modified Multiple Sleep Latency Test testing for objective sleep measurement, the Pittsburgh Sleep Quality Index, Chalder Fatigue Scale and Epworth Sleepiness Scale for subjective sleep measurement. The Psychomotor Vigilance Task and the SIMENDO simulated tasks were used for standardized performance assessment. RESULTS: Surgeons entered sleep in 6 min, on average pre-call. This significantly decreased to an average of 164 s post-call (P = 0.016). Pittsburgh Sleep Quality Index scoring was 5, indicating poor baseline sleep quality. There was higher self-reported fatigue and sleepiness in post-call states. Performance decrements were noted in cognitive performance reaction time and aspects of technical instrument proficiency. CONCLUSIONS: Surgeons are objectively sleep deprived pre-call according to internationally recognized guidelines. This sleep deprivation increases significantly in post-call states. Tasks with higher cognitive demands showed greater levels of diminished performance compared to those with lower cognitive demands. Current models of provision of surgical on-call are not conducive to optimizing sleep in surgeons. Prioritization of workload in post-call states, focusing on preserving individuals cognitive resources and utilizing lower cognitively demanding aspects of work is likely to have positive impacts on performance outcomes.

Self-reported surgeon health behaviours: A multicentre, cross-sectional exploration into the modifiable factors that impact surgical performance with the association of surgeons in training.

INTRODUCTION: Surgeons regularly educate patients on health promoting behaviours including diet, sleep and exercise. No study thus far has explored surgeons' personal compliance with these health behaviours and their relationship with surgical performance. The primary outcomes of this study were self-reported health, health related behaviours, wellbeing, fatigue and surgical performance. METHODS: A survey of validated themes on health related behaviours, workplace variables and performance was distributed to surgical trainees and consultants in the UK and Ireland through the Association for Surgeons in Training (ASiT). Non-parametric analysis was used to determine inferential associations. RESULTS: Ninety five surgeons (51.5% female, 39.9% registrars) completed the survey. 94% and 74% reported 'good' or better overall health and mental wellbeing respectively. The majority (54.7%) reported inconsistent sleep patterns. Less than a quarter engage in regular exercise. Sixty two and 64.2% reported being regularly fatigued and bothered by feelings of anxiety and/or depression respectively. Poor self-reported health and wellbeing were associated with poorer reported off-call performance (p < .01). Higher levels of fatigue negatively impacted self-reported surgical and non-surgical task proficiency (p < .01). DISCUSSION AND CONCLUSION: Surgeons reported high levels of overall health. However, healthy behaviours around sleep, diet and exercise were not consistently reported. Fewer reported good mental health and emotional well-being. Self-reported health behaviours including sleep and physical activity were associated with surgical performance. Strategies to improve modifiable lifestyle factors which will optimise physical health, mental wellbeing and levels of fatigue may optimise surgical performance.

If in Doubt Don't Act Out! Exploring Behaviours in Clinical Decision Making by General Surgeons Towards Surgical Procedures.

BACKGROUND: Clinical decision-making (CDM) plays an integral role to surgeons work and has ramifications for patient outcomes and experience. The factors influencing a surgeons decision-making and the utility of cognitive decisional short cuts used in CDM known as 'heuristics' remains unknown. The aim of this paper is to explore how general surgeons make decisions in high-stake biliary tract clinical scenarios. METHODS: This was a cross sectional survey comprising of two sections-a 'demographics section' and a 'clinical vignettes section'. Participants were recruited by an email distributed by the Royal College of Surgeons in Ireland. Non-parametric testing examined relationships and content analysis was applied for clinical reasoning. RESULTS: 73 participants or 37.6% of the overall population completed the survey. 71.4% of these were male. Most (50%) were higher trainees with moderate levels of overall reflective practice in decision-making. A majority of participants chose conservatively in high-stake biliary tract clinical cases with disease factors (43.5%) weighted highest, followed by personal factors (41.1%) and patient factors (15.4%) in clinical reasoning. The presence of a 'hook' associated with commonly used heuristics did not significantly change decision-making behaviour. CONCLUSION: In high-stake scenarios, surgeons make conservative clinical decisions, predominantly dominated by disease and personal justifications. The utility of heuristics in lower-stake scenarios should be explored regarding clinical decision-making rationale and outcomes. Practitioners should consider use of patient factors in high-stake decisions to enable shared decision-making when appropriate which can reduce post-decisional regret and support the vision of patient-centred care.

COVID-19 and surgery: A thematic analysis of unintended consequences on performance, practice and surgical training.

PURPOSE: The shift in the national focus and allocation of resources to the management of COVID19 has led to significant changes to surgical practice including the delay of elective surgery. The aim of this study was to explore the implications of such changes on surgeons. METHOD: Using a qualitative study design, semi-structured interviews were conducted with general surgery consultants and non-consultant hospital doctors from a major tertiary hospital in the Dublin region between March-May 2020. Data collection proceeded iteratively using a thematic analysis approach with quality controls such as memoing and collaborative analysis. RESULTS: Fourteen surgeons (8 male, 6 female) were interviewed. The majority (n = 11, 78.6%) were NCHDs. Significant themes determined included 'impacts' on a variety of constructs such as performance, self-reported fatigue and wellbeing. Training themes elucidated included the effects of the cancellation of elective admissions on reduced operative exposure for trainees. Senior surgical staff were particularly focused on increased complexity in patient management. New policy requirements such as personal protective equipment use and novel rotas have had implications for aspects of work engagement. The pandemic and subsequent national restrictions imposed has afforded opportunities for improved well-being but also resulted in greater solitude in surgeons. CONCLUSIONS: Rhetoric surrounding fatigue management and virus control dominates the conversation on the relationship between COVID-19 and surgery. Tipping the balance back to parity of fatigue management with service delivery in surgery will be key for sustainability of the surgical workforce.

Would you allow a sleepy surgeon operate on you? A narrative review.

It is unclear if work-flow patterns resulting in sleep deprivation impacts on a surgeon's performance. Similar industries provide mitigating strategies to counteract sleep that may be of benefit to surgeons. A narrative review was conducted utilising Medline, Embase, Cinahl and Google Scholar. All English language papers including sleep and surgery and mitigating strategies for sleep deprivation in similar high-risk industries were included cumulating in 9050 non-duplicate papers. 97 studies were included in the final review. From this narrative review, it appears that there is a problem of sleep deprivation in the surgical profession. Results showed cognitive performance is more impacted than technical performance in the surgical profession in both simulated and real-life performance research. The relationship between sleep and workflow of surgeons is complex with numerous methodological approaches and contrasting research outcomes. Mitigating factors such as mandatory rest, simulation and stimulants have proven effective in other industries which parallel performance standards to surgery. This warrants a systematic review exploring the role of sleep deprivation and the potential role of mitigating interventions in areas of performance less understood like technical skill performance.

Medicine and heuristics: cognitive biases and medical decision-making.

INTRODUCTION: Clinical decision-making is a daily practice conducted by medical practitioners, yet the processes surrounding it are poorly understood. The influence of 'shortcuts' in clinical decision-making, known as heuristics, remains unknown. This paper explores heuristics and the valuable role they play in medical practice, as well as offering potential solutions to minimize the risk of incorrect decision-making. METHOD: The quasi-systematic review was conducted according to modified PRISMA guidelines utilizing the electronic databases Medline, Embase and Cinahl. All English language papers including bias and the medical profession were included. Papers with evidence from other healthcare professions were included if medical practitioners were in the study sample. DISCUSSION: The most common decisional shortcuts used in medicine are the Availability, Anchoring and Confirmatory heuristics. The Representativeness, Overconfidence and Bandwagon effects are also prevalent in medical practice. Heuristics are mostly positive but can also result in negative consequences if not utilized appropriately. Factors such as personality and level of experience may influence a doctor's use of heuristics. Heuristics are influenced by the context and conditions in which they are performed. Mitigating strategies such as reflective practice and technology may reduce the likelihood of inappropriate use. CONCLUSION: It remains unknown if heuristics are primarily positive or negative for clinical decision-making. Future efforts should assess heuristics in real-time and controlled trials should be applied to assess the potential impact of mitigating factors in reducing the negative impact of heuristics and optimizing their efficiency for positive outcomes.

A systematic review of sleep deprivation and technical skill in surgery.

BACKGROUND: It is uncertain if sleep deprivation impacts sleepy surgeons' technical skills. Lapses in surgical performance could increase morbidity and mortality. This review concludes if sleep deprivation impacts on technical skill performance in simulated environments. OBJECTIVE: Primary: 1. To identify if sleep deprivation has an impact on technical skill proficiency in surgeons. Secondary: a. To identify if the level of surgical experience, quality of sleep, or quantity of sleep influences technical skill proficiency in sleep deprived surgeons. METHODS: The review was conducted according to PRISMA guidelines utilising the databases Journals Ovid. Validation followed with two independent reviewers utilising an adapted version of BEME. RESULTS: Thirty-three heterogeneous studies were included. Sleep deprivation likely negatively impacts technical performance between 11.9 and 32% decrement in performance. No strong evidence exists with regards to influence of experience, sleep type, or sleep length on technical proficiency. CONCLUSION: Sleepy surgeons' technical skills are, on balance, between 11.9 and 32% negatively impacted in a standardised simulated environment. This is likely to have clinical implications for patient safety.