One of the best perks about leaving bedside was the reduced physical strains. No more tired back and aching knees. No more needing to sleep for a solid day following a stretch of work shifts. That was the expectation at least. The universe quickly let me know how mistaken I was. Not because of aches and pains, but mental exhaustion. The day after work stretches were still demanding of recuperation but for very different reasons now. I would race through each work day, moving from one set of problems to the next, trying to outrun the fear of making a mistake. It was exhausting. And after I left for the day, the endless rehashing of all the hard choices I made and the associated burden left me in a hazy state of indecision for even basic life decisions. Chicken or fish? Can the youngest go for a sleepover tonight? Should I shower or just go straight to bed??? The inability to make rational decisions after a long day at the hospital (especially in the beginning) was unexpected. It’s something I talk to training and new NPs about a lot, because in my mind, if you are aware of it you will experience less isolation and imposter syndrome. In this post I’ll talk about what it is, why it’s so bad in this new role as a nurse practitioner, and what you can do about it.

I am acutely, painfully aware of what decision fatigue looks and feels like. I’ve always struggled with this, even before I became an NP. But in preparing for this article I performed some research and came across some very interesting facts. The first of which being, did you know April is world stress awareness month? Yeah, me neither and I’m not sure what that does for me except to validate how universal stress and overwhelm are in ALL our lives. You are not alone. Secondly, by the end of the day you will have made nearly 35,000 decisions. Lord. I suppose when you think about it, most minutes of the day are comprised of conscious or unconscious choices. That explains the exhaustion. This data comes from a UK university researcher Eva Krockow.

Decision fatigue is not new, but the terminology is. It was first coined by Roy Baumeister, is a psychologist who expanded on Freud’s theory of mental energy. It focuses on the salient point - when faced with so many choices during a day, there comes a point at which our capacity to weigh pros and cons becomes stretched too thin. This is when less expertise and consideration are given to choices.

One such example is a study which examined parole board judges and found that the largest impact on whether or not parole was granted was the time of day!! What. Not the type of crime, but the time at which the case was reviewed? If the prisoner was seen early in the day 70% of the time they were awarded parole. By the time late afternoon rolled around, only 10% of prisoners were paroled.

I can see it. I can promise you the decisions I make at 3am are less well considered than those during the daytime. Physical and mental fatigue factor into decision fatigue. On top of that you factor in the high number of cases they have had to exert mental strain upon by that time. The how much do you care factor is probably lower.

What are factors that impact how much decision fatigue a person will experience? I mean, why was this never on my radar as a bedside nurse? I still had to make a million decisions a day. Consider the role and the stakes. A high stakes decision is one which involves:

• The possibility of a large loss (financial or emotional). I would argue loss of life should be at the top of this.

• High cost to reverse a wrong choice. Again - loss of life is about as big as one can get when it comes to cost.

Jobs which incur a large quantity/frequency of high stakes decision making would certainly invoke decision fatigue. Professions in which you are responsible for others’ like high level executive leaders; pilots; protective forces like police and firefighters; surgeons, physicians, and you guessed it, nurse practitioners and physician assistants. It makes sense that weighing the balance of life and limb repeatedly throughout our day would impose a great deal of stress. Our pledge is to do no harm. But is that an impossible task when you consider there are almost no all good decisions in medicine? Our job is to consider the risks and benefits and make the best suggestion to the patient. If you choose wrong someone could die. No pressure.

But people have been doing these jobs since the dawn of time and seem to be just fine. Why am I struggling so much?

Several factors feed into how severe you experience decision fatigue. Some are within your control and some are not.

• Role. Most acute care roles will by nature involve higher stakes. Especially super acute like ER, ICU, OR. Even non acute roles have significant decision fatigue. It’s still a human beings well-being we are discussing here.

• Experience. How much time you spent as a bedside nurse in the same unity type you are in now impacts this?

• Education. How thorough was your school experience. You all know my bias about schools. But beyond that is your unique capacity to learn and retain new knowledge?

• Training. How many NP rotations did you do for this specific role?

• Orientation and caseload. How long have you had a sidekick to help you through the day? How many patients are you expected to see per day and does it match your capability.

• Unique personal skill sets like adaptability, multi-tasking, focus.

What can you do about it?

• Eliminate as many low hanging fruit decisions as possible on busy days. Barack Obama says he only ever wore grey and blue suits so that he didn’t have to decide what to wear. Take out inconsequential decisions. Things that come to me and the associated actions (which typically just involve planning):

  • Who is getting the kids to and from school/activites -> I plan the week on Sunday afternoons and line up all helpers then.

  • What they will eat for dinner on the nights I work -> meal plan with my husband. Doesn’t mean I’m cooking, may look like a crock pot turned on before I leave in the morning, him picking up take out. But at least there’s a plan so last minute panic doesn’t become the straw that broke the camel’s back.

  • What I’m getting a family member for their birthday that week -> at Christmas I make a list for the entire year of what I think I want to get people. Don’t be impressed, in many instances it is a gift card. Typically I’ll buy them in advance and have it ready to go.

  • What I’m eating for breakfast and lunch -> not saying it’s for everyone but intermittent fasting eliminates sooo much time and mental energy. Or you could meal prep.

• Eliminate any self control challenges.

  • If you are on keto, your best bet is to plan ahead. When times are stressed, comfort food is mighty tempting.

  • Set recurrent events. If your goal for the year was to do yoga everyday, set a timer and make it a habit and an appointment that does not get dropped. If nothing else do your yoga.

• Automate everything possible. Set up recurring bill payments. Have an arrangement where your babysitters check in with you the night before a work day so you don’t have to be the reminder. Set alerts in your phone for birthday reminders. At work this looks like using DOT phrases. You know I’m obsessed. For good reason. This is the number one way to reduce mental stress in regards to clinical practice, recall of literature, and increasing your efficiency. Another similar process is to acquire as many resources as possible and save contacts. Often, to speed up work and to quickly contact consults I message personally.

• Involve others. Don’t forget, in most cases you are not an island. Obviously it is more challenging in the outpatient role. But even there, most people have colleagues, collaborators they can lean on. See the previous blog article where I talk about mentors to read about a strategy for finding and setting up an arrangement with a work mentor specific to the outpatient arena. Inpatient, use your consultants. They are the experts in their field for a reason, ask fo their input/help. And don’t forget, your patient. Shared decision making is HUGE. Discuss your concerns, the risks/benefits with patients and let them share some of the burden of ownership.

• Reduce your choices.

  • In our situation this may look like first addressing the improbable. Well yes his renal function is essentially null at this point and we should discuss dialysis, however he is end stage liver failure and it is improbable that dialysis will be possible or even offered by our nephrology team, which means we need to focus on goals of care today. This helps center your plan when walking into a very overwhelming patient scenario.

• Offer yourself grace. We were ALL new at some point. No matter the ego, the intimidation factor, the power play - we were ALL new and all went through similar struggles. While it never really goes away, that’s the nature of our work, it will absolutely get better. The transition from bedside (where you can check that “provider notified” box off your mental workload) to provider (where the burden is now yours to ensure the “duly noted” feedback is ok to give) is vast and under anticipated by nearly every NP I have every known.