A Realist Evaluation of a Fatigue Risk Management Plan (FRMP) Implementation in Obstetrics and Gynecology Residency: Calls for Systemic, Structural and Cultural Reform

ObjectiveAccreditation standards in residency education are calling for initiatives to promote the wellness of resident physicians including the implementation of fatigue risk management plans (FRMPs). We sought to conduct a realist evaluation of a FRMP within a five-year Obstetrics and Gynecology (OBGYN) residency training program in labour and delivery units. DesignMixed method study design informed by realist inquiry. SettingA single OBGYN residency program comprised of N=32 resident physicians who provided in-house labour and delivery call at four hospitals across a city of over one million people. MethodRealist inquiry askes what works, for whom, in what circumstances, and why? through examining contexts, mechanisms, and outcomes. We collected quantitative and qualitative data from resident physicians sequentially across three time points. Data were thematically analyzed, and configuration on contexts, mechanisms, and outcomes were identified using a realist approach. ResultsThere was n=19 unique participants (60% response rate). Most of the participants identified as women (93.7%), single (56.2%) and without children (93.7%). Participants mean age was 28.5 years and ranged from junior to senior residents. We found no significant difference between median sleepiness scores across three timepoints (p=0.17) however 20% of residents reported starting and ending shifts with high sleepiness scores signaling impairment that is hazardous to both residents and patients. The n=6 resident interview participants, reported overlooking patient details (forgetting to order tests, and delaying care) as well as personal safety issues such as driving home whilst fatigued despite FRMP implementation. ConclusionSpecific aspects of the OBGYN FRMP such as the nap model and nutrition could help with decreasing perceptions of fatigue related to lack of sleep and lack of available food. While FRMPs might be helpful in de-stigmatizing fatigue in residency, FRMPs are unlikely to decrease levels of resident fatigue because of systemic, structural, and cultural barriers.