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

Background: A ccredi tation standards in residency education are calling for initiatives to promote the wellness of resident physicians i ncluding 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.

R ealist inquiry askes what works, for whom, in what circumstances, and why? through examining contexts, mechanisms, and outcomes. Using a mixed method study design, we collected quantitative and qualitative data from OBGYN residents sequentially across three time points.

There were 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 resident s 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.

Specific aspects of the OBGYN FRMP such as the nap model and nutrition could help with decreasing percepti ons 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. All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Page 3 of 21

and Rationale The problem of poor well-being in residency has been established.1-3 Burnout, depression, and suicidal ideation are prevalent among resident physicians with these issues persisting into practice. 1 4 Leaders in postgraduate medical education (PGME) have been called upon to create evidence-based initiatives for “wellness” 5 including fatigue risk management plans (FRMPs). There is wide acknowledgement in the literature that the burden of fatigue risk management (FRM) must be shared across all stakeholders in PGME as stated by the Fatigue Risk Management Task Force in Canada and worldwide.6 The Royal College of Physicians and Surgeons of Canada (RCPSC) also acknowledges residents and physicians more broadly are susceptible to the effects of fatigue than the rest of the population. 7 Over the past decade, the National Advisory Committee and Expert Working Group8, developed the Fatigue Risk Management (FRM) Toolkit6 with guidance from FRM experts and stakeholders in PGME from across Canada. The FRM toolkit was released in 2018 and is the first national resource for residency programs across Canada. The report provides a “non-prescriptive framework designed to assist clinical learning environments, programs and institutions in developing their own local FRM policies and mitigation strategies” . 6 Furthermore, the FRM toolkit resource recognizes that the guidelines are not a “one-size-fits-all” and that they should “be adapted to suit local resources and contexts ”.6 More recently, Canadian PGME accreditation standards9 are calling for residency programs to ensure: “The curriculum plan includes FRM , specifically education addressing the risks posed by physician All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Page 4 of 21 impairment to the practice setting, and the individual and organizational supports available to manage the risk”.6 Despite the need for FRMP implementation and national support with respect to resources, research has shown that there is much complexity in conceptualizing fatigue, recognizing fatigue, and measuring fatigue before implementation of a FRMP can even occur. For example, fatigue is a multifaceted phenomenon experienced by residents in different ways and requires management beyond duty hours and adequate amounts of sleep. Furthermore, FRMPs should encompass strategies that are aligned with the resident, the program, and the healthcare system in which they work so that there is buy- in, feasibility and sustainability.4 One study showed that fatigue may n ot be uniformly understood as an occupational threat by residents . For example, they reported that u nder the current system and structures of PGME where residents form a large part of the healthcare workforce, fatigue is constructed and reinforced by the training environment and culture of medicine 10 In residency training, fatigue may be seen as a personal challenge rather than a threat to residents ’ own wellness as well as patient safety and a s such , the implementation of FRMPs in residency training may not have a substantial impact on resident fatigue because it is understood as “ines capable, manageable, necessary and surmountable and deeply ingrained in the local training culture.” 10 Similarly, another study found that health care teams hold contradictory beliefs about how fatigue impacts physician performance and patient care outcomes and called this the “ fatigue paradox ”.11 T hey sampled physicians, nurses, and senior residents across eight specialties including Obstetrics and Gynecology (OBGYN). They identified All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Page 5 of 21 that resident physicians may be faced with contradictory messaging of fatigue as an individual resident problem but not for patients or the health care system. Furthermore, the stigma of admitting fatigue may harm patients with few mechanisms to mitigate t his harm requires that they must adopt the identity of an infallible physician and maintain that fatigue does not harm patients. They concluded that unless the systemic and structural issues in residency education are addressed the fatigue paradox will continue to be sustained.11 As there is a need for more FRM research in residency education and considering FRMPs that go beyond targeting the individual fatigued learner, we sought to conduct a realist evaluation of the FRMP implementation within a five-year OBGYN residency training program. O ur Focus on Obstetrics and Gynecology Residency Training The literature commonly shows residents in OBGYN programs in particular encounter unique stressors and have high rates of burnout given the unpredictable nature of obstetrical services.12 13 It is estimated that 25%14 15 of residents are burnt out and 40% to 75%14 15 of practicing obstetricians and gynecologists suffer from work related burnout, making the lifetime risk inescapable.12-15 One study found that residents in OBGYN with burnout reported a lack of support by faculty, fellow residents and perceived there is a greater emphasis on service over education. Residents also report a dissatisfaction with hospital benefits and facilities such as call rooms. 14 Another study found that the number of residents reporting any problem with wellness increased significantly between the first year and second year of training, after All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Page 6 of 21 which it continued to increase as training progressed. Residents reported programs s hould provide personal protected time for maintaining wellness and highlighted incongruencies between current system-l evel solutions and what residents find helpful in maintaining their wellness.14 One recent pilot study demonstrated residents, regardless of postgraduate year (PGY) -level or shift, found non- urgent pages to be a significant contributor to on-call fatigue. To manage fatigue risk, a problem board was established to identify and show potentially urgent cases and categorize the cases in a visual way to ensure patient safety. 16 Given the lack of literature around FRMP implementation in residency education (and specifically in OBGYN residency), as well as the call for FRMPs as part of residency education, we sought to conduct a critical realist evaluation17 to understand the effect of FRMP implementation for OBGYN resident physicians at our institution. Fa tigue Risk Management Plan (FRMP) in Obstetrics and Gynecology Residency Program The rationale for the FRMP was based on our OBGYN program becoming early adopters of FRM strategies, first by changing weekend call from 24 hours at a time to two 12-hour shifts and second, in 2012, the program implemented a unique ‘nap model’ for junior OBGYN residents. In this model, the on-call resident was relieved of their daytime duties between the hours of 13 00-1700 preceding their overnight shift. The residency All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Page 7 of 21 program also aimed to value wellness by allocating several academic half day teaching sessions for a group wellness activity. Against t he existing backdrop of advocacy for program-level FRM initiatives, our team of authors considered FRM strategies across the levels of self (individual), program and system informed by strategies from holistic wellness, residency education (protected time for academic half -day sessions) and human factors ( conceptualization of fatigue, nutrition, and performance) to comprise a comprehensive FRMP for the residents. At the time of the study, the nap model had not yet been evaluated and it was acknowledged that the nap model alone could not be sustainable as the only FRMP. Appendix 1 provides a holistic description of the FRMP in the OBGYN program. We implemented an OBGYN FRMP that targeted all 30 residents across four adult sites with Labour and Delivery Hospital Units in a large Canadian city over the course of one year (2020-2021). Reflexivity Throughout the study and as part of the FRMP implementation the authors each had unique roles in the implementation. The team was led by a medical education and health services scholar working in residency education who assisted with grocery delivery and oversaw the research project. The team also consisted of : a) a research assistant who assisted with study design, ethics approval, data collection and analysis, b) a recent graduate of the OBGYN program and locum who assisted with grocery All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Page 8 of 21 delivery and was also the FRM champion, c) a human factors specialist who provided human factors expertise and conducted the academic half day sessions on human factors, nutrition, sleep, and fatigue and d) a program director of the OBGYN residency program who facilitated connections with the health care system such as L and D units.

T his study was approved by the research ethics board at our university. Philosophical Approach The FRMP is a complex intervention meant to be delivered in multiple contexts and settings. As Ellaway et al., indicate “critical realism and its operationalization in the form of realist inquiry can provide much-needed explanatory power” for interventions such as the FRMP. 18 In critical realism, the fundamental r eason for mixing quantitative and qualitative

is to promote an understanding of the complexity of the reality.19 Furthermore, critical realism assesses the phenomena of existing mechanisms through quantitative data20 21 whilst qualitative methods are used in obtaining in-depth explanations of existing mechanisms. 18, 22 23 We collected survey, validated psychometric scale data and sleep diary logs as quantitative data and resident perceptions through interviews as qualitative data. Study Design This real ist evaluation used a mixed methods design24 and involved collecting both quantitative and qualitative data sequentially during multiple points of time. A realist evaluation17 (by virtue of realist inquiry) helps to explain “what works, for whom, in All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Page 9 of 21 what circumstances, and why?” as opposed to “does it work?” As such, the use of realist inquiry seeks to examine contexts, mechanisms, and outcomes. Through realist inquiry, we explored whether a comprehensive FRMP enhances resident wellness because residents may have made decisions in response to the FRMP. Moreover, the reasoning of the residents in response to the resources or opportunities provided by the FRMP may have led to certain outcomes. The mechanisms refer to the underlying social or psychological drivers that led to the reasoning and decision making of residents regarding their own fatigue management, wellness and that of their colleagues (outcomes). 17 Realist inquiry explains changes (if any) brought about by a complex intervention such as the FRMP under specific conditions (PGY levels, L and D units) within a specific context (across four hospital sites, during COVID-19 pandemic). The residents and the FRMP are embedded in a social reality that influences how FRMPs are implemented and how this impacts resident wellness. The context-mechanism-outcome (CMO) framework is used as the main structure for data analysis in realist inquiry.18 Our initial program theory was informed by the previous research conducted around self, program, and system as well as core components of education (academic half day sessions), wellness (specifically holistic wellness as described by the WISHES framework)25 and human factors (nutrition, fatigue, and impact measurement of sleepiness). Thus, our initial program theory described how, (in L and D units within the OBS/GYN program), a successful FRMP implementation might be implemented and measured by the Karolinska sleepiness scale (KSS) 26 27, Maslach Burnout inventory (MBI)28 and resident perceptions through qualitative interviewing. Our initial program All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Page 10 of 21 theory postulated that within the OBGYN residency training program contexts from PGY 1-PGY5, the FRMP could lead to decreased burnout, decreased sleepiness, overall decreased perceptions of fatigue, and increased perceptions of wellness. Figure 1 summarizes our initial program theory. Setting: The OBGYN resident physicians provide in- house L and D call at four hospitals across the city. During the study, the breakdown of residents training in the program were (N=32) according to postgraduate year (PGY) was as follows: n=6 PGY1, n=6 PGY2, n=6 PGY3, n=8 PGY4 and n=4 PGY5. Two residents were on leave. The investigators along with systems (PGME and health care system ) and national support from the RCPSC recognize the intense demands of the OBGYN residency program, mainly because of the sleep disruption necessary to successfully navigate this specialty. Sampling and Recruitment Authors held an information session about study participation and informed consent during an academic half-day session for the residents. Participants were contacted by the research assistant to participate in the study. Recognizing that the residency program director was also a co-investigator, residents were assured that only the research assistant and principal investigator would know who participated in the study and that participation was completely voluntary. Residents were informed that should they not wish to participate; this would have no bearing on their training and career progression. All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Page 11 of 21 Data Collection To test our initial program theory, we collected both quantitative and qualitative data. Quantitative data: Residents were asked to complete a pre- mid- and post-test survey (at 0, 6 and 12 months respectively) that assessed and measured burnout using Maslach’s burnout inventory28 (which included three sub- scales measuring emotional exhaustion, depersonalization, and personal accomplishment ). Residents were also asked about overall wellness, sleepiness, nutrition, and access to food and were asked to complete a sleep diary documenting their perceived sleepiness and sleep quality over a two- week period concurrent with the pre- mid- and post-program mark. A link to the sleep diary was sent by text message to each participant at 7:00 am daily over the two- week period. At the end of the 12- month period of implementation, two research assistants conducted interviews with residents to further explore the outcomes of the FRMP implementation. Qualitative Data: A semi-structured interview guide was developed by the research team and asked about resident experiences of fatigue (both causes and consequences of fatigue), how they managed fatigue as well as their perceptions of the implemented FRMP. Interviews were conducted by telephone or videoconference and ranged between 28 and 61 minutes. Interviews were transcribed verbatim by an independent transcriptionist and all identifying data were removed. Purposive sampling was conducted to ensure we are gathering data from a broad range of diverse perspectives across residents. Data Analyses All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Page 12 of 21 Survey and sleep diary data were analyzed using SPSS software and we provide descriptive analysis. Interview transcripts were reviewed and coded line by line deductively using the realist inquiry context-mechanism-outcome (CMO) framework using QSR Nvivo software. Regular meetings were held between the research team to ensure discrepancies were discussed. Throughout the research process from 2020 to 2022, we had regular meetings with the FRM taskforce from the RCPSC and an international subject matter expert. T he knowledge dissemination phase has taken place from 2022- present with continuing information sharing meetings to create a community of practice (CoP) .29 The CoP meetings have been facilitated by the RCPSC FRM teams across Canada and are ongoing at the time of writing this manuscript.

There were n=19 unique participants over the course of the study (60% response rate). The demographic information of the 16 participants that completed the initial survey showed that participants mostly identified as women (93.7%), single (56.2%) and without children (93.7%). The participant mean age was 28.5 years. Participants ranged from junior to senior residents with n=2 from PGY1, n=5 from PGY2, n=2 from PGY3, n=4 from PGY4 and n= 3 from PGY5. Quantitative Data: Sleep Diary All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Page 13 of 21 Sleep diary data was collected for n=19 participants over the three time points. 54-68% of shifts lasted over 10 hours at every time point. Average length of shift at baseline was 14.0 hours calculated over 129 shifts, at midpoint was 13.0 hours calculated over 85 shifts and at endpoint was 12.0 hours calculated over 50 shifts. Between 12-18% of the shifts lasted 24 hours or longer. Burnout Across the three timepoints of baseline, mid-point and endpoint respectively (n=14, n=10 and n=7), residents showed median burnout scales indicating emotional exhaustion a few times a month across the three time periods (2.8 vs. 2.8 vs 2.9) whilst residents felt a sense of personal accomplishment between once a week to a few times per week (5.1 vs. 4.5 vs. 4.9). Residents felt a sense of depersonalization between a few times a year or less to once a month or less across the three time points (1.4 vs. 2.2, vs. 1.6). Sleepiness and sleep We found no significant difference between median scores using the KSS before and after resident shifts on the L and D across three timepoints (p=0.17) during the FRMP implementation, however 20% of residents reported that they w ere starting and ending shifts with high KSS scores of 8, 9, or 10. Of note, a KSS score of 8 (sleepy, some effort to keep awake) or higher can be hazardous to both the resident and to patients in their care. 30 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Page 14 of 21 Qualitative Data: Causes, Consequences and Management of Fatigue Findings There was n=6 residents who participated in the interviews. Table 1 describes the causes, consequences, and how residents managed their fatigue. Overall residents reported that the causes of fatigue were related to contextual factors such as being a resident, being on call and the culture of medicine. In terms of mechanisms that were fatigue-related, residents reported decreased emotional regulation impacting their mental, physical, and intellectual wellness. These led to outcomes that impacted patient safety such as overlooking details, forgetting to order tests, and delaying care as well as personal safety issues such as driving home whilst fatigued. In contrast residents reported positive outcomes to their social wellness because of mechanisms such as residency program cohesion: “I totally love my resident cohort. And I feel I have made five soul mate friendships in residency. So, I feel that's been really great. And the rest of the program has been so supportive. And the staff and my seniors are all just such lovely people that I feel socially are very well connected.” – Participant 02 There was also a sense of appreciation that the program was being proactive about FRM which also acted as a mechanism: “I think it’s very good that the program is working on understanding the residents’ fatigue and making it better and trying to work on patient safety because I think, in talking to other residents in other programs this isn’t something that gets talked about and so I think that this is super-important.” – Participant 03 Regarding occupational wellness, there were mixed responses. On the one hand increased covid-19 restrictions in the context of the pandemic allowed for time to take care of oneself leading to a positive outcome: All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Page 15 of 21 “So for example, prior to COVID we would never take any time off, even if we were ill. So, everyone has examples of when they were just so sick, but still came to work. I remember I started getting a lot of muscle aches and pains, and neck pains, especially towards the end of residency, and it was really difficult to find time to recoup around that, because you still had to go to work and perform.” - Participant 04 On the other hand, residents were left feeling more exhausted because of the mechanism of increased workload, clinical complications, and uncertainty of acquiring skills for competence: “There's some pieces of COVID that are just, you feel constantly, clinically exhausted, because we're dealing with really sick people and really bad complications because of COVID. And that's really hard on people. That's really hard on residents. I think it's been hard because there's also uncertainty about acquisition of skill, especially in terms of our competencies.” - Participant 05 Management of fatigue by residents as outcomes were reported as being individual level strategies such as caffeine, exercise, therapy, making notes and lists, and antidepressants. FRMP Evaluation Findings From the quantitative data presented above, we found that the interventions of the FRMP had little tangible impact on fatigue, in terms of reported sleepiness, actual time slept, or burnout. The qualitative data and realist evaluation makes it clear that the interventions were successful in improving the perception of fatigue among some residents but not the fatigue itself. Table 2 provides a summary of the FRMP context- mechanism-outcome configurations (CMOs). Based on the recurring patterns that are evident throughout the CMO configurations, we can theorize that for the FRMP interventions had a positive impact (and may work in other contexts), with the nap All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Page 16 of 21 model and nutrition initiatives seeming to have had the most impact. Overall, the FRMP was an improvement to the resident program experience and was perceived to have positive impacts on perceptions of fatigue, so long as they aligned with already existing individual level mitigation strategies and sources of fatigue. Table 3 highlights perceptions about the FRMP initiatives.

Our study had three main findings. First, despite best efforts of implementation of a FRMP (as per accreditation requirements) for OBGYN residents, there are factors that impede its effectiveness that are inherent to residency such as, long hours, call shifts, a high stress environment, and the culture of medicine. FRMPs at the program level to address fatigue are only a band-aid solution. Second, it remains clear that resident fatigue can have significant impacts on patient and personal safety, this was reported by the residents in this study as well as corroborated by many other studies on this population and others. 10 11 16 31 Last, we found that FRMP interventions that are able to address the systemic, structural and cultural concerns that cause these issues must be aligned with the program level FRMP. We cannot understate the importance of recognition and awareness by the OBGYN program in implementing the FRMP and the consensus is that while FRMPs might be helpful in de-stigmatizing fatigue in residency, such interventions are unlikely to decrease levels of resident fatigue because of the systemic and structural barriers as well as the culture of medicine. Given that programs taking steps to facilitate and All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Page 17 of 21 provide space and resources for wellness and coping strategies helps improve the perception of program support and improves program culture, our findings align with previous studies that while FRMPs might be helpful in certain aspects of fatigue, they may not be holistically helpful. 10 16 31 Additionally, as residents move through residency, they might become more resilient in coping with fatigue which then impedes innovation and the call for systemic, structural and cultural change in medicine. So where to go from here? Residency education and the health care system has to grapple with the issue of liability when it comes to fatigue. Our results showed the increased risk of impairment in fatigued residents which could lead to patient safety and/or personal safety issues. In these cases, we must then ask how can adverse events to both patient and resident be avoided if fatigue is driven by the very nature and key features of how we conduct residency education. Furthermore, who is liable when we inevitably encounter adverse outcomes as a result of residency training? In terms of lessons learned from our realist evaluation, we have now refined our initial program theory (see Figure 2) to encompass systemic and structural barriers as well as culture that could impede program level FRMP implementation. We also would like to re-iterate31 that FRM is a multi-facetted issue with individual differences and ultimately residents rely on their own FRM strategies to help them through residency. In terms of best practices from the FRMP implementation, we suggest normalizing the nap model (so that residents are not reluctant to use it) and allow protected time for self-care, list clear tasks for the FRM officer (such as regular check- All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Page 18 of 21 ins) and provide call room nutrition by way of having a fridge and snacks available on a regular basis. Future research should look at the intersections of fatigue and competence assessment while considering contextual factors such as relational autonomy, emotional tone, socio-cultural aspects as well as technology.32 Future FRMP implementation should also apply complexity theory and implement FRMPs considering complex adaptive systems.33 This would help in considering the bigger picture in which the FRMP interventions are implemented. A major strength of this study is that it is the first to use a realist evaluation for implementation of a FRMP. Despite this, there were several limitations to this study. First in collecting several indices of data, there may have been research-induced fatigue which could have increased the fatigue experienced by residents. In consulting with an international sleep subject matter expert, we had to increase the data collection instruments and make changes to the sleep diary questions across the data collection period which may have impacted the results and induced further fatigue in residents. Second, we had a small sample size with loss to follow-up across the time points which could compromise the generalizability of our results. Only 19 of the 32 residents participated, and even with this sample, we had significant attrition from baseline to endpoint. Another key limitation is that we used self-reported sleep and work diaries, which introduces recall and response bias which could be further confounded by being fatigued. Last, COVID-19 changed the context of this study and did not represent what a usual environment looked like for residents thereby also impacting levels of fatigue. All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Page 19 of 21 CanERA General Standards of Accreditation for Residency Programs require “effective central policies and processes are in place addressing residents’ physical, psychological, and professional safety”, including FRMPs 9. St udies like ours demonstrate the challenges of culture change but also provides examples of achievable and meaningful interventions in FRMPs that residency programs can aim to accomplish. Improvements to existing FRMPs, include regular sessions to help de-stigmatize talking about fatigue, increased outreach to residents by the FRMP officer, in-house seminars by staff who understand systemic, structural and cultural barriers and sustained food and nutrition initiatives. Our study showed findings that refuted our initial program theory that the FRMP would decrease burnout and fatigue. However, we also found aspects of the 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. Future FRMPs should examine the role of the FRM officer and explore contextual features to specific training environments within residency programs such as L and D hospital units as part of OBGYN residency and how various mechanisms moderate outcomes using realist evaluation. In conclusion, resident physician FRMPs cannot be implemented in isolation without consideration of the broader systemic, structural and cultural influences which modulate various contexts, mechanisms and resulting outcomes. All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Page 20 of 21

1. Jennings ML, Slavin SJ. Resident Wellness Matters: Optimizing Resident Education and Wellness Through the Learning Environment. Acad Med 2015;90(9):1246-50. doi: 10.1097/acm.0000000000000842 2. Kassam A, Horton J, Shoimer I, et al. Predictors of Well-Being in Resident Physicians: A Descriptive and Psychometric Study. J Grad Med Educ 2015;7(1):70-4. doi: 10.4300/jgme-d-14-00022.1 3. Ripp JA, Privitera MR, West CP, et al. Well-Being in Graduate Medical Education: A Call for Action. Acad Med 2017;92(7):914-17. doi: 10.1097/acm.0000000000001735 4. Slavin SJ, Chibnall JT. Finding the Why, Changing the How: Improving the Mental Health of Medical Students, Residents, and Physicians. Acad Med 2016;91(9):1194-6. doi: 10.1097/acm.0000000000001226 5. Kassam A, Martimianakis MA. When I say… wellness. Medical Education 2023 6. Fatigue Risk Management Taskforce. Fatigue Risk Management for Residents, Leaders, and Policy Makers in Canadian Postgraduate Medical Education., 2018. 7. Asch DA, Bilimoria KY, Desai SV. Resident Duty Hours and Medical Education Policy - Raising the Evidence Bar. N Engl J Med 2017;376(18):1704-06. doi: 10.1056/NEJMp1703690 [published Online First: 20170405] 8. Gorman L, Imrie K, Selig J, et al. Fatigue, risk and excellence: towards a pan-Canadian consensus on resident duty hours: Royal College of Physicians and Surgeons of Canada 2013. 9. Canadian Residency Accreditation Consortium (CanRAC). General Standards of Accreditation for Residency Programs Ottawa: CanRAC; 2024 [Available from: https://www.canrac.ca/canrac/general-standards-e. 10. Taylor TS, Watling CJ, Teunissen PW, et al. Principles of fatigue in residency education: a qualitative study. CMAJ Open 2016;4(2):E200-4. doi: 10.9778/cmajo.20150086 [published Online First: 20160428] 11. Field E, Lingard L, Cherry R, et al. The fatigue paradox: Team perceptions of physician fatigue. Med Educ 2021;55(12):1388-93. doi: 10.1111/medu.14591 [published Online First: 20210712] 12. Ghetti C, Chang J, Gosman G. Burnout, psychological skills, and empathy: balint training in obstetrics and gynecology residents. J Grad Med Educ 2009;1(2):231-5. doi: 10.4300/jgme-d-09-00049.1 13. Smith RP. Burnout in Obstetricians and Gynecologists. Obstet Gynecol Clin North Am 2017;44(2):297-310. doi: 10.1016/j.ogc.2017.02.006 14. Morgan HK, Winkel AF, Nguyen AT, et al. Obstetrics and Gynecology Residents' Perspectives on Wellness: Findings From a National Survey. Obstet Gynecol 2019;133(3):552-57. doi: 10.1097/aog.0000000000003103 15. Winkel AF, Morgan HK, Hammoud MM, et al. Burnout and Well-Being in Trainees: Findings From a National Survey of US Obstetrics and Gynecology Residents. J Grad Med Educ 2024;16(5):572-80. doi: 10.4300/jgme-d-23-00554.1 [published Online First: 20241015] 16. Regan S, Russell S, Simone K, et al. A Pilot Study in Fatigue Risk Management Among Obstetrics and Gynaecology Residents at the University of Alberta. J Obstet Gynaecol Can 2024;46(6):102431. doi: 10.1016/j.jogc.2024.102431 [published Online First: 20240304] All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Page 21 of 21 17. Pawson R, Tilley N. An introduction to scientific realist evaluation. Evaluation for the 21st century: A handbook. Thousand Oaks, CA, US: Sage Publications, Inc 1997:405-18. 18. Ellaway RH, Kehoe A, Illing J. Critical Realism and Realist Inquiry in Medical Education. Acad Med 2020;95(7):984-88. doi: 10.1097/acm.0000000000003232 19. Sobh R, Perry C. Research design and data analysis in realism research. EUROPEAN JOURNAL OF MARKETING 2006;40(11-12):1194-209. doi: 10.1108/03090560610702777 20. Edwards PK, O'Mahoney J, Vincent S. Studying organizations using critical realism: A practical guide: OUP Oxford 2014. 21. Lawani A. Critical realism: what you should know and how to apply it. Qualitative research journal 2021;21(3):320-33. 22. Bhaskar R. Critical realism and dialectic. In: Archer MS, ed. Critical realism: essential readings: Routledge 1998:575--640. 23. Mukumbang FC. Retroductive Theorizing: A Contribution of Critical Realism to Mixed

Research. Journal of Mixed Methods Research 2023;17(1):93-114. doi: 10.1177/15586898211049847 24. Creswell JW, Clark VLP. Designing and conducting mixed methods research: Sage publications 2017. 25. Kassam A, Ellaway R. Acknowledging a Holistic Framework for Learner Wellness: The Human Capabilities Approach. Acad Med 2020;95(1):9-10. doi: 10.1097/acm.0000000000003026 26. Åkerstedt T, Ingre M, Broman JE, et al. Disturbed sleep in shift workers, day workers, and insomniacs. Chronobiology international 2008;25(2-3):333-48. 27. Akerstedt T, Knutsson A, Westerholm P, et al. Sleep disturbances, work stress and work hours: a cross-sectional study. J Psychosom Res 2002;53(3):741-8. doi: 10.1016/s0022- 3999(02)00333-1 28. Maslach C, Jackson SE, Leiter MP, et al. Maslach Burnout Inventory: Manual: Includes These MBI Review Copies: Human Services-MBI-HSS, Medical Personnel-MBI-HSS (MP), Educators-MBI-ES, General-MBI-GS, Students-MBI-GS (S): Mind Garden 2017. 29. Lave J, Wenger E. Situated Learning: Legitimate Peripheral Participation. Cambridge: Cambridge University Press 1991. 30. Akerstedt T, Anund A, Axelsson J, et al. Subjective sleepiness is a sensitive indicator of insufficient sleep and impaired waking function. J Sleep Res 2014;23(3):240-52. doi: 10.1111/jsr.12158 [published Online First: 20140417] 31. Kassam A, Cowan M, Topps M. Lessons Learned to Aid in Developing Fatigue Risk Management Plans for Resident Physicians. Teach Learn Med 2019;31(2):136-45. doi: 10.1080/10401334.2018.1542307 [published Online First: 20181231] 32. Kassam A, de Vries I, Zabar S, et al. The Next Era of Assessment Within Medical Education: Exploring Intersections of Context and Implementation. Perspect Med Educ 2024;13(1):496-506. doi: 10.5334/pme.1128 [published Online First: 20241009] 33. Greenhalgh T, Papoutsi C. Studying complexity in health services research: desperately seeking an overdue paradigm shift. BMC Medicine 2018;16(1):95. doi: 10.1186/s12916- 018-1089-4 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Table 1: Causes, Consequences and Management of Fatigue Causes of Fatigue Supporting Quotes Residency “My physical wellbeing is definitely worse than it was when I entered residency. I feel there is not as much time to go to the mountains, go hiking, not as much time for just working out….” Participant 02 “….you just like abandon your hobbies. Or just because you spend so much physical time at work, and then you had so much limited time at home, that you needed to recoup, and therefore like that time had to come out of something, which as we know, time is a finite resource, and there just wasn’t enough of it to go around. Participant 04 “So, things look a little bit different I would say as a junior [resident], you’re definitely really more emotionally fatigued because it's the first time you’re dealing with a lot of stuff and there’s a lot of learning that happens really fast and you’re trying to keep up and perform.” Participant 05 “….you know, actually being on L&D and obstetrics for 12, 13 hours is very physically demanding and so you’re often, like not just emotionally and mentally, but like very physically drained too, at the end of the day.” - Participant 06 Being on call “….one of my colleagues when in the throws of doing a lot of call in the week, fell asleep on call and then didn’t answer their pages so then there’s nurses paging about things that like are going unaddressed; and so, if those things are urgent then that’s bad.” - Participant 03 “I would say definitely the physical hours, because you easily work 80-hour weeks, and that doesn’t leave a lot of room for kind of replenishing yourself.” Participant 04 Culture “And then there's been some periods where you're oh, is medicine at all even the right place for me? Or are there yeah, there's been some bad outcomes that I've had that have just kind of lingered and been quite traumatic for everybody that's been involved, including myself and so those have definitely been some low points.” Participant 02 “And then I think also one of the things about residency, that there’s a lot that is hard to argue around, is that everyone says you’re a trainee, and so it really is about getting all – as many hours and experiences as you can in, before you’re out to practice. And I found it really difficult to challenge any notion of, you know, getting more time off to rest, or getting more time off to recoup, because you’re constantly thinking – you’re like, no, this is my training, I have to put in as many hours as I can, this is an expectation of me.” Participant 04 Consequences of Fatigue Impact on patient care “I think that there's probably lots of times when you're rounding on your post call, or really tired, and you probably aren't as thorough in evaluating a patient as you'd like to be. I think also I definitely I'm All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint right now I'm in a rotation where you do home call, and you kind of get woken up in the middle of the night. But you're more likely to be asleep, so you're kind of groggy and I think there's been a time when I had a consult from emerge that I probably didn't, I guess pay close enough attention to. And I wasn't really pleased with how I handled the patient in the end. Just I think I just because I was tired and trying to get some sleep. I probably didn't pay close enough attention and didn't put a plan in place that I was very happy with. Both overnight and then in the morning when I saw the patient. Probably the most specific example I can give I think is mostly just I feel missing things, missing lab

or missing a new symptom or something that when you're tired, you might just kind of not hear or not ask about.” – Participant 01 “I think things get missed. So, whether it's lab results, a patient who might need a blood transfusion and you're waiting for their haemoglobin to come back. Or patients who have preeclampsia and you're monitoring their labs, and maybe debating if you need to start a different medication. Even just I find the main point of safety that is that routinely comes up is at the point of handover. Or it's those little things that you don't have somebody haemorrhaging in front of you. But it's those little things particularly on the unit because they're kind of out of sight and tucked away that get missed. And so, someone might have a very high blood pressure on postpartum and no one's alerting you or there might be different kind of critical results that aren't immediately related to you.” – Participant 02 “I can think of one example where a patient – that happened, and a patient’s C-section got delayed until the morning, and on that baby, the tracing had been fine before that happened, and she was a low-risk patient, so they took her off the monitor, and they let the patient rest. And end of the next morning when they did the C-section, the baby had in fact been in distress. And I can’t remember if the baby passed, or had really poor neurological outcome, yeah. But I mean obviously specifically in that example, who really knows what the issues were, but I do think part of it was no one wants to do something in the middle of the night at three am, yeah, if they think that they can help it. And I think it if had been obvious that the baby had been distressed, obviously people would have acted on it. But when people perceive that there is not as much urgency, I think then – but when the manifestations of people’s fatigue start to become noticeable on patient care.” – Participant 04 Impact on personal Safety “So overall I know nightshifts going to cut years off our lives, we are definitely not as healthy when we work nights as we are when we don’t work nights for sure. I know there’s lots of residents who’ve gotten in car accidents on the way home from call, I haven’t had that happen to me luckily but I'm sure it could. And your physical safety when you’re so tired, I don’t do any high-risk sports when I'm post call the stuff like that I would normally do I don’t do any of that when I could, your reaction times a lot slower for sure. And I think just physically you’re not as fast, you don’t respond as well so definitely in that.” Participant 05 “And I think we had three residents in the last year that were in car accidents on their way home from work. So I feel it would - I know, of residents in general surgery two in the last year that were in a car All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint accident on their way home. So it's actually really common, that people are getting into accidents. And I myself has fallen asleep multiple times driving home.” Participant 02 I've definitely fallen asleep at a red light before and then woken up when someone beeps somewhere. We all sort of joke about that which is very dangerous but its better now than it was before, I'm less tired after a night than I was when I was younger, in the immediate sort of aftermath. But yeah definitely, I mean we’re up for 24 hours there’s – no matter how much intervention I think we’re always going to be tired when we finish 24-hour shifts. - Participant 05 So, I think fatigue contributes to all that and kind of chipping away at maybe your resiliency. But, I mean, like obviously physical and personal safety, like driving home from call shifts and stuff, is probably the most dangerous thing I do in my life sometimes, it feels like, but – yeah. I don’t know what else in terms of safety. Maybe, like personal safety, other than, like emotional, physical wellbeing. I think probably – I feel like people – a feeling like it’s taking away years off your life, you recognise that in the moment, but – I mean I don’t ever feel like I’m in danger, I guess, from fatigue, other than maybe feeling very tired on drives home.” – Participant 06 Well, I think like we drive home from call all the time and so we’re very tired, and then driving while doing that I think is bad. I find like there are things that we can do like we can get taxis home from the hospital, just kind of like a hard system to use because you can’t taxi to the hospital and home, you have to like taxi home and then back to so your car get trapped at the hospital; so like safety -wise that way. Participant 03 Managing Fatigue Snacks and hydration Yeah, I mean, like I think certainly the snacks, to be honest with you. Having any form of just sustenance or nutrition, I realise I think it makes you much less fatigued the next morning. Yeah, I think on nights where you don’t sleep, how drained you are, and I’m sure it’s impacted by even having a small snack or a bite to eat or something. I think it makes a big difference. And hydrating too. I don’t hydrate enough. So, like having a sparkling water or something there was great, because we often forget to also drink any water during the day. And then I think that drains you as well. – Participant 06 Making notes and lists I start using a lot of lists and more binders and highlighters to make sure that I'm trying not to miss the things that either I want to hand over to the oncoming team, or in terms of some of those things that are a little bit easier to forget like this referral that I forgot to put in. Yeah, so I revert to a lot of write things down, and checklists. Participant 02 Caffeine I guess I mean, we all drink, well, most of us drink coffee or tea, so caffeine to try and stay alert and minimise patient safety issues. - Participant 01 “I just drink a lot of coffee. Like a lot of coffee. And then I sleep pretty much all my post call days, some people are very productive, but I'm somebody who comes home and sleeps the entire day.” – Participant 02 Setting realistic expectations But I think just like being aware of fatigue and where it’s coming from and like things that you can do to mitigate it or at least just being, again, like kind with yourself and knowing that this is fatigue, I need All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint to actually put effort and mindfulness into dealing with it and not just hoping it will go away on its own. I think like that will carry forward into like being a staff and those type of things. And also just like remembering how hard residency is moving forward into like one day when I am a staff just like having kindness and forgiveness and like patience with residents who will generally be up many more hours a week than we are as staff. Participant 03 Sports and exercise Well, I definitely use exercise quite a bit I and I find that that's a big factor for me. If I don't exercise, I do notice a change in my mental health and my emotional state as well. So that's a big one for me in terms of wellbeing. – Participant 01 Therapy and antidepressants So, I had to get a therapist, I got myself on antidepressants, I had to talk to my colleagues, a lot of who experienced the exact same thing. Participant 04 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Table 2 Context-Mechanism-Outcome (CMO) Configurations of the Fatigue Risk Management Plan (FRMP) Context Mechanism Outcome Junior residents R1-R3 experience  physical fatigue from long hours/call shifts, emotional fatigue. Fatigue was mitigated by interventions that addressed key sources of fatigue – for example nap model for R2s, fridge and snacks for call rooms. Senior residents R4 and R5 experience  mental fatigue, intellectual fatigue, better balance, and control. FRMP interventions had little impact as none directly addressed sources of fatigue at systemic, structural or cultural levels. Residency program Overwhelming and overprioritized Individual level strategies to reduce impact of fatigue COVID-19 – Disruption of schedules (+) Less time at work (-) Educational milestones (-) Disrupted emotional state and coping (+) More time to engage in self- care. (-) Loss of social supports (+) Denotes a positive aspect in the mechanism or outcome. (-) Denotes a negative aspect in the mechanism or outcome. All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Table 3: Perceptions about the Fatigue Risk Management Plan (FRMP) after Implementation FRMP Intervention Supporting Quote Nap Model for 2nd Year Residents I think it was helpful. I mean it was really helpful in a sense that at least I got bit of a break. Like I definitely preferred it to not having it, yeah. But I think it was really interesting, because I think the unintended consequences of it was like a lot of guilt, and almost shame, for reminding people about the Nap call, guilt because, you know, you were leaving your colleagues when it seemed like it was really busy, and you felt like you couldn’t help them out. – Participant 04 When we had that nap call system I always slept before call and that really helped in second year. Now if I can do it I will but usually as a senior I don’t have the opportunity to take any time off before I go to call. Because I find for me anyway really the call is what gets me, long hours, early mornings I don’t really, I don’t get fatigued as much by that, that I can handle. Participant 05 Nutrition Initiative I've loved the programme for the snacks and the fridge that was provided. And I think that's been actually a really great thing. In terms of keeping us energised, and also keeping us eating something reasonably healthy. And the fridge is great, because it encourages people to bring their own food too so you can eat a bit better. Participant 01 Having healthy granola bars and like those types of things accessible is really helpful because like we’re so busy we don’t always have time to go and buy these types of snacks for ourselves. So just being able to have access to them at all times of day is helpful because there’s a lot of times where we’re so busy that the first time you get to eat in a day is 2 am and so then it’s too late to get anything, so having that available is good. - Participant 03 But one thing I did appreciate was the healthier snacks in the call rooms, because I found sometimes those were the only things that I would eat all day. - Participant 04 I can't speak highly enough about the fridge and the food that has greatly impacted things for me. Participant 06 Nutrition and Sleep Hygiene Seminars The coaching sessions I enjoyed in the moment, but I probably haven't retained as much of that information as they would to or should have. And All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint so, I probably have not been able to implement those, I think maybe if they've been maybe broken down into several sessions, instead of just two at the beginning, it might have been easier to kind of be reminded or to come back to an implement. But I remember enjoying them, I just don't remember the content as well as I would like. Participant 01 I thought the sleep talks were actually helpful. In some ways the talk wasn't as applicable to us because we talked a lot about structured napping, but we just can't when we're doing 24 hours, it's just not possible. But I did take away some tips about trying to manage myself post call and when I'm fatigued otherwise, so that was helpful. I did also take away some stuff from the nutrition talk. So, I've changed the times that I eat carbs on call and sugar. So that kind of stuff was helpful. Having snacks always is nice, because at least I knew coming into a call shift. I didn't have stuff with me, then I would have stuff there. Participant 05 Fatigue Risk Management Officer The FRM Officer is just somebody who reaches out on their own sometimes. For example, I had a very bad case outcome. And they just texted me and [they have] just been a good lifeline and support at different times. But I have not necessarily been using them in their formal role [as FRM Officer]. I miss email sometimes. Participant 02 I didn't actually know that they were assigned as an officer. Participant 05 All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint CONTEXT (C): • Labor and Delivery units across 4 hospital sites in Canada • Obstetrics and Gynecology Residency Training Program (PGY1-PGY5) • Fatigue Risk Management Taskforce Support • Toolkit Application • Royal College of Physicians and Surgeons of Canada Support • COVID-19 Mechanisms (M): • Individual, Program, System approaches • Education, Human factors, Wellness Outcomes (O): • Reduced burnout scores, reduced sleepiness scores, increased resident satisfaction, perceptions of successful fatigue risk management Intervention: Fatigue Risk Management Plan Figure 1: Initial Program Theory All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint Structures Government, policies and practices C: Ministry of Health M: Health workforce O: Fatigue and Well-Being Impact Systems C: Healthcare and Postgraduate Medical Education M: Residency Education O: Fatigue and Well- Being Impact Program C: OBGYN: Labor and Delivery Rotation M: FRMP O: Fatigue and Well- Being Impact Individual C: PGY-level M: Existing coping strategies O: Fatigue and Well- Being Impact Figure 2: Revised Program Theory All rights reserved. No reuse allowed without permission. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for thisthis version posted November 20, 2024. ; https://doi.org/10.1101/2024.11.19.24316016doi: medRxiv preprint