|ORIGINAL RESEARCH ARTICLE
|Year : 2015 | Volume
| Issue : 2 | Page : 118-123
Residents' and attendings' perceptions of a night float system in an internal medicine program in Canada
Anurag Saxena1, Loni Desanghere2, Robert P Skomro3, Thomas W Wilson3
1 Department of Pathology; Dean's Office, Postgraduate Medical Education, Saskatoon, SK, Canada
2 Dean's Office, Postgraduate Medical Education, Saskatoon, SK, Canada
3 Department of Medicine, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
|Date of Web Publication||21-Nov-2015|
Room 402, St. Andrews College, PGME, College of Medicine, University of Saskatchewan, 1121 College Drive, Saskatoon, SK, S7N 0W3
Source of Support: This project was funded by the College of Medicine,
University of Saskatchewan., Conflict of Interest: None
Background: The Night Float system (NFS) is often used in residency training programs to meet work hour regulations. The purpose of this study was to examine resident and attendings' perceptions of the NFS on issues of resident learning, well-being, work, non-educational activities and the health care system (patient safety and quality of care, inter-professional teams, workload on attendings and costs of on-call coverage). Methods: A survey questionnaire with closed and open-ended questions (26 residents and eight attendings in an Internal Medicine program), informal discussions with the program and moonlighting and financial data were collected. Results and Discussion: The main findings included, (i) an overall congruency in opinions between resident and attendings across all mean comparisons, (ii) perceptions of improvement for most aspects of resident well-being (e.g. stress, fatigue) and work environment (e.g. supervision, support), (iii) a neutral effect on the resident learning environment, except resident opinions on an increase in opportunities for learning, (iv) perceptions of improved patient safety and quality of care despite worsened continuity of care, and (v) no increases in work-load on attendings or the health care system (cost-neutral call coverage). Patient safety, handovers and increased utilization of moonlighting opportunities need further exploration.
Keywords: Health care system, night float system, resident duty hours, resident education
|How to cite this article:|
Saxena A, Desanghere L, Skomro RP, Wilson TW. Residents' and attendings' perceptions of a night float system in an internal medicine program in Canada. Educ Health 2015;28:118-23
| Background|| |
Resident duty hours (RDHs) include all time spent in scheduled clinical and academic activities related to the residency program including: Patient-care, administrative duties, in-house call activities and scheduled learning activities. However, extended work hours and attendant sleep deprivation pose risks to the health of residents and can affect their cognitive and behavioral performance,,,,, which can compromise patient safety. These safety concerns have been the main impetus driving RDH reforms.
In Canada, a uniform nationwide policy governing RDHs does not exist, with shift lengths ranging from 16 h in Quebec to up to 24–26 h in other provinces. As a way to address increased concerns of RDHs, many institutions have implemented a Night Float System (NFS), which typically involves consecutive shifts of 10–12 h or alternate nights of longer shifts. Although this system offers a potential solution in addressing RDH restrictions, changes in educational experiences and the effectiveness of the system have resulted in conflicting results in terms of benefits for resident wellness, learning and patient safety (for review see ). For example, research has shown that residents during night float (NF) rotations felt there was less emphasis placed on educational activities,,,, with studies demonstrating a decrease in resident involvement in these activities during their NF rotations. Some research indicates overall negative attitudes from residents, nurses and attendings about the NFS in general. Indeed, some institutions have abandoned the use of the NFS because of perceptions of affected delivery of care in terms of cohesiveness, team spirit and continuity. Conversely, other research  has shown the opposite to be true, with residents favoring the NFS over traditional call and believing that it results in fewer medical errors (for review see ).
Given the inconsistent results in the literature on the effects of the NFS, the purpose of this study was to examine the perceptions of residents and attendings on the impact of the NFS in an Internal Medicine residency program. Since the implementation of such systems necessarily changes many ways in which medical education and health care are delivered, the results from this study will help programs make informed changes when working to effectively reduce RDHs.
| Methods|| |
The NFS at this institution was implemented on July 1, 2012 and was structured in 12-h shifts, five shifts per week, for second and third year (senior) residents. During the previous call system, senior residents were on-call during the nights they covered and typically stayed in hospital until 5 p.m., receiving call throughout the night thereafter. Under the NFS, residents are expected to remain in the hospital from 7:30 p.m. to 11:30 p.m., followed by home call for the remainder of their shift.
It was anticipated that the NFS would have a positive impact on resident learning, work and well-being. For example, the NF structure required schedules to be arranged a year in advance, enabling residents to book conferences, holidays, rounds and clinics; these educational and personal priorities were harder to commit to under the previous system where the schedule was only organized 4–8 weeks in advance. As well, residents were not scheduled for work the day after their NF shift, a change that was anticipated to impact both resident well-being and participation in education-related activities (e.g., academic half days) by decreasing resident fatigue. The NFS also enabled senior residents more opportunities for bedside teaching and observation of patient assessments performed by junior residents. Under the old system there were no requirements to be in-house and first year residents were frequently unassisted and unobserved in their patient assessments.
Twenty-six residents (female = 13; 53% response rate) and eight attendings (27% response rate) participated in this study. All participants were from the Internal Medicine program at the University of Saskatchewan, which has its primary teaching and training sites at the Royal University Hospital and St. Paul's Hospital-two tertiary care hospitals in Saskatoon, Saskatchewan, Canada. All participants had experience with the previous night call system and the newly implemented NFS. Data was initially collected as part of a quality assurance and improvement project and was exempt from Behavioral Research Ethics review at the University of Saskatchewan.
Materials and procedure
An online survey was designed to assess perceptions of the impact of the NFS on residents and the health care system (not all questions were asked to both residents and attendings, [Figure 1]). Responses to questions were evaluated on a 5-point Likert scale (1 = completely disagree; 5 = completely agree). [Figure 1] displays the overarching themes along with the abbreviated questions within each theme. Three of these topics (improved resident stress, improved opportunity for learning, and improved patient safety,) were composed of several specific questions [Table 1]. These scales had acceptable levels of internal consistency for exploratory studies (recommended minimum Cronbach's alpha of 0.6),, as determined by Cronbach alpha's of 0.60, 0.77 and 0.89, respectively. An open-ended question inviting any comments regarding the NFS was included at the end of the survey. All responses were anonymous, and participation was completely voluntary. To ensure residents and attendings did not feel obligated to answer the survey because of pressures of authority, all survey links were sent out through program administrators and participants were ensured of the anonymity of their responses.
|Figure 1: Displays the mean responses, standard errors and 95% confidence intervals of residents and attendings across four themes related to the impact of the NFS on residents and three themes related to the impact of the NFS on the health care system. Mean responses plotted between the dashed lines represent a neutral response, indicating that aspect did not change with the implementation of the NFS. Any means below or above those points represent disagreement or agreement with the improvement of that particular aspect|
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|Table 1: Displays three overarching topics used in the survey and lists the questions comprising those topics. Internal consistency (Cronbachs alpha) is listed for each scaled item. Overall scores are depicted in [Figure 1]|
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Information on moonlighting and financial aspects were obtained from the data bases in the College of Medicine. Descriptive statistics and Mann–Whitney U tests were used to characterize and examine differences between resident and attendings responses. Content analysis was used to extract themes from the open-ended responses.
| Results|| |
Open-ended responses were provided by 27% of residents and 33% of attendings. [Figure 1] displays the data from each survey question; mean values falling above 2.5 and below 3.5 are categorized as having a "neutral" effect, suggesting no changes after the implementation of the NFS. For questions posed to both residents and attendings, Mann–Whitney U tests showed no significant differences in the mean responses (P > 0.05), demonstrating an overall congruency in perceptions between groups on the impact of the NFS across all themes.
| Implementation of the Nfs and Its Impact on Residents|| |
Residents felt that the NFS improved opportunities for learning (e.g., reading, simulation training, increased opportunities for learning); perceptions for all other aspects of learning did not change [Figure 1]a. Open-ended comments suggested that the NFS led to: (a) A better operation of the clinical teaching unit (CTU) with more availability of senior residents to teach, better management of the team, more time for interdisciplinary rounds, and higher morale, and (b) a reduction in the number of call shifts throughout the year that allowed for better learning experiences while on subspecialty rotations.
Residents felt that the NFS had a positive impact their work through better support and supervision [Figure 1]b. Although residents felt that the work associated with handovers and their overall workload was reduced under the NFS, the attendings did not have similar perceptions.
Both residents and attendings agreed that the NFS reduced resident stress and fatigue. Although residents reported increased alertness when woken and an improved social life, attendings thought that these aspects had not changed. Residents and attendings also differed in their opinions on the amount and quality of resident sleep; attendings believed that there was an improvement, whereas residents did not believe these to have changed [Figure 1]c. Open-ended responses from residents reflected an improved work-life balance due to reductions in postcall days taken off rotation as well as fewer call shifts throughout most of the months. Attendings' (n = 2) impressions were that the NFS had a beneficial net effect on well-being due to a reduction in the overall call frequency throughout the year.
Residents' non-educational activities
Neither residents nor attendings believed the NFS enabled residents to start moonlighting or that there was an increase in the moonlighting frequency [Figure 1]d. However, a review of the actual moonlighting data for 18 months preceding (9 requests) and following (23 requests) the implementation of NFS showed significant differences in moonlighting requests [χ2( 1) =6.125, P = 0.013].
| Implementation of the Nfs and Its Impact on the Health Care System|| |
Patient safety and quality of care
Participants agreed that the NFS helped improve patient safety and quality of care despite the attendings' perceptions that the continuity of care worsened after the implementation of the NFS [Figure 1]e. Open-ended responses also reflected improved quality of care and attributed this to higher diligence due to NF permitting more rest.
Neither the residents nor the attendings believed that the NFS increased provision of care by inter-professional teams [Figure 1]f. Residents were concerned that the increased frequency of handovers and a lack of familiarity with patients could result in less clinical information being available for other team members and less flow of information among the inter-professional teams.
All participants agreed that the NFS did not increase workload on either the health care system or on the attendings [Figure 1]g. Informal discussions within the program highlighted occasional concerns including non-committal attitudes of some residents towards patients, admitting a higher number of patients while on night call, and not gaining realistic exposure during residency of night-call due to the shorter length and frequency of shifts.
Examination of the on-call schedule and associated costs for the 10 months prior versus after the implementation of the NFS did not reveal any increases in expenses for on-call coverage. In addition, there were no increases in the requirement for ancillary staff to provide coverage during the NF operation.
| Discussion|| |
There is evidence for both the detrimental ,, and positive ,,,, effects of reducing RDHs through such methods as a NFS. Given the controversy, we aimed to distinguish perceptions of the impact of a NFS from both residents and attendings in an Internal Medicine Program in Canada. Our results showed two overarching findings. First, there was an overall congruency in the opinions between residents and attendings across the themes in how the NFS has affected the residents and its impact on the health care system. The congruency in these perceptions is important because it provides more confidence in how changes in the call system affect resident learning and patient care. Although the mean responses across participants for improved quality and amount of sleep were not statistically different, we still saw that most attendings believed these aspects to have improved, whereas only half of residents reported this as accurate. Incongruent perceptions such as this on aspects of resident well-being could potentially have implications on attendings' assessments and opinions of the residents.
Second, the NFS implementation was perceived to not have adversely affected any aspect of resident learning or the health care system, except the continuity of care where attendings believed this aspect to have worsened; and even this, in their opinion did not affect patient safety or quality of care. The effects of the NFS were perceived as either an improvement (resident well being, resident working environment, patient safety and quality of care, increased quality and opportunity for learning) or no effect. The perceived benefits on resident learning could result from several factors including opportunities for more structured teaching for and by residents, better consult processes since senior residents are contacted first by the consulting physicians followed by appropriate delegation by the senior residents to the junior residents thereby creating opportunities for teaching/learning of intrinsic CanMEDS roles such as communicator and manager roles.
Extended duty hours have been associated with high levels of fatigue, burnout and psychological distress.,,,, In our study, the residents believed that their stress, fatigue, alertness and social life had improved after the implementation of the NFS, while attendings perceived improved amount and quality of sleep in addition to improved stress and reduced fatigue. Improved resident well-being has been shown to be associated with increased quality of care,,,,, a finding corroborated in our study where residents and attendings believed that patient safety and quality of care had improved.
Although residents did not believe that the NFS enabled or increased the amount of moonlighting, official requests for this opportunity were found to increase after the implementation of this system. This could simply be a reflection of rules around moonlighting, which limit moonlighting to weekends only. For example, the residents who get off at 0730 on Friday could moonlight on Saturday (0800–2400) and go back to work at 1930 on Sunday. These explanations are important to ensure that increased moonlighting requests are perceived appropriately preventing sweeping generalizations about how residents use their time.
Our finding that the continuity of care was perceived to be negatively affected is supported by other studies, which have demonstrated that more interruptions to continuity of patient care occur as a result of RDH restrictions in particular , and after a NFS implementation in general.,,, While these studies showed that patient satisfaction and safety were actually negatively impacted due to disruptions of patient care, our study did not directly assess these aspects; both residents and attendings reported perceptions of improved patient safety and quality of care, a finding that is consistent with other studies, which showed lower morality rates, decreases in surgical complications and missed radiological diagnoses following the NF implementation (for review see ). The positive or neutral responses in our study could be the result of residents being committed to one service only, allowing better handovers and time to focus on that specific service.
The NFS did not affect provision of care by inter-professional teams, this is not surprising since most inter-professional interactions occur during daytime hours. There was no perceived increase in work-load on attendings or the health care system in general, an important finding indicating that modifications in RDH do not necessarily increase the need for additional health care professionals. Finally, the NFS did not increase on-call costs and appears to have affected the system positively.
The limitations of our study include (a) low response rates and thus a small sample size, (b) the questionnaire not being validated prior to the study being performed and (c) the changes in actual physician behavior and the effects on patient care were not directly measured.
| Conclusions|| |
Overall, our study indicates that reductions to RDHs, via the NFS, have mainly positive (resident well-being, work environment, increased opportunity for learning, improved patient safety and quality of care – despite perceptions of worsened continuity of care, increased quality and opportunity for learning and cost-neutral effects for on-call work) or neutral (all other aspects) effects. Patient safety, handover issues and increased utilization of moonlighting opportunities need to be further investigated. In Canada, many program directors are faced with little and non-directive evidence-based results regarding the impact of RDH reductions. The perceptions of residents and attendings on aspects of resident well-being, work, learning and non-educational activities, as well as the impact on the health care system, provide valuable information on the consequences and impact to changes in RDHs, which can be used to help inform future changes to programs.
| Acknowledgements|| |
The authors would like to thank Jennifer Dybvig for her assistance in compiling the resident moonlighting and financial data.
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