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The impact of shift patterns on junior doctors perceptions of fatigue, training, work/life balance and the role of social support

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The impact of shift patterns on junior doctors perceptions of fatigue, training, work/life balance and the role of social support
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  The impact of shift patterns on junior doctors’perceptions of fatigue, training, work/life balance andthe role of social support M Brown, 1 P Tucker, 1 F Rapport, 2 H Hutchings, 2 A Dahlgren, 3 G Davies, 4 P Ebden 4 ABSTRACTBackground  The organisation of junior doctors’ workhours has been radically altered following the partialimplementation of the European Working Time Directive.Poorly designed shift schedules cause excessivedisruption to shift workers’ circadian rhythms. Method  Interviews and focus groups were used toexplore perceptions among junior doctors and hospitalmanagers regarding the impact of the European WorkingTime Directive on patient care and doctors’ well-being. Results  Four main themes were identified. Under“Doctors shift rotas”, doctors deliberated the merits anddemerits of working seven nights in row. They alsodiscussed the impact on fatigue of long sequences ofday shifts. “Education and training” focused on concernsabout reduced on-the-job learning opportunities underthe new working time arrangements and also about thedifficulties of finding time and energy to study. “Work/lifebalance” reflected the conflict between the positiveaspects of working on-call or at night and the impact onlife outside work. “Social support structures” focused onthe role of morale and team spirit. Good supportstructures in the work place counteracted andcompensated for the effects of negative role stressors,and arduous and unsocial work schedules. Conclusions  The impact of junior doctors’ workschedules is influenced by the nature of specific shiftsequences, educational considerations, issues of work/ life balance and by social support systems. Poorlydesigned shift rotas can have negative impacts on juniordoctors’ professional performance and educationaltraining, with implications for clinical practice, patientcare and the welfare of junior doctors. The European Working Time Directive (EWTD)stipulates that junior doctors should not spendmore than 13 h at their place of work. 1 2 Conse-quently, most junior doctors in the UK now workrotating shifts. Such schedules may include severalconsecutive night shifts. In some cases, juniordoctors are required to work as many as sevenconsecutive night shifts. 3 This equates to 91 h of night shift in 1 week (permissible under the EWTD,which stipulates limits based on the average weekly hours worked over 17 weeks). Sleep that is takenduring the day between night shifts is generally shorter and of poorer quality than night-time sleep,as it is taken at an inappropriate circadian phase. When several night shifts are worked in a row, sleepbetween shifts continues to be disrupted, as thenight workers ’  circadian rhythms show littleadjustment to the nocturnal routine. 4 This leads toaccumulations of sleepiness, fatigue and reducedmotivation, any or all of which can lead to reducedproductivity and increased accident risk. 5 The majority of previous studies concerningdoctors ’  work hours have been conducted incountries where doctors ’  work and training prac-tices differ from those in the UK. Relatively littlequalitative research has examined the impact onjunior doctors of EWTD compliant rotating shiftsystems. Few studies, if any, have compared therelative effects of the different types of shiftsystems that have been implemented in the wakeof the EWTD. Thus, the current study seeks toexamine junior doctors ’  perceptions of theirprofessional performance and well-being, followingthe (partial) implementation of the EWTD. METHODSRecruitment Presentations outlining the study were delivered at11 NHS Trusts across Wales to junior doctors inFoundation Years One and Two, Specialist Traininggrades and Specialist Registrars. Data collection Participants took part in either an in-depth inter-view or focus group discussion. All interviews wereperformed by one investigator (MB), were audiorecorded and then transcribed for analysis. In-depthinterviews provide a con 󿬁 dential setting in whichto disclose sensitive information and explore key issues in detail. 6  Interviews are complemented by focus group discussions, in which data is enrichedthrough the processes of group interaction. 7 Data analysis  An Inductive Thematic Analysis framework wasapplied to the data, in which each transcript isrelated to the other transcripts to distil the coreconcepts. When this is achieved, a  “ thick descrip-tion ”  is built around the data  󿬁 ndings supported by verbatim quotation. 8 9 Initial interpretation wasconducted by each researcher, working indepen-dently, followed by group analysis sessions (MB,PT, FR, HH and AD). Team members had access toeach other ’ s workings from the individual codi 󿬁 -cation process and discussed within the group howbest to reduce, assess and present that data. Thisiterative process involved moving back and forthbetween individual transcripts and the group of transcripts as a whole, exploring group under-standings based on patterns and incongruities inthe data. The process of cross-comparison andvalidation continued until consensus was achievedaround the meanings, both underlying and 1 Department of Psychology,Swansea University, Swansea,UK 2 School of Medicine, SwanseaUniversity, Swansea, UK 3 Department of Shipping andMarine Technology, ChalmersUniversity, Gothenburg, Sweden 4 Singleton Hospital, Swansea,UK Correspondence to Philip Tucker, Department ofPsychology, SwanseaUniversity, Swansea SA2 8PP,UK; p.t.tucker@swan.ac.ukAccepted 11 November 2009This paper is freely availableonline under the BMJ Journalsunlocked scheme, see http:// qshc.bmj.com/site/about/ unlocked.xhtml Qual Saf Health Care  2010; 19 :e36. doi:10.1136/qshc.2008.030734 1 of 4 Original research  group.bmj.comon February 28, 2014 - Published by qualitysafety.bmj.comDownloaded from   apparent, that participants gave to their experiences. Furtheranalysis was then conducted (FR and MB) to re 󿬁 ne the  󿬁 nalthematic outputs, with transcripts being reread several times, toappreciate the entirety of the interviews and ensure no majorissues had been overlooked or misrepresented. RESULTS Ten junior doctors were interviewed (mean age 24 years, SD 6,range 24 e 30 years; 50% were female). The mean interviewduration was 29 min (range 22 e 35 min). Five of the participantswere in Foundation Year One, three were in Foundation YearTwo and two were Specialist Training grades. Each interviewwas conducted on hospital premises.Twenty-four individuals participated in one of four focusgroups. Seventeen (70%) were female, 11 (46%) were in Foun-dation Year One,  󿬁 ve (21%) in Foundation Year Two, one (4%)was Specialist Training grade, one (4%) was a Specialist Registrarand one (4%) was a Staff grade doctor. Five (21%) were NHSmanagers/administrators.Four inter-related themes emerged, as follows:  Doctors ’   shift rotas Thisthemefocusedonthedifferentwaysinwhichshiftrotascanbe organised. Participants identi 󿬁 ed certain features of their ownrotaasbeingespeciallydisruptiveoftheirlifeoutsideworkand/orfatiguing. Some doctors believed that particular shift sequencesimpaired their ability to maintain adequate patient care.Night shifts were of particular concern. Excessive fatigue towardstheendofsevenconsecutivenightshiftsnegativelyaffectedpatientcare, training opportunities and safety. Doctors who commutedlong distances also raised concerns about fatigue while drivinghome, citing examples of minor accidents and traf  󿬁 c offencescommitted on the way home when working seven nights in a row.Split nights (three or four consecutive shifts) were commonly regarded as more manageable and less fatiguing, with improve-ments in sustained attention and concentration being associatedwith fewer errors (box 1). However, split nights were not favouredby some who felt that they were more disruptive of life outsidework.Splitnightsalsomeanthavingtomakethedif  󿬁 culttransitionbetween a diurnal and a nocturnal routine more often (box 2).Long shift sequences (ie, 12 consecutive day shifts) were associatedwith increased fatigue, decreased alertness and concentration,increased errors, reduced work speed, and impaired informationprocessing and reduced motivation (box 3).  Education and training Participants expressed concerns that the working time arrange-ments might prevent junior doctors from becoming competentconsultants of the future, as a result of the reduced workinghours and training opportunities that followed the partialimplementation of the EWTD (see box 4).Junior doctors also discussed the ways in which high workloadand dif  󿬁 cult work schedules impinged on their protectedteaching time and opportunities for private study. They alsonoted that motivation to learn could suffer as a result of excessive fatigue, particularly during exams (see box 5). Work/life balance Doctors experienced dif  󿬁 culty maintaining a balance betweenthe desire for a successful medical career and their home-lifecommitments. Personal needs were frequently pushed aside infavour of professional commitments. Sacri 󿬁 ces in all lifedomains were discussed; many interviewees openly discussedthe consequences of their decisions, indicating that at timesa high price had been paid (box 6).However, some of the most positive work experiences wereassociated with shifts that were most disruptive of life outsidework. It was felt that regular exposure to on-call shifts andnight shifts enhanced career development by providing exten-sive hands-on experience in clinical situations that demandedcritical personal judgements and con 󿬁 dent decision-makingskills (box 7). Social support Goodmoraleamongcolleaguesandasenseof   “ teamspirit ” helpedjunior doctors cope with their work schedule. Being part of a supportive team acted as a buffer against the effects of arduousschedules and intense work loads, allowing junior doctors to feelmore secure. Team spirit enhanced opportunities for learningfrom colleagues through observation of procedural techniquesand management skills. Conversely, poor communication andlimitedsocialsupportfromcoworkersledtotheerosionofmoraleamong colleagues, which in turn was associated with lack of enjoyment and an inability to cope (box 8). Box 1 Working seven consecutive night shift exacerbatefatigue “Seven days in a row, it really chips away and by about the fifthnight I was missing important things in the results and notspotting things in  x   rays. I just wasn’t fully awake . if you’reabsolutely exhausted your judgement of what’s actually urgent isprobably a bit clouded.” (Male F1)“Doing seven 12 or 13 h shifts in a row I think is quite dangerous,really. I don’t think you’re competent at the end of it.” (FemaleST2)“In (hospital) we just had to do three or four (nights) which wasmanageable. At the end of the surgical nights (seven in a row) Ithink I was quite dangerous really just because I was so tired,certainly driving home there was one incident.” (Male F2) Box 2 Shorter spans of nights shifts disrupt life outside work “Personally I like to do things, everything in one go, in somehospitals they have split the nights, three and four. I would ratherget it over and done with so I have done my nights and I don’thave to worry about it.” (Male F1)“I quite like doing the week of nights because tiring as it may beyou get it over and done with which is quite nice . Its changingthe sleep pattern which is the difficult thing.” (Male F2)“I’m still quite young and I’d rather just get them over and donewith . I feel that if I had to continually change my body clock Ithink it would be worse in the long run.” (Male F1) Box 3 Working twelve consecutive day shifts exacerbatesfatigue “I think working 12 days in a row borders on unsafe and iscertainly horrible to do .  You work the Monday to Friday, wholeweek then the weekend, late Friday, Saturday and Sunday thencarry on the whole week.” (Female ST2)“Little things like prescribing fluids for someone who’s slightlydry, analgesia for someone who’s in a bit of pain, things like that Ihave missed (during 12 consecutive shifts).” (Female F1) 2 of 4  Qual Saf Health Care  2010; 19 :e36. doi:10.1136/qshc.2008.030734 Original research  group.bmj.comon February 28, 2014 - Published by qualitysafety.bmj.comDownloaded from   DISCUSSION In common with night workers in other occupational settings,participants in the current study experienced con 󿬂 ict betweenthe demands of their work schedule and their lives outside work.However, unlike many shift workers, junior doctors ’  night shiftsfeature a degree of job enrichment that is absent from the day shift d for example, learning to have con 󿬁 dence when put ina position of responsibility. Junior doctors are therefore perhapsuniquely appreciative of the opportunity to work night shifts.However, many participants felt that the potential bene 󿬁 ts of working night shifts were being offset by the effects of excessivefatigue. In particular, the latter stages of a block of sevenconsecutive night shifts were characterised by considerablefatigue with obvious implications for patient well-being andsafety and impaired learning process. Conversely, some partici-pants expressed a preference for longer blocks of nights, whichthey felt were less disruptive of life outside work. The majority of previous research has shown that sleep and on-shift alertnessis superior when blocks of night shifts are relatively short (eg,two or three consecutive shifts). 10 e 12 Thus, the choice of theoptimum number of consecutive nights depends on the relativeimportance attached to safety and social problems in any givenworkplace. 13 Given the nature of junior doctors ’  work, thissuggests that rotas of seven consecutive nights should bediscouraged in all but exceptional cases in which fatigue-relatedsafety is not considered to be a signi 󿬁 cant issue.Fatigue also accumulates over successive days when shifts areworked without a break, as re 󿬂 ected in the current participants ’ concerns about working 12 consecutive day shifts. Rest days areimportant for the maintenance of work performance. They alsoprovide opportunities for the dissipation of work-related stressand are thus important for the maintenance of well-being. 14 This suggests that sequences of 12 consecutive day shifts shouldbe avoided whenever possible d for example, by scheduling atleast one rest day following a weekend on-call.Demanding work schedules impinged on junior doctors ’ opportunity and motivation to study during their free time. Itwas also argued that the EWTD ’ s imposition of reduced workhours limits junior doctors ’  opportunity for gaining valuable on-the-job experience. This echoes the  󿬁 ndings of previousresearch. 15 16  However, as yet there appears to be no researchthat has attempted to examine this question using objectivemeasures of performance. Such research is needed to establishwhether the positive effects of the new work-hour restrictionson fatigue and well-being are outweighed by their deleteriousimpact on training outcomes.The fact that many participants struggled to maintaina satisfactory balance between work and personal life is notsurprising and accords with previous  󿬁 ndings. 17 Junior doctorscommonly work long unsocial hours, but they are highly motivated to work such hours to maximise their trainingopportunities. Nevertheless, while a degree of work/life con 󿬂 ictmay be inevitable for doctors, if it is allowed to become toomuch of a problem it can be harmful to psychological health,with doctors becoming disengaged, distracted and alienated. Thedegree of con 󿬂 ict experienced by an individual will depend onthe degree to which their work hours meet their own needs andthose of their partner and any dependents they may have. 18 19 Hence, the design of appropriate rotas is especially important forjunior doctors with families, to help them maintain their healthand their motivation to remain in training.Participants ’  comments about team working are in accordancewith previous  󿬁 ndings that workplace social support can protectindividuals from the harmful effects of stressors, such as workoverload. 20 21 However, it is also interesting to note that suchbene 󿬁 cial effects may be undermined if there is lack of conti-nuity within the membership of work teams. This highlightsthe importance of a second set of organising principles thatshould govern the design of rotas. They should seek to minimisethe accumulation of fatigue in the individual and promotecontinuity of team membership d for example, by having teamscomprising matched partners at each level, sharing the coverageof day and night duties, so that at any one time at least half theteam remains intact. 22 Strengths and limitations of the study  The current study provides an in-depth exploration of theimpact of rotas designed to be compliant with the second stage Box 4 Training and development may be compromised “A doctor is an apprentice, the only way to learn how to dothings, is if you do things. If you’re a plumber or an electrician, it’sby doing it and it just so happens, that cardiac surgery and lots oftypes of surgery are lengthy.” (Male, SpR)“There is a strong movement in surgery against the EWTDbecause it’s not going to be good for the training of doctors of thefuture. They will not be able to gain enough hours of experience”(Female, F2) Box 5 Finding time and motivation to study  “I don’t think we have enough time to learn . I think our theo-retical knowledge is quite poor as we don’t have time to study”.(Female ST2)“I don’t know anyone who doesn’t struggle, mentally strugglingand physically, people get very stressed during exams at themoment on top of a busy job” (Female, F2) Box 6 The impact on work/life balance “I don’t think its very family friendly, so if you have a child, asa woman I don’t think its very easy, not just the schedule but alsothe other commitments that you have after 5 o’clock to do. I thinkthat all combined is difficult . my child is brought up almostcompletely by his grandparents and that way I can get on withmy career.” (Female ST3)“It’s the antisocial aspect which is probably tiring . you gohome at 10 pm but its not 10 pm because by the time you havedone your post take ward round you might be there until 10:30,11 pm sometimes, and then you go home, sleep and you’re backin again.” (Male, F2) Box 7 The positive side of working unsocial hours “When you’re on call you get to do a bit of real medicine, makesome real decisions and I think its good experience, especiallynights as well when there’s not as many people around, you haveto think a lot more.” (Male F2) Qual Saf Health Care  2010; 19 :e36. doi:10.1136/qshc.2008.030734 3 of 4 Original research  group.bmj.comon February 28, 2014 - Published by qualitysafety.bmj.comDownloaded from   of the EWTD ’ s implementation. It facilitated discussion of speci 󿬁 c shift features, by those who regularly work them, ina range of hospitals throughout Wales. However, not all hospi-tals in Wales were represented in the sample. Work commit-ments meant it was dif  󿬁 cult for junior doctors to  󿬁 nd time intheir schedule to commit to an interview. As only a smallnumber of junior doctors took part in the interviews, care shouldbe exercised when generalising from their views. CONCLUSIONS High work demands are part and parcel of junior doctors ’ working life. However, the negative impact of these demands isexacerbated by poorly designed rotas that do not offer suf  󿬁 cientopportunity for rest and recovery. This may be addressed, inpart, by appropriate sequencing of shifts. In addition, workschedule design should, whenever possible, seek to maintaincontinuity of team structure and take into account the needs of those with caring responsibilities. Appropriately designed rotaswill be bene 󿬁 cial to the well-being and performance of juniordoctors and, indirectly, their patients. Moreover, they will helpto maintain and promote junior doctors ’  enthusiasm andcommitment to their chosen profession. Funding  The study was funded by a grant from the Wales Office of Research andDevelopment for Health and Social Care, part of the Wales Assembly Government(reference: ReF06/2/ 220). All researchers involved in this study were independent ofthe funding organisation. The funding organisation had no involvement in the conductor reporting of this research. Competing interests  None. Ethics approval  The study was granted ethical approval by Multi-Centre ResearchEthics Committee for Wales (MREC) on 8 March 2007 (reference: 07/MREC09/18). Contributors  PT and MB coauthored the paper. MB collected the data. PT conceivedthe study, led the funding application that supported its conduct, managed the projectand is the guarantor of the papers’ content. FR supervised the data analysis. MB andFR undertook the bulk of the data analysis, in collaboration with all of the otherauthors. HH, AD, GD and PE contributed to the design of the study, as well to theanalysis of the data. All authors have contributed to the design of the study and thepreparation of the manuscript. Provenance and peer review  Not commissioned; externally peer reviewed. REFERENCES 1. Case C-303/98, Sindicato de Me´dicos de Asistencia Pu´blica (Simap) and Conselleriade Sanidad y Consumo de la Generalidad Valenciana: European Court of Justice,2000.2. Case C-151/02, Landeshauptstadt Kiel and Norbert Jaeger: European Court ofJustice, 2003.3.  Murray A,  Pounder R, Mather H,  et al  . 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Combined effects of job strain and social isolationon cardiovascular disease morbidity and mortality in a random sample of the Swedishmale working population.  Scand J Work Environ Health  1989; 15 :271 e 9.22.  Horrocks N,  Pounder R.  Designing safer rotas for junior doctors in the 48 hour week. London: Royal College of Physicians, 2006. Box 8 The importance of social support at work “I think as it’s such a supportive department there is goodinteraction with colleagues, if it was not supportive I think itwould be horrendous.” (Female F2)“The department on the whole are (sic) very supportive . theregistrar and consultants are very approachable and will helpout.” (Male F1)“I do think we miss out on team spirit and morale . theconsultants’ change every few weeks . there’s also the SHO andthey always change as well. So every couple of weeks youexpect to see a new HO, SHO oh and obviously the registrarschange too . so there’s a great lack of continuity.” (Male F2)“In my last job, because of the rota, I came out in Eczema . Itwas doing so many on-calls and I was trying to sort out my rotaand I wasn’t getting much help from the Trust or medicalpersonnel.” (Female ST1) 4 of 4  Qual Saf Health Care  2010; 19 :e36. doi:10.1136/qshc.2008.030734 Original research  group.bmj.comon February 28, 2014 - Published by qualitysafety.bmj.comDownloaded from   doi: 10.1136/qshc.2008.030734  2010 19: e36 Qual Saf Health Care   M Brown, P Tucker, F Rapport, et al.  supportwork/life balance and the role of socialdoctors' perceptions of fatigue, training, The impact of shift patterns on junior   http://qualitysafety.bmj.com/content/19/6/e36.full.html Updated information and services can be found at: These include:  References   http://qualitysafety.bmj.com/content/19/6/e36.full.html#ref-list-1 This article cites 16 articles, 1 of which can be accessed free at: Open Access http://creativecommons.org/licenses/by-nc/2.0/legalcode.http://creativecommons.org/licenses/by-nc/2.0/ and compliance with the license. See:work is properly cited, the use is non commercial and is otherwise in use, distribution, and reproduction in any medium, provided the srcinalCreative Commons Attribution Non-commercial License, which permits This is an open-access article distributed under the terms of the serviceEmail alerting the box at the top right corner of the online article.Receive free email alerts when new articles cite this article. Sign up in CollectionsTopic  (157 articles)Open access  Articles on similar topics can be found in the following collections Notes   http://group.bmj.com/group/rights-licensing/permissions To request permissions go to:  http://journals.bmj.com/cgi/reprintform To order reprints go to:  http://group.bmj.com/subscribe/ To subscribe to BMJ go to:  group.bmj.comon February 28, 2014 - Published by qualitysafety.bmj.comDownloaded from 
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