2014, 36: 632–638
Foundation doctors working at night: What training opportunities exist? R. COOMBER1, D. SMITH2, D. MCGUINNESS3, E. SHAO4, R. SOOBRAH5 & A. H. FRANKEL6 1
Ipswich Hospital, UK, 2General Medical Council, UK, 3UCL Centre for Nephrology, Royal Free Hospital, UK, West Middlesex Hospital, UK, 5Northwick Park Hospital, UK, and 6London Deanery, UK
4
Abstract Introduction: Foundation Training is designed for doctors in their first two years of post-graduation. The number of foundation doctors (FD) in the UK working nights has reduced because of a perception that clinical supervision at night is unsatisfactory and that minimal training opportunities exist. We aimed to assess the value of night shifts to FDs and hypothesised that removing FDs from nights may be detrimental to training. Methods: Using a survey, we assessed the number of FDs working nights in London, FDs views on working nights and their supervision at night. We evaluated whether working at night, compared to daytime working provided opportunities to achieve foundation competencies. Results: 83% (N ¼ 2157/2593) of FDs completed the survey. Over 90% of FDs who worked nights felt that the experience they gained improved their ability to prioritise, make decisions and plan. FDs who worked nights reported higher scores for achieving competencies in history taking (2.67 vs. 2.51; p ¼ 0.00), examination (2.72 vs. 2.59; p ¼ 0.01) and resuscitation (2.27 vs. 1.96; p ¼ 0.00). The majority (65%) felt adequately supervised. Conclusions: Our survey has demonstrated that FDs find working nights a valuable experience, providing important training opportunities, which are additional to those encountered during daytime working.
Introduction
Practice points
There are concerns that the implementation of the European Working Time Regulations (EWTR) has resulted in a reduction in direct patient contact hours and the associated educational opportunities that this affords (European Community Council Directive 1993; Jaeger vs. Landeshauptstadt Kiel 2003; RCS 2010). Consequently, it is important to preserve opportunities for training where these occur. Foundation Training is designed for doctors in their first two years of post-graduation and is a requirement to enter specialist training in the UK. The first year of training is Foundation Year 1 (F1) and is broadly equivalent to preregistration house officers (PRHO). The second year (F2) is an additional training year, with the purpose of increasing FDs independence. In practice, pre-existing first year senior house officer (SHO) posts were converted into F2 posts. There are over 14,000 FDs in the UK and 2593 working in London. FDs have to demonstrate that they achieve the competencies described within the Foundation Curriculum (UK Foundation Programme Curriculum 2010). These competencies include a variety of topics from history taking and examination of patients, to communication skills. FDs are evaluated by work place-based assessments, such as direct observation of a procedure, reflective practice and teaching which are related to the foundation curriculum. In London, Foundation placements are evaluated annually by a survey, which all FDs are required to complete.
There has been a significant reduction in the number of FDs working night shifts. FDs find working night shifts a valuable experience, which enhances their ability to achieve foundation competencies. While these experiences are valuable they must be in a well supervised environment. HaN teams improved FDs views on supervision at night.
Prior to the introduction of the Foundation Programme in 2005, almost all PRHOs and first year senior house officers would work night shifts. FDs have gradually been removed from working at night, initially because of concerns over clinical supervision and subsequently because of the implementation of the EWTR (Temple 2010). There is some evidence that F1s are able to achieve foundation competencies while working at night and with appropriate clinical supervision (Gallagher et al. 2009). These data were collected in the setting of a regulated Hospital at Night scheme (HaN). However, the work undertaken by F1s was not clearly delineated and the impact of this arrangement on daytime working was not considered. HaN schemes involve a multi-professional team who work together across
Correspondence: Ross Coomber, MRCS – Orthopaedic SpR, Department of Orthopaedic Surgery, Ipswich Hospital, Heath Road, Ipswich IP4 5PD, UK. Tel/Fax: 07957 148 173; E-mail: [email protected]
632
ISSN 0142-159X print/ISSN 1466-187X online/14/70632–7 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.899688
Foundation doctors and night shifts
specialities to look after patients who become unwell at night. It is postulated that these teams provide appropriate clinical supervision to FDs at night, preserving patient safety. Other authors have reported that night time experience is important for the development of clinical decision-making competencies (Wilson et al. 2005). There is limited published data which assesses junior doctors working night shifts and the clinical supervision available at night (Leslie et al. 1990; Turnbull et al. 1990; Mckee & Black 1993). The authors are not aware of any previous research that adequately assesses whether night shifts provide training opportunities for FDs or on the views of FDs who work at night. It is postulated that if FDs are removed entirely from night shifts they will miss out on a significant volume of experience and training. The authors appreciate that a newly qualified doctor working in these environments unsupervised would be detrimental to patient safety. Moreover, night working can be stressful and often involves managing patients who become unwell. However, at some point in training most doctors have to start working nights and we recognise that this experience, in a well supervised team, is valuable to FDs. It is our expectation that working at night will be viewed positively by FDs and will in turn improve their competence, thus improving patient safety. We hypothesise that FDs find night shifts a valuable experience, that night shifts provide opportunities for FDs to gain foundation competencies and that the majority of FDs perceive their clinical supervision to be adequate.
Objectives (1) To assess the number of FDs in London working night shifts. (2) To assess FDs views on the adequacy of their clinical supervision and the affect that working within a hospital at night team has on this parameter. (3) To assess FDs views on the experience they gain from working night shifts. (4) To assess whether night shifts provide additional opportunities for FDs to achieve foundation competencies (i.e. training opportunities at night).
Methods This was a questionnaire survey of FDs in London. In addition to the standard survey questions on the quality of placement, we added questions relating to night time working to the London Deanery annual survey. We asked FDs how many of them worked at night and those who worked at night were asked questions about the adequacy of their clinical supervision. Additionally, we asked FDs about their experiences when working at night and compared their perceived opportunities to achieve foundation competencies at night to daytime working. The survey was emailed to each FD in London and included details of the placement (speciality and location) the FD was expected to evaluate. This was the post they started in
August 2010 and finished in either November 2010 or January 2011 (depending on the length of their placement). Up to five reminder emails were sent to non-responders, over a period of one month. Where email addresses were found to be incorrect, a valid email was sought through placement contact details locally. FDs in academic placements were excluded because they generally do not work in a clinical role during the day. Trust appointed F2s were excluded because they were not in training posts and did not complete the deanery survey.
Questionnaire The survey consisted of the following questions: (1) End of post evaluation questions written by the London Foundation Training Operations Group and designed to map to the Foundation Standards in the GMC’s New Doctor (GMC 2009). (2) 51 questions covering the Foundation Curriculum (pages 6 and 7 of The UK Foundation Programme Curriculum 2010) – A curriculum mapping instrument was included in the survey, which allows each FD to rate the extent to which their current placement provides opportunities to achieve their foundation competencies. Each FD rated 51 foundation competencies and current FDs and senior trainees selected 18 core clinical competencies during the pilot analysis as essential skills for FDs. (3) All FDs who completed the survey rated their ability to achieve foundation competencies. The ratings of FDs who only worked in the daytime were compared to the ratings of FDs who worked at night and daytime. (4) Questions (12) assessing FDs attitudes to working at night (asked only of those FDs who worked at night during the placement under evaluation). Night working was defined as any shift that extended beyond 8 pm for 10 to 12 hours. Before submitting these questions to the FDs we performed a pilot analysis to check their face validity, which did not result in any changes. A Likert scale was used in the questionnaire (five-point scale from Strongly Agree to Strongly disagree).
Clinical supervision score The clinical supervision score was constructed by the mean result of answers to three questions relating to FDs views on their clinical supervision. All FDs were asked these questions. For those FDs who worked at night, these questions were repeated for how they felt about their supervision at night and in the day. Thus, FDs who worked at night answered these questions twice in respect to work undertaken at night and day. In the placement you started in August 2010, when working during the DAY/NIGHT, how often have you felt forced to cope with clinical problems beyond your competence or experience? In the placement you started in August 2010, when working during the DAY/NIGHT, how often, if ever, have you been supervised by someone who you feel isn’t competent to do so?
633
R. Coomber et al.
In the placement you started in August 2010, when working during the DAY/NIGHT do you always know who is providing your clinical supervision when you are working? The mean clinical supervision score was calculated from the answers to the above questions. A Likert scale was used and produced a number between 15 and 100, the higher the number the more positive the FD was about their clinical supervision. We analysed our data to assess whether clinical supervision at night differed from clinical supervision during the day using this score. In addition, we compared FDs clinical supervision score when they were part of a hospital at night team.
Data analysis The Mann–Whitney test was used where the data were nonparametric in distribution. To remove variance associated with speciality and with trusts where all FDs worked at night, the analysis was run using FDs from each speciality separately. FDs working at hospitals where everyone reported working at night were excluded.
Results Number of FDs working at night We received responses from 2157 of 2593 (83%) FDs. This included 1114 F1 and 1043 F2 doctors. This varied by speciality and included 284 FDs working in emergency medicine; 854 FDs working in medical specialities; 601 FDs working in surgical specialities and no FDs working nights in general practice or pathology (Table 1). Of these 390 (35%) F1 and 699 (67%) F2 doctors reported working at night.
Table 1. Who works nights?.
Grade
In the placement you started in August 2010, have you worked night shifts (a shift extending beyond 2000 for 10–12 Number hours)? – % Yes of doctors
F1 (Foundation Year 1) F2 (Foundation Year 2)
35% 67%
1114 1043
Placement speciality Anaesthetics group Emergency medicine group General practice (GP) group Medicine group Obstetrics and gynaecology group Ophthalmology group Paediatrics group Pathology group Psychiatry group Public health Radiology group Surgical group Total
30% 88% 0% 47% 51% 40% 56% 0% 52% 0% 50% 53% 50%
57 284 171 854 57 5 62 5 42 5 14 601 2157
634
The variation by hospital of FDs working nights ranged from 22 to 94% (excluding hospitals with less than five FDs, specialist trusts and mental health trusts). In total, 12 hospital sites had no F1s working at night; whilst one site had 98% of F1s working at night.
FDs experiences while working at night A total of 995 of 1084 (92%) FDs (who worked at night) felt working night shifts enhanced their training, 976 (90%) of FDs felt nights improved their decision-making skills and 954 (88%) of FDs felt nights improved their planning and prioritisation of tasks. The majority of FDs surveyed claimed they gained skills on their night shifts that they would not have gained during day shifts (85% N ¼ 923/1084, Table 2).
Clinical supervision at night The majority of FDs who worked nights felt adequately supported (65% N ¼ 707/1084) and having experienced night shifts would recommend them for F1 doctors (75% N ¼ 816/ 1084). A proportion felt unsupported at night (25% N ¼ 269/ 1084) and 13% (N ¼ 144/1084) had been asked to perform procedures beyond their competence (Table 2). Of the speciality groups, the surgical FDs felt most unsupported at night (Table 3).
Hospital at night team FDs who were part of a hospital at night team reported no difference between their night clinical supervision compared to their day clinical supervision (mean 80.4 day vs. 79.2 night; p ¼ 0.067, N ¼ 620). In comparison, FDs who were not part of a HaN team reported lower ratings for their clinical supervision at night compared to their supervision during the day (80.2 day vs. 78.3 night; p50.001, N ¼ 464, Table 4). Table 2. Attitudes to working at night – N ¼ 1084 Doctors who reported working at night (Amalgamated F1 and F2 doctors).
Question I feel my experience of working nights enhanced my training My night time experience improved my decision–making skills My night time experience improved my planning and prioritising skills I gained experiences on nights that I would not have gained during day shifts I felt un-supported whilst working night shifts I was asked to perform procedures that I was not competent in without adequate supervision Overall there was adequate supervision of foundation doctors during the night shift I worked Overall F1’s should do night shifts
Overall agree %
Overall disagree %
91.8
2.4
90.1
2.9
88.0
3.1
85.1
6.6
24.8
52.9
13.3
71.2
65.2
17.7
75.3
9.7
Foundation doctors and night shifts
Table 3. Attitudes to working at night by speciality group.
N ¼ 1084 is those working at night only
Attitudes towards experience at night
Attitudes towards clinical supervision at night
Clinical supervision at night
Clinical supervision at day
Emergency medicine group Mean N
83.47 251
71.02 251
76.34 251
79.15 251
Medicine group Mean N
87.03 405
73.17 405
81.04 405
82.67 405
Surgical group Mean N
87.44 316
67.38 316
76.61 316
77.49 316
Total Mean N F P
86.25 972 7.10 0.00
70.74 972 9.92 0.00
78.39 972 9.85 0.00
80.07 972 11.24 0.00
Table 4. Clinical supervision during the day and during the night.
Clinical supervision score (15–100) Mean
N (number of FDs)
Std. deviation
Lower 95% CI
Upper 95% CI
Pair-sample t-test
p Value
80.3 78.8
1084 1084
15.18 15.83
79.42 77.87
81.23 79.75
3.23
0.00
FDs who reported being part of a hospital at night team Day 80.4 620 Night 79.2 620
15.28 15.27
79.20 78.0
81.6 80.4
1.84
0.07
FDs who reported NOT being part of a hospital at night team Day 80.2 464 Night 78.3 464
15.05 16.56
78.85 76.78
81.59 79.80
2.93
0.00
Overall Day Night
FD ¼ Foundation Doctor. The clinical supervision score was constructed by the mean result of answers to three questions relating to FDs views on their clinical supervision. A Likert scale was used and produced a number between 15 and 100, the higher the number the more positive the FD was about their clinical supervision. A night shift was defined as any shift that extended beyond 8 pm for 10 to 12 hours, while a day shift ended no later than 9 pm.
Foundation competencies We compared FD ratings for relevant clinical foundation competencies, while in medicine or surgery because the majority of FDs were in these posts (67% of respondents) and the experience in other specialities may not have been directly comparable. Using the curriculum mapping competencies we compared FD responses in posts that only featured daytime working and those that had day and night working, the results of which are demonstrated in Tables 5 and 6. There were differences in FDs perceived ability to achieve foundation competencies when they worked both at night and daytime compared to working in the day only. FDs working night shifts in medical posts rated 12 out of the 18 relevant curriculum items more highly. The competencies included history taking, examination, the assessment and management of patients and resuscitation (Table 5 – Statistically significant rows are highlighted). FDs working night shifts in surgical posts rated seven out of the 18 relevant curriculum items more highly. These included competencies such as history taking, examination, diagnosis and clinical decision making, which were all rated statistically significantly better by those FDs who
worked at night compared to those who only worked in the day (Table 6).
Discussion Using a questionnaire, we asked FDs their views on working at night. We found that only a third of F1s worked at night. This is in comparison to the majority of PRHOs working nights prior to the introduction of Foundation training. When the FD was not part of a HaN team, a small, but statistically significant difference in clinical supervision was reported suggesting that supervision was less robust at night than in the daytime. However, when working within a HaN team there was no difference between supervision scores between night and daytime. Nonetheless, we must acknowledge that 18% of FDs feeling inadequately supervised at night is unacceptably high. Levels of supervision do vary by speciality group, with the surgical group demonstrating the lowest clinical supervision score (Table 3). Lower clinical supervision scores for doctors in surgical posts are consistent with data produced by the National Survey of Trainee Doctors (GMC 2006–2011; 2011).
635
R. Coomber et al.
Table 5. Curriculum coverage: Medical FDs, N ¼ 767 (cases from six trusts excluded).
Curriculum mapping item
Worked nights
Did not work nights
Z
p (Bonferroni correction applied)
2.67 2.72 2.61 2.55 2.61 2.64
2.51 2.59 2.45 2.35 2.41 2.3
3.71 3.49 3.86 4.55 4.57 7.31
0.00 0.01 0.00 0.00 0.00 0.00
2.61 2.55
2.42 2.35
4.58 4.77
0.00 0.00
2.81
2.64
3.75
0.00
2.23
1.92
5.38
0.00
2.65
2.37
5.74
0.00
2.27 2.3 2.71 2.73 2.63 2.53 2.1 318
1.96 2.21 2.69 2.68 2.59 2.47 1.94 449
5.50 1.67 0.75 1.38 0.98 1.30 2.08
0.00 1.72 8.19 3.02 5.87 3.52 0.68
2.1 2.2 2.3 3.1 3.2 3.3
Eliciting a history Examination Diagnosis and clinical decision-making Promptly assesses the acutely ill or collapsed patient Identifies and responds to acutely abnormal physiology Where appropriate, delivers a fluid challenge safely to an acutely ill patient 3.4 Reassesses ill patients appropriately after starting treatment 3.5 Undertakes a further patient review to establish a differential diagnosis 3.6 Obtains an arterial blood gas sample safely, interprets results correctly 3.7 Manages patients with impaired consciousness, including convulsions 3.10 Ensures safe continuing care of patients on handover between shifts, on call staff or with ‘hospital at night’ team by meticulous attention to detail and reflection on performance 4.1 Resuscitation 11.2 Valid consent 14.1 Communication with colleagues and teamwork for patient safety 14.2 Interface with different specialities and with other professionals Selection and interpretation of investigations – p42 of curriculum Procedures F1 – p43 of curriculum Procedures F2 – p44 of curriculum N
Table 6. Curriculum coverage: Surgical FDs, N ¼ 514 (cases from six trusts excluded).
Curriculum mapping item Eliciting a history Examination Diagnosis and clinical decision-making Promptly assesses the acutely ill or collapsed patient Identifies and responds to acutely abnormal physiology Where appropriate, delivers a fluid challenge safely to an acutely ill patient 3.4 Reassesses ill patients appropriately after starting treatment 3.5 Undertakes a further patient review to establish a differential diagnosis 3.6 Obtains an arterial blood gas sample safely, interprets results correctly 3.7 Manages patients with impaired consciousness, including convulsions 3.10 Ensures safe continuing care of patients on handover between shifts, on call staff or with ‘hospital at night’ team by meticulous attention to detail and reflection on performance 4.1 Resuscitation 11.2 Valid consent 14.1 Communication with colleagues and teamwork for patient safety 14.2 Interface with different specialities and with other professionals Selection and interpretation of investigations – p42 of curriculum Procedures F1 – p43 of curriculum Procedures F2 – p44 of curriculum N
Worked nights
2.1 2.2 2.3 3.1 3.2 3.3
636
Z
p (Bonferroni correction applied)
2.64 2.72 2.59 2.46 2.54 2.66
2.4 2.49 2.32 2.34 2.46 2.48
4.53 4.84 4.97 2.55 1.60 3.60
0.00 0.00 0.00 0.19 1.95 0.01
2.59
2.45
3.00
0.05
2.45
2.28
2.87
0.08
2.62
2.6
0.90
6.64
1.85
1.6
3.39
0.01
2.56
2.39
3.14
0.03
1.83 2.44 2.68
1.71 2.28 2.63
1.54 2.37 1.36
2.24 0.32 3.14
2.72
2.67
1.55
2.19
2.58
2.5
1.80
1.29
2.48 1.77 285
1.82 2.36
1.24 0.33
2.56 1.97 229
The data demonstrate FDs find working nights a valuable experience to their training, they report greater access to some curriculum competencies by working at night in comparison to those who purely worked in
Did not work nights
the daytime. The vast majority of FDs surveyed, felt they gained experiences at night they would not have otherwise gained in their day shifts (85%) and almost 90% of FDs felt that the experience they gained on night shifts improved
Foundation doctors and night shifts
their ability to prioritise, make decisions and plan (Tables 5 and 6). The clinical implications of our findings suggest that the dramatic reduction in FDs working night shifts has resulted in FDs missing out on opportunities to gain foundation competencies. In the correct environment, with appropriate clinical supervision and where patient safety can be assured FDs who work at night have an increased opportunity to improve their technical ability and their independence. Therefore, the current trend of removing FDs from working at night may eventually produce less well-trained doctors entering speciality programmes, resulting in poorer care to patients and adversely affecting patient safety. The survey response rate of over 80% (2157) provides assurance that this is an assessment of the majority of FDs working night shifts in London. The size of the study and the invariable structure of the foundation programme increases the generalisability to the population of FDs working nights in the UK and perhaps internationally to those doctors in their first year of work. The curriculum opportunity ratings for FDs that worked at night showed higher scores across a number of areas for FDs in medical and surgical posts. We speculate that there are a number of possible reasons for these differences including: working in smaller teams with closer communication, fewer administrative duties, fewer families to speak to, no elective work and the stability of a team through the night time period. These factors probably contribute to both the greater experience attained by FDs working at night and may explain why FDs generally feel supported. An ordinary daytime shift of a FD, either medically or surgically based, involves a ward round with a senior doctor in the morning and quite often no further contact, certainly with the consultant until the following day. The duties of the registrar and consultant in the daytime explain why few training opportunities exist with senior staff as they are tied up with service provision. This is in stark contrast to night shifts where every patient should be discussed with the registrar; all histories and examinations, certainly by F1s should be checked and confirmed by a more senior member of the team. Moreover, because of this increased contact between junior and senior members of the team at night, a greater rapport is built between them. Interpretations of the Temple Report (Temple 2010) have been used as an argument for reducing the time that FDs spend working out-of-hours, including night shifts. Temple suggests that during night work there is less likely to be contact with senior trainers and educational supervisors leading to inadequate supervision and therefore reduced opportunities for training. It is also suggested that working at night results in the FD missing out on the planned training opportunities during the day, due to compensatory rest. The Temple Report suggests a greater degree of consultant involvement in 24 hour hospital cover (Temple 2010). However, a consultant led service should not preclude trainees from working at night where they may attain valuable clinical training. Gallagher et al. (2009) found that the hospital at night initiative provides ample opportunity for FDs to achieve their
competencies at night. They suggest many of the F2 competencies can be achieved in one foundation year through utilising the training opportunities on night shifts in a hospital at night system. There has been much publicity on junior doctors working night shifts both in the lay media and medical literature. While research has shown that consultant cover over night, especially in emergency departments reduces waiting times, admission rates and complaints, it does not automatically follow that FDs should cease from working at night (Sen 2011). Our analysis supports the move to working within a well organised team at night, such as a HaN team. While we have not assessed consultant cover at night this may be an area for further research. The limitations of our work include that the evidence is based around a questionnaire and there is no objective evidence that FDs who work at night are better trained or perform better in the long term. Additionally, we recognise that FDs who work at night earn higher salaries, this may affect their views on working at night. This was not assessed in the current paper. We believe that these results support our hypothesis and that working at night as part of a properly constituted HaN team should be a part of all FDs training. Otherwise, we risk losing the general clinical exposure of night shifts, which is detrimental to the development of competence in FDs. Therefore, some experience of working at night, in functional teams should be compulsory for all FDs within acute medical and surgical rotations.
Further work We appreciate that the evidence attained in this paper is generated by the questionnaire analysis. Thus, it is likely that a more objective comparison of FDs who work at night would provide more robust data to support our conclusions. Additionally, an assessment of the difference between night versus daytime informal teaching opportunities and night versus daytime completion of assessments would be of interest. We would hypothesise there are more informal teaching opportunities and more time for assessments of FDs during night shifts.
Conclusion Our data support that the contention that FDs find working night shifts a valuable experience, enabling them to achieve foundation competencies. This is particularly highlighted in the response of FDs to the question ‘I feel my experience of working nights enhanced my training?’ with over 91% agreeing and only 2% of FDs disagreeing with this question. We have demonstrated that training opportunities exist at night, which are additional to those experienced during daytime working. While these experiences are valuable it must be in a well supervised environment and must ensure that patient safety is not compromised. Moreover, it is not acceptable that 18% of FDs felt inadequately supervised. We have shown that a hospital at night team can improve FDs perceived supervision when working night shifts.
637
R. Coomber et al.
Therefore, the postgraduate training community should reconsider their current attitude of excluding FDs from night shifts. To implement this we should incorporate a robust HaN team to ensure an adequate clinical supervision, promoting a well supervised, enjoyable and worthwhile experience for FDs working at night.
Notes on contributions R. COOMBER, BSc, MBBS, MRCS, substantial contributions to conception and design, acquisition of data and interpretation of data; revising the article critically for important intellectual content; and final approval of the version to be published. D. SMITH, BSc, MSc, substantial contributions to conception and design, acquisition of data and interpretation of data; revising the article critically for important intellectual content; and final approval of the version to be published. D MCGUINNESS, BSc, MBBS, MRCP, substantial contributions to conception and design, acquisition of data and interpretation of data; revising the article critically for important intellectual content; and final approval of the version to be published. E. SHAO, MBBS, substantial contributions to conception and design, acquisition of data and interpretation of data; revising the article critically for important intellectual content; and final approval of the version to be published. R. SOOBRAH, BSc, MBBS, MRCS, MMedEd, substantial contributions to conception and design, acquisition of data and interpretation of data; revising the article critically for important intellectual content; and final approval of the version to be published. A. FRANKEL, FRCP, substantial contributions to conception and design, acquisition of data and interpretation of data; revising the article critically for important intellectual content; and final approval of the version to be published.
Current Research Questions
Do night shifts provide opportunities for FDs to complete work-based placed assessments? Are FDs that work night shifts in F1 better prepared for working as an F2? How can we improve the clinical supervision of FDs working night shifts?
Declaration of interest: All authors have completed the Unified Competing Interest form at www.icmje.org/ coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or
638
activities that could appear to have influenced the submitted work. No funding has been received for this work from any source. Ethical approval: We did not seek ethical approval for this study because participants could not be identified from the material presented and no plausible harm was anticipated to participating individuals that would arise from the study. This data was analysed from our anonymised quality management database.
References European Community Council Directive 93/104/EC. Official Journal of the European Community. 1993;L307:18. Available from http://europa.eu/ legislation_summaries/other/c10405_en.htm. Gallagher P, McLean P, Campbell R, Gallacher S, Kennon B. 2009. Medical training and the hospital at night team: An oxymoron? Med Educ 43(11):1056–1061. General Medical Council (GMC). 2006–2011. National Training Surveys. National training survey reports. Available from http://www.gmcuk.org/education/surveys.asp. General Medical Council (GMC). 2009. The New Doctor. Guidance on foundation training. Available from http://www.gmc-uk.org/ New_Doctor09_FINAL.pdf_27493417.pdf_39279971.pdf. General Medical Council (GMC). 2011. The trainee doctor. Foundation and specialty, including GP training. Available from http://www.gmc-uk. org/Trainee_Doctor.pdf_39274940.pdf. Jaeger vs. Landeshauptstadt Kiel. 2003. Social Policy – Council Directive 93/1 04/EC – Concepts of working time and rest period – On-call service provided by doctors in hospitals. Leslie PJ, Williams JA, McKenna C, Smith G, Heading RC. 1990. Hours, volume, and type of work of pre-registration house officers. Br Med J 300:1038–1041. Mckee M, Black N. 1993. Junior doctors’ work at night: What is done and how much is appropriate? J Public Heal Med 15(1):16–24. Royal College of Surgeons (RCS) of England statement on EWTD. 2010. Available from http://www.rcseng.ac.uk/policy/ewtd-timeline. Sen A, Hill D, Menon D, Rae F, Hughes H, Roop R. 2011. The impact of consultant delivered service in emergency medicine: The Wrexham Model. Emerg Med J 28(12):1004–1007. Sir John Temple. 2010. Time for training. A review of the impact of the European working time directive on the quality of training. Available from http://www.mee.nhs.uk/PDF/14274%20Bookmark%20Web%20 Version.pdf. Turnbull NB, Miles NA, Gallen IW. 1990. Junior doctors’ on call activities: Differences in workload and work patterns among grades. Br Med J 301:1191–1192. UK Foundation Programme Curriculum. 2010. The Foundation Programme. Foundation Programme Curriculum. Cardiff, United Kingdom: Foundation Programme Office; 2007. Available from http://www.foundationprogramme.nhs.uk/pages/home. Wilson TR, Wilson JI, Alexander DJ. 2005. Maximising SHO training by inclusion of research fellows into a novel hybrid rota. Ann R Coll Surg England 87(3):199–202.
Copyright of Medical Teacher is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Foundation doctors working at night: What training opportunities exist? R. COOMBER1, D. SMITH2, D. MCGUINNESS3, E. SHAO4, R. SOOBRAH5 & A. H. FRANKEL6 1
Ipswich Hospital, UK, 2General Medical Council, UK, 3UCL Centre for Nephrology, Royal Free Hospital, UK, West Middlesex Hospital, UK, 5Northwick Park Hospital, UK, and 6London Deanery, UK
4
Abstract Introduction: Foundation Training is designed for doctors in their first two years of post-graduation. The number of foundation doctors (FD) in the UK working nights has reduced because of a perception that clinical supervision at night is unsatisfactory and that minimal training opportunities exist. We aimed to assess the value of night shifts to FDs and hypothesised that removing FDs from nights may be detrimental to training. Methods: Using a survey, we assessed the number of FDs working nights in London, FDs views on working nights and their supervision at night. We evaluated whether working at night, compared to daytime working provided opportunities to achieve foundation competencies. Results: 83% (N ¼ 2157/2593) of FDs completed the survey. Over 90% of FDs who worked nights felt that the experience they gained improved their ability to prioritise, make decisions and plan. FDs who worked nights reported higher scores for achieving competencies in history taking (2.67 vs. 2.51; p ¼ 0.00), examination (2.72 vs. 2.59; p ¼ 0.01) and resuscitation (2.27 vs. 1.96; p ¼ 0.00). The majority (65%) felt adequately supervised. Conclusions: Our survey has demonstrated that FDs find working nights a valuable experience, providing important training opportunities, which are additional to those encountered during daytime working.
Introduction
Practice points
There are concerns that the implementation of the European Working Time Regulations (EWTR) has resulted in a reduction in direct patient contact hours and the associated educational opportunities that this affords (European Community Council Directive 1993; Jaeger vs. Landeshauptstadt Kiel 2003; RCS 2010). Consequently, it is important to preserve opportunities for training where these occur. Foundation Training is designed for doctors in their first two years of post-graduation and is a requirement to enter specialist training in the UK. The first year of training is Foundation Year 1 (F1) and is broadly equivalent to preregistration house officers (PRHO). The second year (F2) is an additional training year, with the purpose of increasing FDs independence. In practice, pre-existing first year senior house officer (SHO) posts were converted into F2 posts. There are over 14,000 FDs in the UK and 2593 working in London. FDs have to demonstrate that they achieve the competencies described within the Foundation Curriculum (UK Foundation Programme Curriculum 2010). These competencies include a variety of topics from history taking and examination of patients, to communication skills. FDs are evaluated by work place-based assessments, such as direct observation of a procedure, reflective practice and teaching which are related to the foundation curriculum. In London, Foundation placements are evaluated annually by a survey, which all FDs are required to complete.
There has been a significant reduction in the number of FDs working night shifts. FDs find working night shifts a valuable experience, which enhances their ability to achieve foundation competencies. While these experiences are valuable they must be in a well supervised environment. HaN teams improved FDs views on supervision at night.
Prior to the introduction of the Foundation Programme in 2005, almost all PRHOs and first year senior house officers would work night shifts. FDs have gradually been removed from working at night, initially because of concerns over clinical supervision and subsequently because of the implementation of the EWTR (Temple 2010). There is some evidence that F1s are able to achieve foundation competencies while working at night and with appropriate clinical supervision (Gallagher et al. 2009). These data were collected in the setting of a regulated Hospital at Night scheme (HaN). However, the work undertaken by F1s was not clearly delineated and the impact of this arrangement on daytime working was not considered. HaN schemes involve a multi-professional team who work together across
Correspondence: Ross Coomber, MRCS – Orthopaedic SpR, Department of Orthopaedic Surgery, Ipswich Hospital, Heath Road, Ipswich IP4 5PD, UK. Tel/Fax: 07957 148 173; E-mail: [email protected]
632
ISSN 0142-159X print/ISSN 1466-187X online/14/70632–7 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.899688
Foundation doctors and night shifts
specialities to look after patients who become unwell at night. It is postulated that these teams provide appropriate clinical supervision to FDs at night, preserving patient safety. Other authors have reported that night time experience is important for the development of clinical decision-making competencies (Wilson et al. 2005). There is limited published data which assesses junior doctors working night shifts and the clinical supervision available at night (Leslie et al. 1990; Turnbull et al. 1990; Mckee & Black 1993). The authors are not aware of any previous research that adequately assesses whether night shifts provide training opportunities for FDs or on the views of FDs who work at night. It is postulated that if FDs are removed entirely from night shifts they will miss out on a significant volume of experience and training. The authors appreciate that a newly qualified doctor working in these environments unsupervised would be detrimental to patient safety. Moreover, night working can be stressful and often involves managing patients who become unwell. However, at some point in training most doctors have to start working nights and we recognise that this experience, in a well supervised team, is valuable to FDs. It is our expectation that working at night will be viewed positively by FDs and will in turn improve their competence, thus improving patient safety. We hypothesise that FDs find night shifts a valuable experience, that night shifts provide opportunities for FDs to gain foundation competencies and that the majority of FDs perceive their clinical supervision to be adequate.
Objectives (1) To assess the number of FDs in London working night shifts. (2) To assess FDs views on the adequacy of their clinical supervision and the affect that working within a hospital at night team has on this parameter. (3) To assess FDs views on the experience they gain from working night shifts. (4) To assess whether night shifts provide additional opportunities for FDs to achieve foundation competencies (i.e. training opportunities at night).
Methods This was a questionnaire survey of FDs in London. In addition to the standard survey questions on the quality of placement, we added questions relating to night time working to the London Deanery annual survey. We asked FDs how many of them worked at night and those who worked at night were asked questions about the adequacy of their clinical supervision. Additionally, we asked FDs about their experiences when working at night and compared their perceived opportunities to achieve foundation competencies at night to daytime working. The survey was emailed to each FD in London and included details of the placement (speciality and location) the FD was expected to evaluate. This was the post they started in
August 2010 and finished in either November 2010 or January 2011 (depending on the length of their placement). Up to five reminder emails were sent to non-responders, over a period of one month. Where email addresses were found to be incorrect, a valid email was sought through placement contact details locally. FDs in academic placements were excluded because they generally do not work in a clinical role during the day. Trust appointed F2s were excluded because they were not in training posts and did not complete the deanery survey.
Questionnaire The survey consisted of the following questions: (1) End of post evaluation questions written by the London Foundation Training Operations Group and designed to map to the Foundation Standards in the GMC’s New Doctor (GMC 2009). (2) 51 questions covering the Foundation Curriculum (pages 6 and 7 of The UK Foundation Programme Curriculum 2010) – A curriculum mapping instrument was included in the survey, which allows each FD to rate the extent to which their current placement provides opportunities to achieve their foundation competencies. Each FD rated 51 foundation competencies and current FDs and senior trainees selected 18 core clinical competencies during the pilot analysis as essential skills for FDs. (3) All FDs who completed the survey rated their ability to achieve foundation competencies. The ratings of FDs who only worked in the daytime were compared to the ratings of FDs who worked at night and daytime. (4) Questions (12) assessing FDs attitudes to working at night (asked only of those FDs who worked at night during the placement under evaluation). Night working was defined as any shift that extended beyond 8 pm for 10 to 12 hours. Before submitting these questions to the FDs we performed a pilot analysis to check their face validity, which did not result in any changes. A Likert scale was used in the questionnaire (five-point scale from Strongly Agree to Strongly disagree).
Clinical supervision score The clinical supervision score was constructed by the mean result of answers to three questions relating to FDs views on their clinical supervision. All FDs were asked these questions. For those FDs who worked at night, these questions were repeated for how they felt about their supervision at night and in the day. Thus, FDs who worked at night answered these questions twice in respect to work undertaken at night and day. In the placement you started in August 2010, when working during the DAY/NIGHT, how often have you felt forced to cope with clinical problems beyond your competence or experience? In the placement you started in August 2010, when working during the DAY/NIGHT, how often, if ever, have you been supervised by someone who you feel isn’t competent to do so?
633
R. Coomber et al.
In the placement you started in August 2010, when working during the DAY/NIGHT do you always know who is providing your clinical supervision when you are working? The mean clinical supervision score was calculated from the answers to the above questions. A Likert scale was used and produced a number between 15 and 100, the higher the number the more positive the FD was about their clinical supervision. We analysed our data to assess whether clinical supervision at night differed from clinical supervision during the day using this score. In addition, we compared FDs clinical supervision score when they were part of a hospital at night team.
Data analysis The Mann–Whitney test was used where the data were nonparametric in distribution. To remove variance associated with speciality and with trusts where all FDs worked at night, the analysis was run using FDs from each speciality separately. FDs working at hospitals where everyone reported working at night were excluded.
Results Number of FDs working at night We received responses from 2157 of 2593 (83%) FDs. This included 1114 F1 and 1043 F2 doctors. This varied by speciality and included 284 FDs working in emergency medicine; 854 FDs working in medical specialities; 601 FDs working in surgical specialities and no FDs working nights in general practice or pathology (Table 1). Of these 390 (35%) F1 and 699 (67%) F2 doctors reported working at night.
Table 1. Who works nights?.
Grade
In the placement you started in August 2010, have you worked night shifts (a shift extending beyond 2000 for 10–12 Number hours)? – % Yes of doctors
F1 (Foundation Year 1) F2 (Foundation Year 2)
35% 67%
1114 1043
Placement speciality Anaesthetics group Emergency medicine group General practice (GP) group Medicine group Obstetrics and gynaecology group Ophthalmology group Paediatrics group Pathology group Psychiatry group Public health Radiology group Surgical group Total
30% 88% 0% 47% 51% 40% 56% 0% 52% 0% 50% 53% 50%
57 284 171 854 57 5 62 5 42 5 14 601 2157
634
The variation by hospital of FDs working nights ranged from 22 to 94% (excluding hospitals with less than five FDs, specialist trusts and mental health trusts). In total, 12 hospital sites had no F1s working at night; whilst one site had 98% of F1s working at night.
FDs experiences while working at night A total of 995 of 1084 (92%) FDs (who worked at night) felt working night shifts enhanced their training, 976 (90%) of FDs felt nights improved their decision-making skills and 954 (88%) of FDs felt nights improved their planning and prioritisation of tasks. The majority of FDs surveyed claimed they gained skills on their night shifts that they would not have gained during day shifts (85% N ¼ 923/1084, Table 2).
Clinical supervision at night The majority of FDs who worked nights felt adequately supported (65% N ¼ 707/1084) and having experienced night shifts would recommend them for F1 doctors (75% N ¼ 816/ 1084). A proportion felt unsupported at night (25% N ¼ 269/ 1084) and 13% (N ¼ 144/1084) had been asked to perform procedures beyond their competence (Table 2). Of the speciality groups, the surgical FDs felt most unsupported at night (Table 3).
Hospital at night team FDs who were part of a hospital at night team reported no difference between their night clinical supervision compared to their day clinical supervision (mean 80.4 day vs. 79.2 night; p ¼ 0.067, N ¼ 620). In comparison, FDs who were not part of a HaN team reported lower ratings for their clinical supervision at night compared to their supervision during the day (80.2 day vs. 78.3 night; p50.001, N ¼ 464, Table 4). Table 2. Attitudes to working at night – N ¼ 1084 Doctors who reported working at night (Amalgamated F1 and F2 doctors).
Question I feel my experience of working nights enhanced my training My night time experience improved my decision–making skills My night time experience improved my planning and prioritising skills I gained experiences on nights that I would not have gained during day shifts I felt un-supported whilst working night shifts I was asked to perform procedures that I was not competent in without adequate supervision Overall there was adequate supervision of foundation doctors during the night shift I worked Overall F1’s should do night shifts
Overall agree %
Overall disagree %
91.8
2.4
90.1
2.9
88.0
3.1
85.1
6.6
24.8
52.9
13.3
71.2
65.2
17.7
75.3
9.7
Foundation doctors and night shifts
Table 3. Attitudes to working at night by speciality group.
N ¼ 1084 is those working at night only
Attitudes towards experience at night
Attitudes towards clinical supervision at night
Clinical supervision at night
Clinical supervision at day
Emergency medicine group Mean N
83.47 251
71.02 251
76.34 251
79.15 251
Medicine group Mean N
87.03 405
73.17 405
81.04 405
82.67 405
Surgical group Mean N
87.44 316
67.38 316
76.61 316
77.49 316
Total Mean N F P
86.25 972 7.10 0.00
70.74 972 9.92 0.00
78.39 972 9.85 0.00
80.07 972 11.24 0.00
Table 4. Clinical supervision during the day and during the night.
Clinical supervision score (15–100) Mean
N (number of FDs)
Std. deviation
Lower 95% CI
Upper 95% CI
Pair-sample t-test
p Value
80.3 78.8
1084 1084
15.18 15.83
79.42 77.87
81.23 79.75
3.23
0.00
FDs who reported being part of a hospital at night team Day 80.4 620 Night 79.2 620
15.28 15.27
79.20 78.0
81.6 80.4
1.84
0.07
FDs who reported NOT being part of a hospital at night team Day 80.2 464 Night 78.3 464
15.05 16.56
78.85 76.78
81.59 79.80
2.93
0.00
Overall Day Night
FD ¼ Foundation Doctor. The clinical supervision score was constructed by the mean result of answers to three questions relating to FDs views on their clinical supervision. A Likert scale was used and produced a number between 15 and 100, the higher the number the more positive the FD was about their clinical supervision. A night shift was defined as any shift that extended beyond 8 pm for 10 to 12 hours, while a day shift ended no later than 9 pm.
Foundation competencies We compared FD ratings for relevant clinical foundation competencies, while in medicine or surgery because the majority of FDs were in these posts (67% of respondents) and the experience in other specialities may not have been directly comparable. Using the curriculum mapping competencies we compared FD responses in posts that only featured daytime working and those that had day and night working, the results of which are demonstrated in Tables 5 and 6. There were differences in FDs perceived ability to achieve foundation competencies when they worked both at night and daytime compared to working in the day only. FDs working night shifts in medical posts rated 12 out of the 18 relevant curriculum items more highly. The competencies included history taking, examination, the assessment and management of patients and resuscitation (Table 5 – Statistically significant rows are highlighted). FDs working night shifts in surgical posts rated seven out of the 18 relevant curriculum items more highly. These included competencies such as history taking, examination, diagnosis and clinical decision making, which were all rated statistically significantly better by those FDs who
worked at night compared to those who only worked in the day (Table 6).
Discussion Using a questionnaire, we asked FDs their views on working at night. We found that only a third of F1s worked at night. This is in comparison to the majority of PRHOs working nights prior to the introduction of Foundation training. When the FD was not part of a HaN team, a small, but statistically significant difference in clinical supervision was reported suggesting that supervision was less robust at night than in the daytime. However, when working within a HaN team there was no difference between supervision scores between night and daytime. Nonetheless, we must acknowledge that 18% of FDs feeling inadequately supervised at night is unacceptably high. Levels of supervision do vary by speciality group, with the surgical group demonstrating the lowest clinical supervision score (Table 3). Lower clinical supervision scores for doctors in surgical posts are consistent with data produced by the National Survey of Trainee Doctors (GMC 2006–2011; 2011).
635
R. Coomber et al.
Table 5. Curriculum coverage: Medical FDs, N ¼ 767 (cases from six trusts excluded).
Curriculum mapping item
Worked nights
Did not work nights
Z
p (Bonferroni correction applied)
2.67 2.72 2.61 2.55 2.61 2.64
2.51 2.59 2.45 2.35 2.41 2.3
3.71 3.49 3.86 4.55 4.57 7.31
0.00 0.01 0.00 0.00 0.00 0.00
2.61 2.55
2.42 2.35
4.58 4.77
0.00 0.00
2.81
2.64
3.75
0.00
2.23
1.92
5.38
0.00
2.65
2.37
5.74
0.00
2.27 2.3 2.71 2.73 2.63 2.53 2.1 318
1.96 2.21 2.69 2.68 2.59 2.47 1.94 449
5.50 1.67 0.75 1.38 0.98 1.30 2.08
0.00 1.72 8.19 3.02 5.87 3.52 0.68
2.1 2.2 2.3 3.1 3.2 3.3
Eliciting a history Examination Diagnosis and clinical decision-making Promptly assesses the acutely ill or collapsed patient Identifies and responds to acutely abnormal physiology Where appropriate, delivers a fluid challenge safely to an acutely ill patient 3.4 Reassesses ill patients appropriately after starting treatment 3.5 Undertakes a further patient review to establish a differential diagnosis 3.6 Obtains an arterial blood gas sample safely, interprets results correctly 3.7 Manages patients with impaired consciousness, including convulsions 3.10 Ensures safe continuing care of patients on handover between shifts, on call staff or with ‘hospital at night’ team by meticulous attention to detail and reflection on performance 4.1 Resuscitation 11.2 Valid consent 14.1 Communication with colleagues and teamwork for patient safety 14.2 Interface with different specialities and with other professionals Selection and interpretation of investigations – p42 of curriculum Procedures F1 – p43 of curriculum Procedures F2 – p44 of curriculum N
Table 6. Curriculum coverage: Surgical FDs, N ¼ 514 (cases from six trusts excluded).
Curriculum mapping item Eliciting a history Examination Diagnosis and clinical decision-making Promptly assesses the acutely ill or collapsed patient Identifies and responds to acutely abnormal physiology Where appropriate, delivers a fluid challenge safely to an acutely ill patient 3.4 Reassesses ill patients appropriately after starting treatment 3.5 Undertakes a further patient review to establish a differential diagnosis 3.6 Obtains an arterial blood gas sample safely, interprets results correctly 3.7 Manages patients with impaired consciousness, including convulsions 3.10 Ensures safe continuing care of patients on handover between shifts, on call staff or with ‘hospital at night’ team by meticulous attention to detail and reflection on performance 4.1 Resuscitation 11.2 Valid consent 14.1 Communication with colleagues and teamwork for patient safety 14.2 Interface with different specialities and with other professionals Selection and interpretation of investigations – p42 of curriculum Procedures F1 – p43 of curriculum Procedures F2 – p44 of curriculum N
Worked nights
2.1 2.2 2.3 3.1 3.2 3.3
636
Z
p (Bonferroni correction applied)
2.64 2.72 2.59 2.46 2.54 2.66
2.4 2.49 2.32 2.34 2.46 2.48
4.53 4.84 4.97 2.55 1.60 3.60
0.00 0.00 0.00 0.19 1.95 0.01
2.59
2.45
3.00
0.05
2.45
2.28
2.87
0.08
2.62
2.6
0.90
6.64
1.85
1.6
3.39
0.01
2.56
2.39
3.14
0.03
1.83 2.44 2.68
1.71 2.28 2.63
1.54 2.37 1.36
2.24 0.32 3.14
2.72
2.67
1.55
2.19
2.58
2.5
1.80
1.29
2.48 1.77 285
1.82 2.36
1.24 0.33
2.56 1.97 229
The data demonstrate FDs find working nights a valuable experience to their training, they report greater access to some curriculum competencies by working at night in comparison to those who purely worked in
Did not work nights
the daytime. The vast majority of FDs surveyed, felt they gained experiences at night they would not have otherwise gained in their day shifts (85%) and almost 90% of FDs felt that the experience they gained on night shifts improved
Foundation doctors and night shifts
their ability to prioritise, make decisions and plan (Tables 5 and 6). The clinical implications of our findings suggest that the dramatic reduction in FDs working night shifts has resulted in FDs missing out on opportunities to gain foundation competencies. In the correct environment, with appropriate clinical supervision and where patient safety can be assured FDs who work at night have an increased opportunity to improve their technical ability and their independence. Therefore, the current trend of removing FDs from working at night may eventually produce less well-trained doctors entering speciality programmes, resulting in poorer care to patients and adversely affecting patient safety. The survey response rate of over 80% (2157) provides assurance that this is an assessment of the majority of FDs working night shifts in London. The size of the study and the invariable structure of the foundation programme increases the generalisability to the population of FDs working nights in the UK and perhaps internationally to those doctors in their first year of work. The curriculum opportunity ratings for FDs that worked at night showed higher scores across a number of areas for FDs in medical and surgical posts. We speculate that there are a number of possible reasons for these differences including: working in smaller teams with closer communication, fewer administrative duties, fewer families to speak to, no elective work and the stability of a team through the night time period. These factors probably contribute to both the greater experience attained by FDs working at night and may explain why FDs generally feel supported. An ordinary daytime shift of a FD, either medically or surgically based, involves a ward round with a senior doctor in the morning and quite often no further contact, certainly with the consultant until the following day. The duties of the registrar and consultant in the daytime explain why few training opportunities exist with senior staff as they are tied up with service provision. This is in stark contrast to night shifts where every patient should be discussed with the registrar; all histories and examinations, certainly by F1s should be checked and confirmed by a more senior member of the team. Moreover, because of this increased contact between junior and senior members of the team at night, a greater rapport is built between them. Interpretations of the Temple Report (Temple 2010) have been used as an argument for reducing the time that FDs spend working out-of-hours, including night shifts. Temple suggests that during night work there is less likely to be contact with senior trainers and educational supervisors leading to inadequate supervision and therefore reduced opportunities for training. It is also suggested that working at night results in the FD missing out on the planned training opportunities during the day, due to compensatory rest. The Temple Report suggests a greater degree of consultant involvement in 24 hour hospital cover (Temple 2010). However, a consultant led service should not preclude trainees from working at night where they may attain valuable clinical training. Gallagher et al. (2009) found that the hospital at night initiative provides ample opportunity for FDs to achieve their
competencies at night. They suggest many of the F2 competencies can be achieved in one foundation year through utilising the training opportunities on night shifts in a hospital at night system. There has been much publicity on junior doctors working night shifts both in the lay media and medical literature. While research has shown that consultant cover over night, especially in emergency departments reduces waiting times, admission rates and complaints, it does not automatically follow that FDs should cease from working at night (Sen 2011). Our analysis supports the move to working within a well organised team at night, such as a HaN team. While we have not assessed consultant cover at night this may be an area for further research. The limitations of our work include that the evidence is based around a questionnaire and there is no objective evidence that FDs who work at night are better trained or perform better in the long term. Additionally, we recognise that FDs who work at night earn higher salaries, this may affect their views on working at night. This was not assessed in the current paper. We believe that these results support our hypothesis and that working at night as part of a properly constituted HaN team should be a part of all FDs training. Otherwise, we risk losing the general clinical exposure of night shifts, which is detrimental to the development of competence in FDs. Therefore, some experience of working at night, in functional teams should be compulsory for all FDs within acute medical and surgical rotations.
Further work We appreciate that the evidence attained in this paper is generated by the questionnaire analysis. Thus, it is likely that a more objective comparison of FDs who work at night would provide more robust data to support our conclusions. Additionally, an assessment of the difference between night versus daytime informal teaching opportunities and night versus daytime completion of assessments would be of interest. We would hypothesise there are more informal teaching opportunities and more time for assessments of FDs during night shifts.
Conclusion Our data support that the contention that FDs find working night shifts a valuable experience, enabling them to achieve foundation competencies. This is particularly highlighted in the response of FDs to the question ‘I feel my experience of working nights enhanced my training?’ with over 91% agreeing and only 2% of FDs disagreeing with this question. We have demonstrated that training opportunities exist at night, which are additional to those experienced during daytime working. While these experiences are valuable it must be in a well supervised environment and must ensure that patient safety is not compromised. Moreover, it is not acceptable that 18% of FDs felt inadequately supervised. We have shown that a hospital at night team can improve FDs perceived supervision when working night shifts.
637
R. Coomber et al.
Therefore, the postgraduate training community should reconsider their current attitude of excluding FDs from night shifts. To implement this we should incorporate a robust HaN team to ensure an adequate clinical supervision, promoting a well supervised, enjoyable and worthwhile experience for FDs working at night.
Notes on contributions R. COOMBER, BSc, MBBS, MRCS, substantial contributions to conception and design, acquisition of data and interpretation of data; revising the article critically for important intellectual content; and final approval of the version to be published. D. SMITH, BSc, MSc, substantial contributions to conception and design, acquisition of data and interpretation of data; revising the article critically for important intellectual content; and final approval of the version to be published. D MCGUINNESS, BSc, MBBS, MRCP, substantial contributions to conception and design, acquisition of data and interpretation of data; revising the article critically for important intellectual content; and final approval of the version to be published. E. SHAO, MBBS, substantial contributions to conception and design, acquisition of data and interpretation of data; revising the article critically for important intellectual content; and final approval of the version to be published. R. SOOBRAH, BSc, MBBS, MRCS, MMedEd, substantial contributions to conception and design, acquisition of data and interpretation of data; revising the article critically for important intellectual content; and final approval of the version to be published. A. FRANKEL, FRCP, substantial contributions to conception and design, acquisition of data and interpretation of data; revising the article critically for important intellectual content; and final approval of the version to be published.
Current Research Questions
Do night shifts provide opportunities for FDs to complete work-based placed assessments? Are FDs that work night shifts in F1 better prepared for working as an F2? How can we improve the clinical supervision of FDs working night shifts?
Declaration of interest: All authors have completed the Unified Competing Interest form at www.icmje.org/ coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or
638
activities that could appear to have influenced the submitted work. No funding has been received for this work from any source. Ethical approval: We did not seek ethical approval for this study because participants could not be identified from the material presented and no plausible harm was anticipated to participating individuals that would arise from the study. This data was analysed from our anonymised quality management database.
References European Community Council Directive 93/104/EC. Official Journal of the European Community. 1993;L307:18. Available from http://europa.eu/ legislation_summaries/other/c10405_en.htm. Gallagher P, McLean P, Campbell R, Gallacher S, Kennon B. 2009. Medical training and the hospital at night team: An oxymoron? Med Educ 43(11):1056–1061. General Medical Council (GMC). 2006–2011. National Training Surveys. National training survey reports. Available from http://www.gmcuk.org/education/surveys.asp. General Medical Council (GMC). 2009. The New Doctor. Guidance on foundation training. Available from http://www.gmc-uk.org/ New_Doctor09_FINAL.pdf_27493417.pdf_39279971.pdf. General Medical Council (GMC). 2011. The trainee doctor. Foundation and specialty, including GP training. Available from http://www.gmc-uk. org/Trainee_Doctor.pdf_39274940.pdf. Jaeger vs. Landeshauptstadt Kiel. 2003. Social Policy – Council Directive 93/1 04/EC – Concepts of working time and rest period – On-call service provided by doctors in hospitals. Leslie PJ, Williams JA, McKenna C, Smith G, Heading RC. 1990. Hours, volume, and type of work of pre-registration house officers. Br Med J 300:1038–1041. Mckee M, Black N. 1993. Junior doctors’ work at night: What is done and how much is appropriate? J Public Heal Med 15(1):16–24. Royal College of Surgeons (RCS) of England statement on EWTD. 2010. Available from http://www.rcseng.ac.uk/policy/ewtd-timeline. Sen A, Hill D, Menon D, Rae F, Hughes H, Roop R. 2011. The impact of consultant delivered service in emergency medicine: The Wrexham Model. Emerg Med J 28(12):1004–1007. Sir John Temple. 2010. Time for training. A review of the impact of the European working time directive on the quality of training. Available from http://www.mee.nhs.uk/PDF/14274%20Bookmark%20Web%20 Version.pdf. Turnbull NB, Miles NA, Gallen IW. 1990. Junior doctors’ on call activities: Differences in workload and work patterns among grades. Br Med J 301:1191–1192. UK Foundation Programme Curriculum. 2010. The Foundation Programme. Foundation Programme Curriculum. Cardiff, United Kingdom: Foundation Programme Office; 2007. Available from http://www.foundationprogramme.nhs.uk/pages/home. Wilson TR, Wilson JI, Alexander DJ. 2005. Maximising SHO training by inclusion of research fellows into a novel hybrid rota. Ann R Coll Surg England 87(3):199–202.
Copyright of Medical Teacher is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
