Improving compliance with requirements on junior doctors' hours
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7409.270 (Published 31 July 2003) Cite this as: BMJ 2003;327:270All rapid responses
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Dear Sir / Madam,
The paper “Improving compliance with requirements on junior doctors’
hours” illustrates one solution to the problem that will, very soon, be
faced by us all and takes the route of employing nurses/nurse
practitioners to undertake most of the junior doctors’ tasks. In their
conclusion they suggest that doctors may no longer be allowed to sleep at
night when they adopt a shift system. It is well recognized that night
shifts disrupt circadian rhythms causing sleep deficit and fatigue. (1-3)
This will be further compounded by long working hours as doctors may still
work up to 56 hours a week compared with average 37 ½ hours for nursing
staff. (4) This can reduce both the cognitive and practical skills of
doctors and can potentially lead to errors, which may be harmful to both
the patient and the doctor involved, especially in these litigious times.
(5-7)
Naps are an integral part of a 12-hour night shift for pilots who
have a 6-hour break to ensure maximum safety. This practice has been
adopted by some nurses in Japan where they have a 2-hour nap during a 16-
hour night shift. (8) Other studies suggest short naps can improve
alertness at night. (9)
We aim to provide the best care for our patients whether it is day or
night and this can be improved by naps during the night shift when
performance is naturally reduced. We would suggest that naps should be an
integral part of night cover for all staff, including doctors.
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Jansen NWH, van Amelsvoort LGPM, Kristensen TS, van den Brandt PA, Kant
IJ. Occup Environ Med., 2003;60 Suppl 1:i47-53.
4) Health and safety problems associated with long working hours: a review
of the current position. Spurgeon A, Harrington JM, Cooper CL. Occup
Environ Med., 1997, n.54, 367-375.
5) The effects of consecutive night shifts on neuropsychological
performance of interns in the emergency department: a pilot study.
Rollinson DC, Rathlev NK, Moss M, Killiany R, Sassower KC, Auerbach S,
Fish SS. Ann Emerg Med. 2003;41(3):400-406
6) Laparoscopic performance after one night on call in a surgical
department: prospective study. Grantcharov TP, Bardram L, FunchJensen P,
Rosenberg J. BMJ 2001;323:1222–1223
7) Causes of prescribing errors in hospital inpatients: a prospective
study. Dean B, Schachter M, Vincent C, Barber N. Lancet 2002; 359: 1373–78
8) Shift work-related problems in 16-h night shift nurses (2):
Effects on subjective symptoms, physical activity, heart rate, and sleep.
Takahashi M, Fukuda H, Miki K, Haratani T, Kurabayashi L, Hisanaga N,
Arito H, Takahashi H, Egoshi M, Sakurai M.
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Herbison GP. J. Sleep Res. (2002) 11, 219–227
Competing interests:
None declared
Competing interests: No competing interests
Thanks to those who took the time to read and respond to our paper.
An issue flagged up by a number of respondents was one that we anticipated
- whether changes implemented in an 'Ivory Tower' (as termed by Macartney)
are generalisable elsewhere.
In writing this article we did not intend to produce a rota solution
or template that could be 'cut and pasted' into other settings - we fully
recognise that each hospital and speciality faces different challenges and
solutions. However, the article was intended to demonstrate those
principles that can be generalised - specifically, the need to audit
workload, to maximise clinical time through better administrative support,
to reduce tiers of cover where possible, to cross-cover as broadly as is
feasible, and most importantly to work as a team with extended
professional roles. All of these principles can and are being generalised
to other settings; the DoH is supporting pilots in a number of district
general hospitals across the country which are adopting every one of these
strategies.
Whilst warning against generalisation, Shailesh extrapolates well
beyond the reliability of the data to predict a 300% increase in critical
incidents. Our comments related not to the number (which is too small to
extrapolate from), but to the nature of the critical incidents, which
indicate a worrying change in the professionalism of the doctors
concerned. Whilst we are fully committed to delivering safe hours, we
believe that the inflexibility of the monitoring systems is having a
detrimental effect.
Finally, we are in agreement with the comments of Saunders and very
interested in the views of Haller. Both indicate the need for a
fundamental change in attitudes and substantial redesign of the role of
junior doctors within the clinical service. Education and continuity of
care through long hours of continuous duty are dead and gone. Whether or
not clinicians agree with the demise of this model of practice, the time
has come to mourn it and move on.
Competing interests:
First author - competing interests as previously declared
Competing interests: No competing interests
Modifying the organisation of work in clinical practice, such as
described by Cass HD et al 1, needs to take into account its potential
impact on patient safety. Cross speciality cover, rotating night shifts
and multidisciplinary teams all increase complexity. Experience gained
from accident analysis in other industry settings (nuclear power
plants,aviation) is that system complexity adds to the risk of error 2.
To deal with complexity and ensure coordination of the patient care
work, the medical profession traditionally relies on what organisational
theorists call ‘standardisation of skill and knowledge’ 3. People know
what task to do and what to expect of each other. They are trained to do
so and share the same background knowledge. Mutual adjustments can be done
by brief summaries or short conversations if necessary. When complexity
increases this traditional coordination method is overwhelmed and
discontinuities appear. It is therefore not very surprising that the three
critical incidents reported here1 were related to some kind of
discontinuity of care.
To address complexity and discontinuity, other industries such as the
airline industry have also placed great emphasis on coordination through
the standardisation of work processes 4. The work itself is standardised
and procedures are specified. Clinical guidelines and standardised medical
record keeping are examples of this approach in clinical care.
We agree with Cass HD et al 1 that meeting the requirements on junior
doctors’ hours requires more than just attention to rostering. However, if
equal attention is to be given to improving safety and quality, changes to
the system of clinical work should aim to make it less complex.
One strategy to achieve this could be to reduce the continuous rotation of
junior staff through clinical areas for the purpose of training, so as to
maximise the benefit of learning the work routines. Another could be the
learning of standardised techniques during the training process so as to
combine harmoniously skill and work based coordination mechanisms.
Finally, guidelines should be made directly accessible into electronic
medical records.
To conclude, compliance with requirements for junior doctors’ hours
is just another window into the unfulfilled need to redesign the nature of
clinical work and the role of junior doctors in it.
References
1. Cass HD, Smith I, Unthank C, Starling C, Collins JE. Improving
compliance with requirements on junior doctors' hours. BMJ 2003;327: 270
-3.
2. Perrow C. Complexity, coupling and catastrophe. In: Normal
accidents-Living with high-risk technologies. Princeton: Princeton
university press,1999: 62-101.
3. Glouberman S, Mintzberg H. Managing the care of health and the
cure of disease--Part II: Integration. Health Care Manage Rev 2001;26: 70-
84.
4. International civil aviation organisation. International Standards
and Recommended Practises. International civil aviation organisation
publications. Montreal: 1946 and updates.
Competing interests:
None declared
Competing interests: No competing interests
Interesting article with a few sticking points. Unfortunately authors
have produced a report on paediatric rota and than have generalised it.
What is acceptable for one speciality is not necessarily good for other
specialities. Surgical rota with shift system has left continuity of care
and education for surgical trainees at risk. One junior who admits the
patient does not always follows the patient through the journey and that
is not really good for surgical learning/teaching. The answer to every
problem these days is “ employ nurse practitioners”. Are we not just
trying to solve problems by changing the name of good old ward sisters who
used to do all these tasks but with out the title of “nurse practitioner”.
By the authors’ own admission there were 3 critical incidents in 6 months
period as compared to 2 in 12 months prior to changes in working pattern.
By the rule of average that will be 300% increase in the critical
incidents. We have to follow EWTD (Europian Working Time Directive) but at
a cost and that cost, especially on surgical side, is lack of continuity
of education for juniors.
Competing interests:
None declared
Competing interests: No competing interests
The article by Cass et al is fascinating, demonstrating how a
hospital without an A&E needs 4 junior doctors to cover the medical
paediatric specialties. I presume this did not include the ICU,
anaesthetics, or surgery. If a hospital with such a staggeringly large
staffing is only just able to comply, I fail to see the relevance of the
article to the real world where the rest of us work. I look forward to the
response from the deanery when I ask that we be allowed the same ratio of
doctors to patients in my hospital.
Competing interests:
None declared
Competing interests: No competing interests
I agree that compliance today will be quality tomorrow. Those on
Night shift (9pm-10am) in my hospital would lose daytime training for whole
week every 7 weeks (3.5 weeks in 24 weeks! Also service delivery to
patients in smaller DGHs will be severly affected [Our out patient (OPD)
numbers have to be reduced (by 30-40%)]on the days and next day SHO are
oncall for night shift and Long days. I think DOH (Department of Health)
and BMA (British Medical Associaion) should have come clean to say to
patient user group that new deal would mean less patients seen in
outpatient clinics (as training SHO {senior House officer} / SpR
{Specialist Registrar} numbers are limited) and Trusts would try to fill
the manpower crisis by substandard clinical fellows / staff grades / Trust
doctors (most served by new arrivals from overseas without any experience
in British Medicine).
Trusts would be penalised heavily for disregarding hours and by the DOH
& Govt. for delaying patient appointment or increase in waiting lists.
Can we come clean and say that UK has not got the capacity to deliver the
services needed at present due to Medical graduates and training scarcity
created by Govt. 10 years ago?
Competing interests:
None declared
Competing interests: No competing interests
Work patterns are clearly having to change as we strive to meet the
UK regulations on junior doctors hours, and more particularly the European
Working Time directive. The model proposed by Cass et al has clearly had
an effect to make all working patterns within the trust compliant but
there are a number of concerns. Firstly, the rota described was set up in
a tertiary referral centre providing very specilaist care with no accident
and emergency commitment. The comment is made in the paper that senior
house officers had 'substantial on-call experience elsewhere, so they
would not lose important experience overnight'. If a similar system of
cover was set up using the same model across the board we would have to
ask where the 'senior' overnight cover would be coming from in the future
as HOs and SHOs would no longer gain the experience of today.
It is commented in the paper that trainees expressed concerns about
exposure to their own subspeciality. This would be a potentially greater
problem in smaller trusts where night shifts by necessity would be more
frequent and would have a greater impact on training.
Complying with the working time directive will be very challenging for
many trusts. Care must be taken not to adopt systems which meet hours
targets in the short term but may have long term implications for training
and experience, particularly for the most junior staff.
Competing interests:
None declared
Competing interests: No competing interests
Australian hospital staffing levels are significantly lower than the
NHS, after hours. The majority of acute SHO cover is via the Emergency
department which is more intensively staffed overnight than the NHS.
Wards are covered by resident medical officers with a senior medical SHO
equivelent often being the most senior person in the hospital overnight.
Most advanced training registrars are on a call back system and deal with
problems by phone , comming in if needed. The system works because of the
presence of well trained Emergency Physicians and Registrars who are
trained through their own college. Emergency Medicine is a popular career
choice in Australia.
A fundemental change in perceptions is needed to achieve the European
directive. Most junior staff in Australia are working 40-50 hours per
week. Employing them beyond this has become too expensive due to penalty
payments. This provides a secure system where the hospital management has
no financial interest in overworking it's staff.Money always talks.
Competing interests:
None declared
Competing interests: No competing interests
We must ensure residence is paid for
The EWTD is specifically related to health and safety not to pay.
We cannot, as the current review of the SIMAP judgement points out, easily
argue on common sense grounds that time spent snoring in a bed in an on
call room can be deemed to be working in the health and safety point of
view i.e. from the 48 / 56 hours weekly allowance BUT I can see the
management then extrapolating this to the pay packet. We must argue that
being on the premises, all be it in bed asleep puts us in the same
position as nursing staff resident at night to man the theatres, portering
staff with, on a quiet night, nothing to do, all sleeping in the corner or
playing cards. They need paying as much as we. There is a precident, I
think, where a burger chain tried to get away with only paying staff when
there were customers in the cafe!
Increasingly there is pressure on consultants to be resident, particularly
in accute specialities such as paediatrics, anaesthetics, A&E,
obstetrics &c. The number of junior staff resident is being cut to
save working hour time but also, coincidently, saving on pay.
We MUST make clear that we will require to be paid for being resident OR
ELSE.........
Competing interests:
Working consultant
Competing interests: No competing interests