When should doctors start to perform night duty?
When should newly qualified doctors be able to start to perform night duty? This is an issue the NZRDA has been concerned with for some time now. Starting to perform night duty promptly after finishing medical school raises a number of health and safety issues. It is imperative that the newly qualified doctor and the hospital environment in which patient care is carried out is appropriately equipped to deal with the various risks that night duty involves.
The employers have previously sought to remove the current 3 and 6 months time limits on newly graduating doctors from commencing nights. If these time limits were removed then this would leave newly qualified doctors working on night shifts from six weeks after commencing working as a doctor, assuming the MCNZ retained their 6 week provision.
Why is there a need to take night duty seriously?
Working at night time in a hospital is quite different from working during the day. Amongst other things, night shifts require a doctor to be able to cope with high workloads, working largely in isolation, experiencing fatigue from sleep deprivation and the impact of nocturnal work. Doctors that are on night duty often deal with very sick patients at a time when there is the least support and supervision available (in comparison to the support and supervision available during the day).
In a survey of 1,412 New Zealand (resident) doctors* considering work patterns in the previous two weeks, Gander et al. (2007) reported that, 66% of resident doctors could recall making a fatigue-related clinical error in their career, and 42% could recall making a fatigue-related error in the past six months. The survey illustrated that night work in the last fortnight, working shifts of extended duration, inadequate breaks between shifts and work schedule changes were independent predictors of reporting a fatigue-related clinical error in the past six months. 1
The review of the Gander et al. (2007) studies showed that there is reasonable consistent evidence that decreased patient and doctor safety, decreased sleep and increased sleepiness, decreased subjective health and wellbeing, decreased performance and poor work life balance are associated with increased hours of work, working night shift compared with day
shift, increased shift length and working more consecutive nights and decreased sleep.2
It is therefore highly important for both patient and doctor that we ensure that those with the least experience are ready to commence nights and the environment in which they work is sufficiently supportive in order to provide for the best possible patient care and professional safety at night.
*with a response rate of 66%.
1. See “Best Practice Rostering, Shift Work and Hours of Work for Resident Doctors: A Review” O’Keeffe and Gander.
2. Above at 1.
Why is there a need to take night duty seriously?
As a result of the issues surrounding the timeframes for first year house officers after which night shifts are able to be performed, the NZRDA undertook two surveys in 2014 to gain some further insight into:
1. From an RMOs perspective, when should doctors start to perform night duty (Survey 1); and
2. What factors provide confidence in the hospital environment for newly qualified doctors to work at night, or a lack of confidence (Survey 2).
Survey One : When should newly qualified doctors start performing night shifts?
A survey of resident doctors was undertaken to ascertain views on what timeframe were felt to be appropriate for newly qualified doctors to start performing night shifts.
71% of respondents felt newly graduated doctors should not start night shifts before they have completed 6 months practice as a doctor. Only 7.73% of respondents felt 6 weeks (the MCNZ guideline) was sufficient time from graduation as a doctor to starting night shifts. 21.63% of respondents felt that 3 months was sufficient.
The level of response to the different time frames varied between DHBs: In Lakes, South Canterbury, MidCentral, Waikato and Capital & Coast DHBs, doctors are least confident to have first years on night before six months compared to in Auckland, Hutt Valley, Taranaki, Canterbury and Waitemata DHBs, where doctors are more confident.
Only at Auckland DHB did more than half (51%) of resident doctors believe new graduates should perform night shifts in their first 6 months after graduation from medical school.
The size of the hospital did not appear to impact on the level of confidence.
For the breakdown by hospital click on the following:
Survey Two : What is it like on nights that you work?
Survey 2 was undertaken to identify what factors exist that provide a hospital environment of confidence or lack of confidence. The survey asked whether there were any
assessment or audit processes in place in hospitals to monitor RMO safety and whether the hospitals provided adequate
and appropriate orientation to nights. These results were summarised across the various DHBs.
Is there an assessment or audit process in place that monitors safety for RMOs and their patients on nights?
An almost universal deficit was identified across DHBs: the absence of an assessment/audit process in place to monitor safety for RMOs and their patients on nights. Only 0.8% of respondents were aware of such a process being in place to monitor RMOs and their patient’s safety at night.
The second almost universal deficit: provision of adequate and appropriate orientation to nights. No DHB was universally felt to provide adequate orientation (Nelson Marlborough, Waikato, Waitakere, Wairarapa and West Coast Hospitals were rated the poorest DHBs in this respect).
*How did your DHB rank in other parameters? Go to “Hot Topics” on this website to view the summarised results for each DHB.
The survey findings made clear that most RMOs do not feel confident for first year house officers to work nights earlier than 6 months from when they graduate medical school. It was also clear that many DHBs do not have in operation processes aimed at managing RMO and their patient’s safety on night duty and do not provide house officers with adequate and appropriate night duty orientation.
In addition, the survey findings made clear that there is a lack of satisfactory hospital processes in place to identify and
confidently manage risks associated with RMOs performing night duty. The findings of the two NZRDA surveys are supportive
of the need to have in place genuine documented and audited standards in order to provide for a ‘checks and balances’ process. Such a process in place will enhance the confidence of the patient, doctor and hospital (see Schedule 7 of the MECA).
It has been proposed to have a more tailored approach with respect to determining whether or not it is appropriate for an RMO to start to perform night duty. Instead of the previous system which relied on a generic weeks or months time-based threshold, a set of quality and safety criteria should be in place and must be consistently met by both the hospital and RMO.
As a result of recent MECA bargaining the current position regarding first years on nights is that the 3 and 6 months provisions remain unless you agree that certain safety protocol parameters have been met and continue to be met (see clause 6.5, Schedule 7 and the Guidelines of the new MECA). Annual review is required and if the provisions are not met the 3 and 6 month provisions come back into force. NZRDA will carry out a survey next year to see if the DHBs have improved their position.
It is essential that written documentation surrounding each parameter and DHBs facilities and support is readily available to review and undergo reassessment in November when first years start work and in June ahead of the particularly busy and often pressured winter months of each year.