The new education frontier: clinical teaching at night

Implementation of a Night-Float Curriculum: Impact on Intern Confidence over Time

OBJECTIVES

Formal nighttime education is becoming increasingly necessary as more internal medicine (IM) residency programs adopt night-float rotations (NFRs); however, the efficacy of an NFR curriculum throughout an academic year and which topics in an NFR curriculum increase trainee confidence are unknown. We implemented a 12-module, self-paced NFR curriculum for 76 postgraduate year-1 residents at an academic IM residency program. We evaluated the impact of this curriculum on postgraduate year-1 residents' clinical confidence, as well as longitudinal efficacy of the curriculum.

METHODS

Night-float interns' (NFIs) clinical confidence regarding specific curricular topics was evaluated overall and during specific timeframes within the academic year. Pre- and post-NFR surveys using Likert scales for each topic were administered to NFIs from June 24, 2020 to March 2, 2021, representing 32 week-long NFR cycles.

RESULTS

NFIs' pre- and postrotation confidence in managing clinical scenarios significantly improved for all 12 topics in the NFR curriculum. The NFR curriculum resulted most significantly in improved confidence during the first 4 months of the academic year, with 11 of 12 curricular topics reaching the threshold for statistical significance. Modules on altered mental status, hypotension, narrow-complex tachyarrhythmias, new fever, and sepsis and antibiotic escalation maintained their efficacy for the longest periods of time.

CONCLUSIONS

It may be especially important to emphasize an NFR curriculum at the beginning of the academic year. IM residency programs also may wish to carefully consider that certain topics may maintain their efficacy throughout the year, whereas other topics should potentially be replaced with more complex modules as the academic year progresses.

A Prospective Trial of an In-house Overnight Fellow Rotation in the Intensive Care Unit

Background

Although previous studies in academic intensive care units (ICUs) have found no improvement in patient care outcomes with in-house overnight attending physician coverage compared with home call coverage, the effect of in-house supervision on trainee education and well-being is less clear. In addition, no studies have examined the effect of in-house coverage by fellow physicians overnight.

Objective

What is the impact of an in-house overnight critical care fellow on resident, fellow, and attending perception of patient safety, house staff education, and house staff well-being?

Methods

A prospective trial alternating 2-week periods of in-house overnight critical care fellow coverage with 2-week periods of home call coverage was performed in our tertiary medical ICU. Residents, fellows, and attendings were surveyed to evaluate perceptions of the night fellows' impact on patient care, communication, supervision, educational experience, autonomy, well-being, and job satisfaction.

Results

Over the 6-month study period, surveys were sent to 83 residents, 22 fellows, and 23 attendings, with completion by 56 (67%), 22 (100%), and 16 (70%), respectively. Overall, 89% of residents, 68% of fellows, and 81% of attendings reported perceived improvements in patient care with an in-house fellow. The in-house fellow was also associated with improved well-being in 79% of residents and 73% of fellows, and 82% of residents felt that it positively impacted education.

Conclusion

As compared with the traditional home call system, an in-house night critical care fellow can improve the perception of patient care, trainee well-being, and education in a tertiary ICU at an academic hospital.

Increasing the Frequency of Night Float Teaching with a Daily Management System: Where Medical Education Meets Quality Improvement

Daytime resident rotations have a well-established system for incorporating didactic teaching into clinical rotations. However, how to create and sustain a parallel system of didactics for night rotations is less established. We aimed to use Lean methodology to increase the frequency of didactic teaching at night and improve house staff perception of the educational value of night float. Our educational intervention was comprised of the implementation of a daily management system (DMS) with a visual dashboard to track whether evening report was held and a repository of prepared lectures. With this intervention, the rate of evening report tripled from 18 to 55%, demonstrating that a daily management system can be successfully used to improve performance of an educational outcome by increasing attending and resident engagement on night float.

Exploring the meaning of night shift placement in nursing education: A European multicentre qualitative study

BACKGROUND

An appropriate clinical learning environment has been identified as pivotal in nursing undergraduate education and should be planned responsibly. Specifically, night shifts placements have been documented as an important opportunity for developing a full understanding of the nursing profession and the whole process of nursing care. However, night shifts during placement have been reported to be stressful and anxiety-provoking, so their usefulness for nursing students is still debated.

OBJECTIVES

To elicit nursing students' perceptions of night shift placement through metaphors, with the aim of discussing the pedagogical and ethical implications.

DESIGN

A descriptive qualitative study was performed based on metaphors collected in an international cross-sectional study in 2016.

SETTINGS

A network comprising five Bachelor of Nursing Science degrees located in the Czech Republic, Italy, Poland, Portugal, and Slovakia was established.

METHODS

A total of 907 out of 1347 eligible nursing students from the five European countries described their learning experience on night shifts using a metaphor.

RESULTS

Overall, 288/907 (31.7%) metaphors emerged as being negative-oriented and 137/907 (15.1%) as positive, while the remaining students (482; 53.2%) did not report any metaphors. In all five countries, negative metaphors prevailed: 'Wasting time' (37/288), 'Useless' (32/288) and 'Handyman' (22/288) were the most negative reported metaphors on working a night shift. However, doing a night shift is also perceived as a 'Learning opportunity' (22/137), a 'New experience' (20/137) and an 'Opportunity to socialize with the profession' (14/137) as underlined by the positive metaphors.

CONCLUSIONS

Students perceive night shift placements mainly as a negative experience, which has little to do with education. While planning night shift placements, nursing educators should responsibly consider the whole process of education, analysing not only the learning outcomes that should be achieved but also the position of students and their experience as a person. Clinical mentoring can be a key resource in supporting students in transforming their night shift placements' experiences into a more meaningful or worthwhile experience. Moreover, night shifts should be offered to more experienced students, independent in their self-learning processes and capable of managing the limited possibility of interacting with other team members and patients.

Midnight Report: A Novel Faculty-Guided Night Curriculum to Enhance Resident Nighttime Education

OBJECTIVES

A large discrepancy exists in resident educational activities between daytime and nighttime medical rotations. The Accreditation Council for Graduate Medical Education duty-hour regulations led to the increased adoption of the dedicated nighttime rotation called night float. Nighttime education has largely been negatively perceived by night float medical residents. Although there have been attempts to improve nighttime education, none of the initiatives included faculty-guided structured night curriculum. Our objective was to improve resident experience with and perception of nighttime education by implementing a structured, faculty-guided, nighttime educational curriculum.

METHODS

This was an assessment of an educational initiative at a single academic medical center, Virginia Commonwealth University Health System. The internal medicine residency program implemented a teaching nocturnist program in 2013 and a novel faculty-guided nighttime teaching curriculum in 2016 called midnight report. We then evaluated resident experience with and perception of nighttime education at our institution using anonymous free-response surveys for the academic year July 2016-June 2017.

RESULTS

Of the 142 eligible residents, 95 (67%) responded to the survey. The majority of the residents (54%-77%) positively perceived their experience of the nighttime educational environment during their night float rotation after implementation of the teaching nocturnist program and midnight report.

CONCLUSIONS

Compared with the published literature reporting negative perceptions of the nighttime educational environment by residents at different academic centers, our results showed that the majority of our residents positively perceived the impact of our new faculty-guided nighttime educational curriculum.

Night shifts as a learning experience among nursing students across Europe: Findings from a cross-sectional survey

BACKGROUND

Organising clinical placements during nights has been reported as an additional opportunity to introduce students to the whole picture of their future responsibilities. However, studies in this field are still lacking.

OBJECTIVES

To describe and compare (a) the night shift experience of nursing students across Europe, (b) the patient-related problems that they face during night shifts, (c) the night care activities nursing students are called to perform, and (d) the perceived effects of night shift work on learning outcomes.

DESIGN

A cross-sectional study, 2016.

SETTINGS

Five European countries: Czech Republic, Italy, Poland, Portugal, and Slovakia.

PARTICIPANTS

Nursing students from nine Bachelor of Nursing Science degree programmes attending night shifts during their study period and who were willing to participate were included. A total of 907 out of 1347 (67.3%) eligible students participated.

METHODS

Questionnaire based on the available literature, translated into five languages.

RESULTS

The duration of the night shift was from an average of 9.8 (CI 95% 9.6-10.0) in Italy to 11.9 (CI 95% 11.7-12.0) in the Czech Republic. Students faced mainly patients' pain without statistical differences across countries (at the overall level, 717 out of 907; 79%; p = .318). However, significant differences in the tasks performed during nights emerged: Polish students reported being more involved in performing basic nursing care (72; 93.5%) as compared to other countries (e.g., Portuguese students 337; 84.9%), (p = .02). Overall, an average of 28.9% of the night shift time was reported to be free of commitments, with higher values among Polish (38%, CI 95% 33.6-42.3) and Slovakian students (33.4%, CI 95% 30.6-36.3) and lower values among Czech Republic students (20.4%, CI 95% 17.6-23.2) (p .001). Boredom and satisfaction were reported as the main feelings during night shifts, with significant differences (p .001) across countries. Students reported significant different effects (p .001) of night shifts on their understanding of a nurse's role (from 5.2 out of 10 in Poland to 6.5 in the Czech Republic), on the understanding of the continuity of nursing care (from 5.2 in Poland to 6.7 in Italy), and on having a relationship with the clinical mentors (from 2.7 and 4.2 in Poland and the Czech Republic, respectively, to 6.9 in Italy).

CONCLUSIONS

Night shifts can be both a valuable and a non-valuable learning experience, suggesting the need to carefully plan and assess their effectiveness at the unit level.

Shining a Light on Overnight Education: Hospitalist and Resident Impressions of the Current State, Barriers, and Methods for Improvement

INTRODUCTION

Restrictions on resident work hours and increased requirements for resident supervision have led to night float rotations overseen by overnight hospitalists (nocturnists). The educational value of night float rotations for residents has traditionally been low and studies have yet to elucidate the optimal role of nocturnists in resident education.

METHODS

We performed a cross-sectional survey of all residents within our training program and attending hospitalists in the department of medicine at our three teaching medical centers. Questions sought to investigate the current state of overnight education within an internal medicine residency program, understand barriers to overnight education, and define best practices for nighttime teaching.

RESULTS

Both attending and resident physicians reported low satisfaction with the current state of overnight education, while simultaneously expressing high levels of interest in performing and receiving dedicated nighttime teaching. Attending and resident physicians identified similar barriers to overnight teaching (clinical work, time coordination, provider fatigue) and agreed on the ideal format for overnight didactics (case-based, chalk-talk, 20-minute duration between 10 pm to 2 am).

CONCLUSION

Our study identifies a desire by both faculty and trainees for increased overnight teaching and offers a simple initial framework for programs to improve overnight housestaff education utilizing nocturnist providers.

Supervision and autonomy of ophthalmology residents in the outpatient Clinic in the United States: a survey of ACGME-accredited programs

BACKGROUND

The development and demonstration of incremental trainee autonomy is required by the ACGME. However, there is scant published research concerning autonomy of ophthalmology residents in the outpatient clinic setting. This study explored the landscape of resident ophthalmology outpatient clinics in the United States.

METHODS

A link to an online survey using the QualtricsTM platform was emailed to the program directors of all 115 ACGME-accredited ophthalmology programs in the United States. Survey questions explored whether resident training programs hosted a continuity clinic where residents would see their own patients, and if so, the degree of faculty supervision provided therein. Metrics such as size of the resident program, number of faculty and clinic setting were also recorded. Correlations between the degree of faculty supervision and other metrics were explored.

RESULTS

The response rate was 94%; 69% of respondents indicated that their trainees hosted continuity clinics. Of those programs, 30% required a faculty member to see each patient treated by a resident, while 42% expected the faculty member to at least discuss (if not see) each patient. All programs expected some degree of faculty interaction based upon circumstances such as the level of training of the resident or complexity of the clinical situation. 67% of programs that tracked the contribution of the clinic to resident surgical caseloads reported that these clinics provided more than half of the resident surgical volumes. More ¾ of resident clinics were located in urban settings. The degree of faculty supervision did not correlate to any of the other metrics evaluated.

CONCLUSIONS

The majority of ophthalmology resident training programs in the United States host a continuity clinic located in an urban environment where residents follow their own patients. Furthermore, most of these clinics require supervising faculty to review both the patients seen and the medical documentation created by the resident encounters. The different degrees of faculty supervision outlined by this survey might provide a useful guide presuming they can be correlated with validated metrics of educational quality. Finally, this study could provide an adjunctive resource to current international efforts to standardize ophthalmic residency education.

Impact of an Overnight Internal Medicine Academic Hospitalist Program on Patient Outcomes

BACKGROUND

Many academic hospitals have implemented overnight hospitalists to supervise house staff and improve outcomes, but few studies have described the impact of this role.

OBJECTIVE

To investigate the effect of an overnight academic hospitalist program on patient-level outcomes. Secondary objectives were to describe the program's revenue generation and work tasks.

DESIGN

Retrospective interrupted time-series analysis of patients admitted to the medicine service before and after implementation of the program.

PARTICIPANTS

All patients aged 18 and older admitted to the acute or intermediate care units between 7:00 p.m. and 6:59 a.m. during the period before (April 2011-August 2012) and after (September 2012-April 2014) program implementation.

INTERVENTION

An on-site attending-level physician directly supervising medicine house staff overnight, providing clinical care during high-volume periods, and ensuring safe handoffs to daytime providers.

MAIN MEASURES

Primary outcomes included in-hospital mortality, 30-day hospital readmissions, length of stay, and upgrades in care on the night of admission and during hospitalization. Multivariable models estimated the effect on outcomes after adjusting for secular trends. Revenue generation and work tasks are reported descriptively.

KEY RESULTS

During the study period, 6484 patients were admitted to the medicine service: 2722 (42 %) before and 3762 (58 %) after implementation. No differences were found in mortality (1.1 % vs. 0.9 %, p=0.38), 30-day readmissions (14.8 % vs. 15.6 %, p=0.39), mean length of stay (3.09 vs. 3.08 days, p=0.86), or upgrades to intensive care on the night of admission (0.4 % vs. 0.7 %, p=0.11) or during hospitalization (3.5 % vs. 4.2 %, p=0.20). During the first year, hospitalists billed 1209 patient encounters (3.3/shift) and 63 procedures (0.2/shift), and supervised 1939 patient admissions (6.12/shift) while supervising house staff 3-h/shifts.

CONCLUSIONS

Implementation of an overnight academic hospitalist program showed no impact on several important clinical outcomes, and revenue generation was modest. As overnight hospitalist programs develop, investigations are needed to delineate the return on investment and focus on other outcomes that may be more sensitive to change, such as errors and provider/patient satisfaction.

Implementation of a Novel, Resident-Led, Nocturnal Curriculum

BACKGROUND

Duty hour restrictions for resident physicians have led to radical changes in graduate medical education, including a shift to more night float rotations. These rotations have been viewed by residents as predominantly service focused with little opportunity for formalized education.

OBJECTIVE

To develop and deliver a resident-driven, nocturnal curriculum to enhance the educational content and value of night float rotations.

METHODS

The Hospital of the University of Pennsylvania is a 695-bed, tertiary care academic medical center. Upper-level internal medicine residents developed and peer-reviewed case-based scripts designed to be delivered in 15- to 20-minute teaching sessions. We evaluated the quality of teaching using anonymous, free-response surveys.

RESULTS

Twenty-four scripts were developed that explored the differential diagnoses, diagnostic pitfalls, and management of clinical problems that interns frequently encounter on night float rotations. Of 83 eligible residents, 45 (54%) responded to the survey. Teaching occurred an average of 4 nights per week and was uniformly viewed as high yield and topical by night float interns.

CONCLUSIONS

A resident-driven, nocturnal curriculum was implemented through the use of case-based teaching scripts, allowing for delivery of a standardized curriculum that capitalizes on the teaching opportunities afforded by the night shift. This intervention may serve as a model for nocturnal education in other departments and institutions.

Strategies for improving education on night-float rotations: a review

INTRODUCTION

Night float rotations (NF) have been developed as a means of achieving duty hour compliance among residency programs. These were initially pioneered in the late 1980s as a response to fatigue among residents. The NF experience had its genesis in work hour reform and providing hospital service moreso than education. However, as NF has become ubiquitous, it is not clear that we have adequately revisited the educational component of this experience. We systematically reviewed the literature on educational aspects of a night float experience.

METHODS

PubMed searches were conducted for the terms "night float" and "night, curriculum, residency." This yielded 320 articles. Concerning educational aspects of the NF reduced the total to 134 articles. Editorials and those concerning procedural volumes or handoffs were also excluded. Most articles used surveys as methodology, so formal statistical analysis was not possible.

RESULTS

In total, 42 independent articles were found that directly related to the educational value of NF rotations, spanning all of the medical disciplines. Each study was searched for interventions or strategies that may affect the educational value of the NF experience. These may be grouped broadly into 3 discrete categories: (1) attention to the sleep-wake cycle, (2) addition of personal to augment the experience and (3) incorporation of formal educational elements to night rotations. A summary of these strategies is presented in Table 3.

CONCLUSIONS

NF is a practical solution to the challenge of work hour restrictions in residency, and is likely to persist in the future. Some educational issues arise due to the altered physiology of a reversed sleep-wake cycle, which may be best resolved through structural limitations of the night rotations. Other deficiencies are based on lack of interactions, for which there are strategies to improving the NF educational experience.