European Working Time Directive and doctors' health: a systematic review of the available epidemiological evidence

Donor Lung Preservation at 10°C: Clinical and Logistical Impact

INTRODUCTION

Cold static donor lung preservation at 10°C appears to be a promising method to safely extend the cold ischemic time (CIT) and improve lung transplant (LTx) logistics.

METHODS

LTx from November 2021 to February 2023 were included in this single institution, prospective, non-randomized study comparing prolonged preservation at 10°C versus standard preservation on ice. The inclusion criteria for 10°C preservation were suitable grafts for LTx without any donor retrieval concerns.

PRIMARY ENDPOINT

primary graft dysfunction (PGD) grade-3 at 72-h. Secondary endpoints: clinical outcomes, cytokine profile and logistical impact.

RESULTS

Thirty-three out of fifty-seven cases were preserved at 10°C. Donor and recipient characteristics were similar across the groups. Total preservation times (h:min) were longer (p<0.001) in the 10°C group [1st lung: median 12:09 (IQR 9:23-13:29); 2nd: 14:24 (12:00-16:20)] vs. standard group [1st lung: median 5:47 (IQR 5:18-6:40); 2nd: 7:15 (6:33-7:40)]. PGD grade-3 at 72-h was 9.4% in 10°C group vs. 12.5% in standard group (p=0.440). Length of mechanical ventilation (MV), ICU and hospital stays were similar in both groups. Thirty and ninety-day mortality rates were 0% in 10°C group (vs. 4.2% in standard group). IL-8 concentration was significantly higher 6-h post-LTx in the standard group (p=0.025) and IL-10 concentration was increased 72-h post-LTx in the 10°C group (p=0.045).

CONCLUSIONS

Preservation at 10°C may represent a safe and feasible strategy to intentionally prolong the CIT. In our center, extending the CIT at 10°C may allow for semi-elective LTx and improve logistics with similar outcomes compared to the current standard preservation on ice.

"Multivariate analysis of the impact of sleep and working hours on medical errors: a MICE approach"

BACKGROUND

The main objective of this study was to describe the relationship between working conditions, sleep and psycho-affective variables and medical errors.

METHODS

This was an observational, analytical and cross-sectional study in which 661 medical residents answered questionnaires about working conditions, sleep and psycho-affective variables. Actigraphic sleep parameters and peripheral temperature circadian rhythm were measured in a subgroup of 38 subjects. Bivariate and multivariate predictors of medical errors were assessed.

RESULTS

Medical residents reported working 66.2 ± 21.9 weekly hours. The longest continuous shift was of 28.4 ± 10.9 h. They reported sleeping 6.1 ± 1.6 h per day, with a sleep debt of 94 ± 129 min in workdays. A high percentage of them reported symptoms related to psycho-affective disorders. The longest continuous shift duration (OR = 1.03 [95% CI, 1.00-1.05], p = 0.01), working more than six monthly on-call shifts (OR = 1.87 [95% CI, 1.16-3.02], p = 0.01) and sleeping less than six hours per working day (OR = 1.66 [95% CI, 1.10-2.51], p = 0.02) were independently associated with self-reported medical errors. The report of medical errors was associated with an increase in the percentage of diurnal sleep (2.2% [95% CI, 0.1-4.3] vs 14.5% [95% CI, 5.9-23.0]; p = 0.01) in the actigraphic recording.

CONCLUSIONS

Medical residents have a high working hour load that affect their sleep opportunities, circadian rhythms and psycho-affective health, which are also related to the report of medical errors. These results highlight the importance of implementing multidimensional strategies to improve medical trainees' sleep and wellbeing, increasing in turn their own and patients' safety.

Resident physician duty hours, resting times and European Working Time Directive compliance in Spain: a cross-sectional study

BACKGROUND

There is a growing interest in understanding the impact of duty hours and resting times on training outcomes and the well-being of resident physicians. However, to this date no state-wide analysis exists in any European country.

OBJECTIVES

Our aim is to describe the shift work scheduling and to detail the degree of compliance with the Spanish legislation and the European Working Time Directive (EWTD) of Spanish resident physicians, focusing on territorial and specialty distribution.

MATERIAL AND METHODS

A descriptive cross-sectional analytical study was designed through an online survey adapted from the existing literature.

RESULTS

Out of the 2035 surveyed resident physicians undergoing PGT in Spain, 80.49% exceeded the 48 h per week limit set by the EWTD and 13% of them did not rest after a 24-h on-call shift. The mean number of on-call shifts in the last 3 months was 15.03, with the highest mean reported in Asturias, La Rioja, and Extremadura. 51.6% of respondents had a day-off after a Saturday on-call shift. Significant differences are observed by region and type of specialty.

CONCLUSION

Resident physicians in Spain greatly exceed the established 48 h/week EWTD limit. Likewise, non-compliance with labor regulations regarding mandatory rest after on-call duty and minimum weekly rest periods are observed.

Changes in weekly working hours, proportion of doctors with hours above the limitations of European Working Time Directive (EWTD) and time spent on direct patient care for doctors in Norway from 2016 to 2019: a study based on repeated surveys

OBJECTIVES

To compare the total weekly working hours, proportions with work hours above the limitations of European working time directive (EWTD) and time spent on direct patient care in 2016 and 2019 for doctors working in different job positions in Norway.

DESIGN

Repeated postal surveys in 2016 and 2019.

SETTING

Norway.

PARTICIPANTS

Representative samples of doctors; the response rates were 73.1% (1604/2195) in 2016 and 72.5% (1511/2084) in 2019.

MAIN OUTCOME MEASURES

Self-reported weekly working hours, proportions with hours above the limitations of EWTD defined as >48 hours/week and time spent on direct patient care.

ANALYSES

Linear mixed models with estimated marginal means and proportions.

RESULTS

From 2016 to 2019, the weekly working hours increased significantly for male general practitioners (GPs) (48.7 hours to 50.9 hours) and male hospital doctors in leading positions (48.2 hours to 50.5 hours), and significantly decreased for female specialists in private practice (48.6 hours to 44.9 hours). The proportion of time spent on direct patient care was noted to be similar between genders and over time. In 2019, it was higher for specialists in private practice (66.4%) and GPs (65.5%) than for doctors in other positions, such as senior hospital consultants (43.5%), specialty registrars (39.8%) and hospital doctors in leading positions (34.3%). Working >48 hours/week increased significantly for both male and female GPs (m: 45.2% to 57.7%; f: 27.8% to 47.0%) and hospital doctors in leading positions (m: 34.4% to 57.1%; f: 17.4% to 46.4%), while it significantly decreased for female specialty registrars (13.2% to 6.9%).

CONCLUSIONS

Working hours increased significantly for GPs and hospital doctors in leading positions from 2016 to 2019, resulting in increased proportions of doctors with work hours above the EWTD. As work hours above the EWTD can be harmful for health personnel and for safety at work, initiatives to reduce long working weeks are needed.

[Physician working hours and effects on health, satisfaction and healthcare]

Changes in the working environment with respect to innovative working time models are also increasingly affecting patient care. The number of physicians working part-time, for example, is continuously rising. At the same time, a general increase in chronic diseases and multimorbid conditions as well as the growing shortage of medical staff, leads to more workload and dissatisfaction among this profession. This short overview summarizes the current study situation and associated consequences regarding working hours of physicians and gives a first explorative overview of possible solutions.

Work like a Doc: A comparison of regulations on residents' working hours in 14 high-income countries

BACKGROUND

Medical residents work long, continuous hours. Working in conditions of extreme fatigue has adverse effects on the quality and safety of care, and on residents' quality of life. Many countries have attempted to regulate residents' work hours.

OBJECTIVES

We aimed to review residents' work hours regulations in different countries with an emphasis on night shifts.

METHODS

Standardized qualitative data on residents' working hours were collected with the assistance of experts from 14 high-income countries through a questionnaire. An international comparative analysis was performed.

RESULTS

All countries reviewed limit the weekly working hours; North-American countries limit to 60-80 h, European countries limit to 48 h. In most countries, residents work 24 or 26 consecutive hours, but the number of long overnight shifts varies, ranging from two to ten. Many European countries face difficulties in complying with the weekly hour limit and allow opt-out contracts to exceed it.

CONCLUSIONS

In the countries analyzed, residents still work long hours. Attempts to limit the shift length or the weekly working hours resulted in modest improvements in residents' quality of life with mixed effects on quality of care and residents' education.

Analysis of one- versus two-staged reconstruction in head and neck cancer patients: What are the benefits?

In head and neck oncology, surgical treatment frequently results in microvascular reconstruction. Oncologic resection followed by immediate reconstruction is often associated with prolonged working and surgical duration, challenging a surgeon's concentration level and potentially worsening patient outcome. To improve the surgeon's performance and to reduce risk of potential complications, we implemented a two-stage procedure in patients with head and neck cancer. This study critically analyzed the surgical outcomes, organizational benefits, and investigated job satisfaction among affected health care professionals. A retrospective data analysis of patients who had undergone microvascular reconstruction after oncologic head and neck surgery between 2010 and 2021 included 33 patients (n = 33). Twenty patients underwent single-stage reconstruction (group 1, n = 20) and 13 patients underwent two-stage reconstruction (group 2, n = 13) with 12.2 (± 7.4) days between surgeries. The mean surgical duration, and mean start and end time of the reconstructive surgery component differed significantly (p = 0.002). The mean total complication rate (p = 0.58) did not differ significantly, although a trend toward higher demands for blood products was observed in group 1. There was no significant difference in five-year survival (p = 0.28). A questionnaire on subjective work performance was answered by the affected health care professionals (n = 34) and it revealed that 88% preferred long surgeries to be scheduled first and that 97% work most efficiently in the morning. In conclusion, two-stage reconstruction is a suitable option in selected head and neck cancer patients offering the possibility of optimizing preoperative planning and organization. This may result in regular working hours, reduced surgeon fatigue, and improved job satisfaction without compromising patient outcomes or survival.

The prevalence and factors associated with anxiety symptoms among resident physicians in Oman: a cross-sectional study

Background

Anxiety disorders are a significant factor associated with physician burnout and poor patient care, reported to have a significant frequency among the youth in the Middle East. However, to date, no study has explored the prevalence of anxiety among resident physicians in the Arabian Gulf country of Oman. This cross-sectional study, conducted among a random sample of residents affiliated with the Oman Medical Specialty Board, aimed to examine the frequency and factors associated with anxiety symptoms among them. Participants were asked to complete the General Anxiety Disorder Assessment (GAD-7) to assess anxiety, as well as a socio-demographic questionnaire.

Results

In a total of 251 residents, the prevalence of anxiety was 14.7% (GAD-7 cut-off score ≥ 10). More than 60% of the respondents were female (68.9%). The age breakdown ranged from 25 to 30 years old (66.5%) and the majority were married (64.9%). More than 70% of respondents attended at least 5 shifts in their weekly schedule and received at least 5 on-call shifts from the hospital per week. Logistic regression showed that residents with chronic disease were 2.5 times (95% CI 1.36–4.72, p = 0.003) more likely to have anxiety than those without them. Those residents who did not exercise were 2.1 times (95% CI 1.04–4.46, p = 0.038) more likely to have anxiety than those who exercise often or regularly. Residents who received 6 or more on-calls from the hospital were 2.6 times (95% CI 1.35–5.25, p = 0.005) more likely to have anxiety than those who received 5 or fewer on-calls in a month.

Conclusions

The factors seemingly responsible for anxiety symptoms in this sample of resident physicians are those that are typically associated with poor work-life balance and unhealthy lifestyles. Pending further scrutiny, these results could be used to lay the groundwork for the identification of those who will require more protracted help during their training in Oman and in other culturally similar Middle Eastern countries.

It's about time - Associations between working time dimensions and well-being of physicians

Several working time characteristics have been linked to negative outcomes for health personnel. The aim was to investigate the impact of working time dimensions on well-being in a representative sample of physicians. Data was collected during a baseline study. Linear regression analysis was performed on a sample including 669 physicians of different medical specialties. The questionnaire included sociodemographic characteristics and information on working time dimensions (e.g. shift work). In addition, job satisfaction, workload and self-reported health were explored. The majority were female, working in internal medicine and the mean age was 42.5 years. Findings reveal that overtime hours (β = -0.478, p = .011) and autonomy (β = 0.444, p < .001) were significantly associated with job satisfaction. The number of free weekends (β = -2.622, p = .005) and autonomy significantly predicted personal (β = -6.153, p < .001), work-related (β = -6.597, p < .001) and patient-related workload (β = -4.731, p < .001). Overall health was only affected by working time autonomy (β = 3.804, p < .001). In conclusion, the study suggests that working time characteristics have negative consequences for well-being and need to be addressed to ensure health, performance and safety of physicians.

Nigerian resident doctors' work schedule: A national study

Background and Aim

The deleterious effects of Resident Doctors' (RDs') long duty hours are well documented. Driven by concerns over the physician's well-being and patient safety, the RDs' duty hours in many developed countries have been capped. However, in Nigeria and many African countries, there are no official regulations on work hours of RDs. This study evaluated the work schedule of Nigerian RDs and its impact on their wellbeing and patient safety.

Subjects and Methods

A national survey of 1105 Nigerian RDs from all specialties in 59 training institutions was conducted. With an electronic questionnaire designed using Google Forms, data on the work activities of RDs were obtained and analyzed using the IBM SPSS software version 24. The associations were compared using Chi-squared test with the level of significance set at < 0.05.

Results

The mean weekly duty hours (h) of the RDs was 106.5 ± 50.4. Surgical residents worked significantly longer hours than non-surgical residents (122.7 ± 34.2 h vs 100.0 ± 43.9 h; P < 0.001). The modal on-call frequency was two weekday on-calls per week (474, 42.9%) and two weekend on-calls per month (495, 44.8%), with the majority of RDs working continuously for up to 24 hours during weekday on-calls (854, 77.3%) and 48-72 hours during weekend on-calls (568, 51.4%), sleeping for an average of only four hours during these on-calls. The majority of RDs had post-call clinical responsibilities (975, 88.2%) and desired official regulation of duty hours (1,031, 93.3%).

Conclusion

The duty hours of Nigerian RDs are currently long and unregulated. There is an urgent need to regulate them for patient and physician safety.

Working hours, on-call shifts, and risk of occupational injuries among hospital physicians: A case-crossover study

Objective

To investigate the association of hospital physicians’ working hours and on‐call shifts with the risk of occupational injuries.

Methods

In this nested cohort study of 556 Finnish hospital physicians, we linked electronic records from working‐hour and on‐call duty payroll data to occupational injury data obtained from the Finnish Workers’ Compensation Center for the period 2005–2019. We used a case‐crossover design with matched intervals for a 7‐day ‘case window’ immediately prior to occupational injury and a ‘control window’ 7 days prior to the beginning of the case window, and analyzed their associations using conditional logistic regression models.

Results

We noted 556 occupational injuries, 281 at the workplace and 275 while commuting. Having three to four long (>12 h) work shifts on the preceding 7 days was associated with a higher probability of an occupational injury (odds ratio [OR] 2.14, 95% confidence interval [CI] 1.11, 4.09), and the OR for three to four on‐call shifts was 3.54 (95%CI 2.11, 5.92) in comparison to having none of these work shift types. A higher number of several consecutive working days was associated with a higher probability of injury in a dose‐response manner. Moreover, increasing weekly working hours was associated with an increased likelihood of injury (OR 1.03, 95%CI 1.01, 1.04), whereas the number of normal (≤12 h) work shifts reduced this likelihood (OR 0.79, 95%CI 0.64, 0.98).

Conclusions

Our findings suggest that accumulated working‐hour load, as opposed to single, very long (>24 h) work shifts, may increase the risk of occupational injury among hospital physicians.

Association Between Physicians' Workload and Prescribing Quality in One Tertiary Hospital in China

BACKGROUND

Alarming increasing trends in physician workload have attracted much attention in recent years. Heavy workload may compromise the quality of medication use. Previous studies have identified a series of factors contributing to inappropriate prescribing; however, there is no demonstrated evidence supporting an association between workload and the appropriateness of physicians' prescriptions in China. This study aimed to investigate the relationship between physician workload and prescription quality in a tertiary hospital in Beijing, China.

METHODS

Our study was a single-center, retrospective study, with all outpatient electronic health records extracted from hospital information system of a tertiary hospital in Beijing from July 1 to November 30, 2015. We used outpatient volume in each 5-hour shift as the measure of physician workload. The evaluation of prescribing quality was based on the Rational Drug Use System. Generalized linear models with a γ distribution and a log link were used to explore factors associated with inappropriate prescribing, and we undertook a series of robustness tests with respect to different exclusion criteria.

RESULTS

A total of 457,784 prescriptions from 502 physicians were included in the study. Physicians had an average workload of 34.3 (±19.8) patients per shift, and the mean rate of inappropriate prescribing per shift was 14.1% (±14.6%). Higher rates of inappropriate prescribing were associated with heavier workloads (P < 0.001). Physicians who worked in the afternoon, chief physicians, those working in surgical department, males, and those with more than 20-year experience had higher rates of inappropriate prescribing with increasing workload.

CONCLUSIONS

Heavier workload was associated with higher risk of prescribing inappropriately. It requires great efforts to determine optimal physician workloads and mitigate the potential adverse effects on the prescription quality.

Working hours are closely associated with depressive mood and suicidal ideation in Korean adults: a nationwide cross-sectional study

Long working hours have been presumed to negatively influence health. However, evidence is lacking regarding any associations of working hours with depressive mood or suicidal ideation. We investigated the relationships of working hours with depressive mood and suicidal ideation in a representative sample of the Korean general population. We analyzed data collected by the Korea National Health and Nutrition Examination Surveys VI and VII (2013–2018). Depressive mood and suicidal ideation were identified through self-reporting. We divided participants into four groups according to weekly working hours: 30–40, 41–50, 51–60, and > 60 h/week. Sampling weights were applied to obtain estimates for the general Korean population. We analyzed 14,625 participants, of whom 5383 (36.8%), 4656 (31.8%), 2553 (17.5%), and 2033 (13.9%) worked 30–40, 41–50, 51–60, and > 60 h/week, respectively. In these groups, 3.6%, 4.4%, 5.2%, and 6.3% of the participants reported depressive mood, while 1.8%, 1.9%, 2.2%, and 3.6% reported suicidal ideation. In multiple regression analyses, compared with the 30–40 h/week group, the adjusted odds ratios of the 41–50, 51–60, and > 60 h/week groups for depressive mood were 1.35 (1.08–1.69), 1.5 (1.14–1.97), and 1.6 (1.19–2.14). A similar trend was evident for suicidal ideation (odds ratios 1.16 [0.82–1.63], 1.48 [0.99–2.21], and 2.29 [1.53–3.42]). Long working hours are significantly associated with depressive mood and suicidal ideation.

Association of working hour characteristics and on-call work with risk of short sickness absence among hospital physicians: A longitudinal cohort study

Physicians often work long hours and on-call shifts, which may expose them to circadian misalignment and negative health outcomes. However, few studies have examined whether these working hour characteristics, ascertained using objective working hour records, are associated with the physicians' risk of sickness absence. We investigated the associations of 14 characteristics of payroll-based working hours and on-call work with the risk of short sickness absence among hospital physicians. In this cohort study, 2845 physicians from six Finnish hospital districts were linked to electronic payroll-based records of daily working hours, on-call duty and short (1-3 days) sickness absence between 2005 and 2019. A case-crossover design was applied using conditional logistic regression with the 28 day case and control windows to estimate odds ratios (ORs) and 95% confidence intervals (CI) for short sickness absence. After controlling for weekly working hours and the number of normal (≤12 h) shifts, a higher number of long (>12 h) shifts (ORs for ≥5 versus none: 2.54, 95% CI 1.68-3.84), very long (>24 h) shifts (ORs for ≥5 versus none: 2.62, 95%CI 1.61-4.27), and on-call shifts (OR for ≥5 versus none: 2.15, 95% CI 1.44-3.21) and a higher number of short (<11 h) shift intervals (OR for ≥5 versus none: 12.61, 95% CI 8.88-17.90) were all associated with the increased risk of short sickness absence. These associations did not differ between male and female physicians or between age groups. To conclude, the findings from objective working hour records show that long work shifts, on-call shifts and short shift intervals are related to the risk of short (1-3 days) sickness absence among hospital physicians.

The Case for Junior Doctor Academic Internships: A Narrative Review of the Published Literature

INTRODUCTION

There is a growing concern with the dwindling academic workforce especially in medicine. Academic internships refer to a hybrid internship during which an intern spends a period of time (typically 3-6 months) in academic/research endeavours. These may serve as initial research experience for junior doctors. However, the merits of this programme have not been assessed to date.

METHODS

Studies on integrated academic internships by junior doctors (ie, interns) were included in the present review. The identified articles were grouped into themes. For each article, the methodological approach (and subsequent implemented methods) was noted. The articles were also critically appraised for methodological soundness (both at the study-level, and the outcome-level).

RESULTS

A total of 1621 publication titles were identified and screened, of which 8 publications were included in the final review. The major themes of the identified publications are: overview of the academic internship programme, evaluation of a programme's experience and outcomes, and other miscellaneous publications.

DISCUSSION

The studies to date have only reported on "soft outcomes", but overall, interns and supervisors alike appear to be satisfied with the programme. Whether the programme increases the likelihood of future academic careers is difficult to establish at this juncture. The academic internship posts appear to be competitive, which reflect their popularity among graduating medical students.

The number and composition of work hours for attending physicians in Taiwan

Long work hours among physicians is a worldwide issue in the healthcare arena. Previous studies have largely focused on the work hours of resident physicians rather than those of attending physicians. The purpose of this study was to investigate total work hours and the composition of those work hours for attending physicians across different hospital settings and across different medical specialties through a nationwide survey. This included examining differences in physician workload and its composition with respect to different hospital characteristics, and grouping medical specialties according to the work similarities. A cross-sectional self-reported nationwide survey was conducted from June to September of 2018, and the two questionnaires were distributed to all accredited hospitals in Taiwan. The number of physician work hours in different types of duty shifts were answered by medical specialty in each surveyed hospital. Each medical specialty in a hospital filled only one response for its attending physicians. The findings reveal that the average total work hours per week of an attending physician is around 69.1 h, but the total work hours and their composition of different duty shifts varied among hospital accreditation levels, geographic locations, emergency care responsibilities, and medical specialties. Because of the variance in the number and composition of attending physicians' work hours, adjusting physician work hours to a reasonable level will be a major challenge for health authority and hospital managers.

The Impact of Physicians' Working Hours on Inappropriate Use of Outpatient Medicine in a Tertiary Hospital in China

BACKGROUND

Inappropriate prescribing is an important health system problem in China. Several studies have identified critical factors influencing prescription quality, but the impact of physicians' working hours remains unknown. In China, tertiary hospitals face ever-increasing outpatient volumes. Physicians are asked to work long hours and the impact of shift duration on prescription quality is unknown.

OBJECTIVE

We aimed to investigate the association between consecutive working hours and the quality of physicians' prescriptions in a Chinese tertiary hospital.

METHODS

We obtained all outpatient electronic health records from the hospital information system (HIS) of a tertiary hospital in Beijing, China from 1 July to 30 November 2015. Prescriptions made during two periods were analyzed: a morning shift from 7:30 to 12:30, and an afternoon shift from 13:30 to 18:30. The time when a physician issued the first prescription was considered the beginning of the work shift and prescriptions within the next 4 consecutive hours were included. Potentially inappropriate prescriptions were based on the Rational Drug Use (RDU) system that was developed and validated for this study. We used multivariable logistic regression to examine the impact of shift duration and other clinical and physician factors on potentially inappropriate prescribing.

RESULTS

Of the total 560,529 prescriptions, 15.3% were classified as inappropriate by the RDU system. Physicians' inappropriate prescribing increased in the last hour in each work shift (odds ratio (OR) for the fourth hour compared to the first = 1.12 (95% CI, 1.09-1.15)). We also found that physicians who worked all day had a higher rate of inappropriate prescribing than those who only worked half a day (OR = 1.05 (95% CI, 1.04-1.07)).

CONCLUSIONS

Longer working hours are a risk factor for inappropriate prescribing. Relevant interventions are urgently needed to establish working hour limits in China to reduce the likelihood of inappropriate prescribing by physicians.

Working hours, common mental disorder and suicidal ideation among junior doctors in Australia: a cross-sectional survey

OBJECTIVE

Despite concern regarding high rates of mental illness and suicide amongst the medical profession, the link between working hours and doctors' mental health remains unclear. This study examines the relationship between average weekly working hours and junior doctors' (JDs') mental health in Australia.

DESIGN AND PARTICIPANTS

A randomly selected sample of 42 942 Australian doctors were invited to take part in an anonymous Beyondblue National Mental Health Survey in 2013, of whom 12 252 doctors provided valid data (response rate approximately 27%). The sample of interest comprised 2706 full-time graduate medical trainees in various specialties, at either intern, prevocational or vocational training stage. Consultants and retired doctors were excluded.

OUTCOME MEASURES

Main outcomes of interest were caseness of common mental disorder (CMD) (assessed using a cut-off of 4 as a threshold on total General Health Questionnaire-28 score), presence of suicidal ideation (SI) (assessed with a single item) and average weekly working hours. Logistic regression modelling was used to account for the impact of age, gender, stage of training, location of work, specialty, marital status and whether JDs had trained outside Australia.

RESULTS

JDs reported working an average of 50.1 hours per week (SD=13.4). JDs who worked over 55 hours a week were more than twice as likely to report CMD (adjusted OR=2.05; 95% CI 1.62 to 2.59, p<0.001) and SI (adjusted OR=2.00; 95% CI 1.42 to 2.81, p<0.001) compared to those working 40-44 hours per week.

CONCLUSIONS

Our results show that around one in four JDs are currently working hours that are associated with a doubling of their risk of common mental health problems and SI. These findings suggest that management of working hours represents an important focus for workplaces to improve the mental health of medical trainees.

EXPO-S.T.O.P. 2016 and 2017 blood exposure surveys: An alarming rise

BACKGROUND

The annual Exposure Survey of Trends in Occupational Practice (EXPO-S.T.O.P.), conducted by the Association of Occupational Health Professionals in Healthcare, provides a U.S. national overview of sharps injuries (SIs) and mucocutaneous exposures (MCEs). This study presents the 2016 and 2017 surveys.

METHODS

An 18-item survey was distributed to Association of Occupational Health Professionals in Healthcare members and colleagues and requested total SIs and MCEs; SI in nurses, doctors, and surgery; staffed beds; teaching status; full-time equivalent staff (FTE), nurse FTE, and average daily census (ADC).

RESULTS

In 2016, 170 hospitals reported 10,271 exposures (72.9% SIs); in 2017, 224 hospitals reported 12,672 exposures (74.4% SIs). In 2016, SI rates were 27.0 per 100 ADC, 2.3 per 100 FTE, and 2.8 per 100 nurse FTE. Of the total SIs, 36.4% were nurses, 35.6% were doctors, and 39.0% occurred during surgery. In 2017, the respective SI rates were 27.7 per 100 ADC, 2.5 per 100 FTE, and 2.7 per 100 nurse FTE. Of the total SIs, 37.6% were nurses, 32.7% were doctors, and 39.9% occurred during surgery. In 2016, MCE rates were 11.2 per 100 ADC and 0.82 per 100 FTE, and in 2017, MCE rates were 9.6 per 100 ADC and 0.87 per 100 FTE. Teaching hospitals had higher rates than nonteaching hospitals.

DISCUSSION

EXPO-S.T.O.P. SI rates have risen year-on-year for 3 years and now match 2001-2005 levels.

CONCLUSIONS

There is an urgent need for aggressive SI-reduction strategies, including leadership support, safety-engineered devices (SED) training/education, and adoption of safer, less user-dependent SED. Further research on SI mechanisms, SED effectiveness, and reduction strategies is required.

The relationship between organisational stressors and mental wellbeing within police officers: a systematic review

BACKGROUND

Occupational stressors in police work increase the risk for officer mental health morbidities. Officers' poor mental wellbeing is harmful to the individual, can affect professionalism, organisational effectiveness, and public safety. While the impact of operational stressors on officers' mental wellbeing is well documented, no review has systematically investigated organisational stressor impacts. This study aimed to conduct a systematic review to assess the relationship between organisational stressors and police officer mental wellbeing.

METHODS

Systematic review conducted following PRISMA and Cochrane Collaboration guidelines. Literature search was undertaken from 1990 to May 2017 on four databases (EBSCOHOST Medline/SocINDEX/PsycINFO/OVID Embase) and grey literature. Included articles were critically appraised and assessed for risk of bias. Narrative and evidence syntheses were performed by specific mental health outcomes.

RESULTS

In total, 3571 results were returned, and 15 studies met the inclusion criteria. All included studies were published in English between 1995 and 2016, had cross-sectional study designs, spanned across four continents and covered 15,150 officers. Strong evidence of significant associations was identified for organisational stressors and the outcomes of: occupational stress, psychiatric symptoms/psychological distress, emotional exhaustion and personal accomplishment. The organisational stressors most often demonstrating consistently significant associations with mental health outcomes included lack of support, demand, job pressure, administrative/organisational pressure and long working-hours.

CONCLUSIONS

This review is the first to systematically examine organisational stressors and mental health in police officers. Organisational stressors that can be targeted by interventions and policy changes to secure officer wellbeing, a healthy work environment, and benefits to the organisation and the public are identified.

The clinical learning environment

Learning in a clinical context is foundational in the training of health professionals; there is simply no alternative. The subject of the clinical learning environment (CLE) is at the forefront of discussions. In this introduction to a themed issue on the CLE, we present an expanded conceptual model that approaches the CLE through six different lenses, termed "avenues:" architectural, digital, diversity and inclusion, education, psychological, and sociocultural, with each avenue represented by a paper. The aim is to facilitate dialog around the contributions of different academic disciplines to research on the CLE. Collectively the papers highlight the overlap between the various "avenues" in how they influence each other, and how they collectively have shaped the work to understand and improve the CLE. The expectation is that the various avenues can add to existing knowledge and create new ideas for interventions to improve the clinical learning environment across nations for learners and teachers with the ultimate aim of improving patient care. Research and efforts to improve the CLE are critical to learning, professional socialization and well-being for trainees as they learn and participate in patient care, and to the quality of care they will deliver over decades of practice after graduation.

The Impact of Shift Work on Sleep, Alertness and Performance in Healthcare Workers

Shift work is associated with impaired alertness and performance due to sleep loss and circadian misalignment. This study examined sleep between shift types (day, evening, night), and alertness and performance during day and night shifts in 52 intensive care workers. Sleep and wake duration between shifts were evaluated using wrist actigraphs and diaries. Subjective sleepiness (Karolinska Sleepiness Scale, KSS) and Psychomotor Vigilance Test (PVT) performance were examined during day shift, and on the first and subsequent night shifts (3^rd, 4^th or 5^th). Circadian phase was assessed using urinary 6-sulphatoxymelatonin rhythms. Sleep was most restricted between consecutive night shifts (5.74 ± 1.30 h), consecutive day shifts (5.83 ± 0.92 h) and between evening and day shifts (5.20 ± 0.90 h). KSS and PVT mean reaction times were higher at the end of the first and subsequent night shift compared to day shift, with KSS highest at the end of the first night. On nights, working during the circadian acrophase of the urinary melatonin rhythm led to poorer outcomes on the KSS and PVT. In rotating shift workers, early day shifts can be associated with similar sleep restriction to night shifts, particularly when scheduled immediately following an evening shift. Alertness and performance remain most impaired during night shifts given the lack of circadian adaptation to night work. Although healthcare workers perceive themselves to be less alert on the first night shift compared to subsequent night shifts, objective performance is equally impaired on subsequent nights.

Doctors don't Do-little: a national cross-sectional study of workplace well-being of hospital doctors in Ireland

OBJECTIVES

To measure levels of occupational stress, burn-out, work-life balance, presenteeism, work ability (balance between work and personal resources) and desire to practise in trainee and consultant hospital doctors in Ireland.

DESIGN

National cross-sectional study of randomised sample of hospital doctors. Participants provided sociodemographic data (age, sex), work grade (consultant, higher/basic specialist trainee), specialty, work hours and completed workplace well-being questionnaires (Effort-Reward Imbalance (ERI) Scale, overcommitment, Maslach Burnout Inventory) and single item measures of work ability, presenteeism, work-life balance and desire to practise.

SETTING

Irish publicly funded hospitals and residential institutions.

PARTICIPANTS

1749 doctors (response rate of 55%). All hospital specialties were represented except radiology.

RESULTS

29% of respondents had insufficient work ability and there was no sex, age or grade difference. 70.6% reported strong or very strong desire to practise medicine, 22% reported good work-life balance, 82% experienced workplace stress, with effort greatly exceeding reward, exacerbated by overcommitment. Burn-out was evident in 29.7% and was significantly associated with male sex, younger age, lower years of practice, lower desire to practise, lower work ability, higher ERI ratio and greater overcommitment. Apart from the measures of work ability and overcommitment, there was no sex or age difference across any variable. However, ERI and burn-out were significantly lower in consultants than trainees.

CONCLUSIONS

Hospital doctors across all grades in Ireland had insufficient work ability, low levels of work-life balance, high levels of work stress and almost one-third experienced burn-out indicating suboptimal work conditions and environment. Yet, most had high desire to practise medicine. Measurement of these indices should become a quality indicator for hospitals and research should focus on the efficacy of a range of individual and organisational interventions for burn-out and occupational stress.

Improving the working environment for the delivery of safe surgical care in the UK: a qualitative cross-sectional analysis

OBJECTIVES

The aim of this study was to identify current problems and potential solutions to improve the working environment for the delivery of safe surgical care in the UK.

DESIGN

Prospective, questionnaire-based cross-sectional study.

SETTING/PARTICIPANTS

Following validation, an electronic questionnaire was distributed to postgraduate local education and training board distribution lists, the Royal College of Surgeons of Edinburgh (RCSEd) mailing lists and trainee organisations. This consisted of a single open-ended question inviting five open-ended responses. Throughout the 13-week study period, the survey was also published on a number of social media platforms.

RESULTS

A total of 505 responders completed the survey, of which 35% were consultants, 30% foundation doctors, 17% specialty trainees, 11% specialty doctors, 5% core trainees and <1% surgical nurse practitioners. A total of 2238 free-text answers detailed specific actions to improve the working environment. These responses were individually coded and then grouped into nine categories (staff resources, non-staff resources, support, working conditions, communication and team work, systems improvement, patient centred, training and education, and miscellaneous).

CONCLUSIONS

The results of this study have identified a number of key areas that, if addressed, may improve the environment for the delivery of safer surgical care. Common themes that emerged across all grades included: increased front-line staff; a return to a 'firm' structure to improve team continuity; greater senior support; and improved hospital facilities to help staff rest and recuperate. While unlimited funding remains unrealistic, many of the suggestions could be implemented in a cost-neutral fashion and include insightful ideas for remodelling or restructuring the workforce to improve the efficiency of the surgical team. The findings of this study formed the basis of a set of recommendations published by the RCSEd as a discussion paper.

Surgical quality in organ procurement during day and night: an analysis of quality forms

OBJECTIVES

To analyse a potential association between surgical quality and time of day.

DESIGN

A retrospective analysis of complete sets of quality forms filled out by the procuring and accepting surgeon on organs from deceased donors.

SETTING

Procurement procedures in the Netherlands are organised per region. All procedures are performed by an independent, dedicated procurement team that is associated with an academic medical centre in the region.

PARTICIPANTS

In 18 months' time, 771 organs were accepted and procured in The Netherlands. Of these, 17 organs were declined before transport and therefore excluded. For the remaining 754 organs, 591 (78%) sets of forms were completed (procurement and transplantation). Baseline characteristics were comparable in both daytime and evening/night-time with the exception of height (p=0.003).

PRIMARY OUTCOME MEASURE

All complete sets of quality forms were retrospectively analysed for the primary outcome, procurement-related surgical injury. Organs were categorised based on the starting time of the procurement in either daytime (8:00-17:00) or evening/night-time (17:00-8:00).

RESULTS

Out of 591 procured organs, 129 organs (22%) were procured during daytime and 462 organs (78%) during evening/night-time. The incidence of surgical injury was significantly lower during daytime; 22 organs (17%) compared with 126 organs (27%) procured during evening/night-time (p=0.016). This association persists when adjusted for confounders.

CONCLUSIONS

This study shows an increased incidence of procurement-related surgical injury in evening/night-time procedures as compared with daytime. Time of day might (in)directly influence surgical performance and should be considered a potential risk factor for injury in organ procurement procedures.

Simulation-Based Mastery Learning of Flexible Bronchoscopy: Deciding Factors for Completion

BACKGROUND

Several studies have shown the beneficial effects of mastery learning of a simulation-based course, but not all trainees complete it.

OBJECTIVES

The purpose of this study was to find deciding factors for the completion of a simulation-based mastery learning course with distributive practice in flexible bronchoscopy.

METHODS

Seventy-seven trainees who signed up for the course were invited to a survey for deciding factors of completing the course. Sixty-two (81%) trainees answered the survey.

RESULTS

Male trainees were more likely to complete the course. The most important factor for completion was clinical relevance, and the most important factor for not completing the course was being "too busy."

CONCLUSION

Several deciding factors for completing the course were identified. Successful simulation-based mastery learning courses should be clinically relevant, and the trainees should be provided protected time to complete the training. The instructional design should also be adapted systematically for male and female trainees to achieve the necessary competencies.

The Measurement of Orthopaedic Surgeon Quality and Quantity of Sleep Using a Validated Wearable Device

Introduction:

Recurrent episodes of partial sleep deprivation resulting from shift work or call schedules are commonly seen in physicians. This study measures the quantity and quality of sleep in orthopaedic surgeons and determines the factors that are correlated with decreased quantity and quality of sleep.

Methods:

Orthopaedic surgery residents and attending surgeons at a single institution were prospectively enrolled and provided with a validated wearable device to objectively determine sleep quantity (total hours of sleep) and quality (sleep disturbances; sleep latency; sleep efficiency; and amount of rapid eye movement [REM] sleep, deep sleep, and light sleep). Sleep deprivation was defined as getting less than 7 hours of sleep per day. Bivariate correlations were determined using Spearman rank correlation. Multiple linear regression models were constructed to determine the effect of independent variables (age, attending physician, resident, postgraduate year [PGY] level, sex, number of calls, and total hours worked) and sleep quantity and quality. All P values were reported, and a significance level of α = 0.05 was used (ie, P < 0.05).

Results:

Of 26 enrolled subjects, 21 (80.8%; 12 residents and 9 attending surgeons, where 15 were men and 6 women, with mean age of 37.2 ± 10.9 years) completed the 4-week duration of the study. Orthopaedic surgeons obtained 6.5 ± 0.8 hours of sleep per night (17.7% REM, 19.4% deep sleep, and 62.6% light sleep; 4.5 ± 1.1 minutes of sleep latency; 4.9 ± 1.7 sleep disturbances; and 89.9% sleep efficiency). Fourteen orthopaedic surgeons (66.7%) of the 21 slept less than the recommended 7 hours of sleep per night. The total hours worked had a moderate negative correlation (r = −0.550; P = 0.010) with total sleep. PGY level had a moderate positive correlation with sleep latency (r = 0.546; P = 0.010).

Discussion:

Diminished sleep quantity is considered sleeping less than 7 hours per night, whereas decreased sleep quality is associated with decreased REM sleep, decreased deep sleep, increased light sleep, decreased sleep latency, decreased sleep efficiency, and increased sleep disturbances. Sleep deprivation in orthopaedic surgeons poses notable health and safety risks for both surgeons and patients.

Conclusion:

Orthopaedic surgeons demonstrate poor sleep quantity and quality which is markedly worse than the general population, with increased work hours markedly correlated with decreased hours of sleep.

Impact of working hours on sleep and mental health

Background

The number of hours people are required to work has a pervasive influence on both physical and mental health. Excessive working hours can also negatively affect sleep quality. The impact at work of mental health problems can have serious consequences for individuals' as well as for organizations' productivity.

Aims

To evaluate differences in sleep quality and anxiety and depression symptoms between longer working hours group (LWHG) and regular working hours group (RWHG). To examine factors influencing weekly working hours, sleep quality and anxiety and depressive symptoms.

Methods

Participants were divided into two groups, RWHG and LWHG, based on working hours, with a cut-off of 48 h per week. We used the Hospital Anxiety and Depression Scale (HADS) to assess anxiety and depression symptoms and the Pittsburgh Sleep Quality Index (PSQI) to measure the quality and patterns of sleep.

Results

The response rate was 23%. Among the 429 study participants, those in the LWHG group (n = 256, 53%) had significantly more depressive and anxiety symptoms and worse sleep quality than those in RWHG (n = 223, 47%). Working time was significantly positively correlated with higher corporate position and HADS scores. Moreover, HADS scores were positively correlated with PSQI scores and negatively correlated with age.

Conclusions

This study suggests that longer working hours are associated with poorer mental health status and increasing levels of anxiety and depression symptoms. There was a positive correlation between these symptoms and sleep disturbances.

The Importance of Fostering Ownership During Medical Training

There is a need to consider the impact of the new resident-hours regulations on the variety of aspects of medical education and patient care. Most existing literature about this subject has focused on the role of fatigue in resident performance, education, and health care delivery. However, there are other possible consequences of these new regulations, including a negative impact on decision ownership. Our main assumption of is that increased shift work in medicine can decrease ownership of treatment decisions and impact negatively on quality of care. We review some potential components of decision ownership in treatment context and suggest possible ways in which the absence of decision ownership may decrease the quality of medical decision making. The article opens with the definition of decision ownership and the overview of some contextual factors that may contribute to the development of ownership in medical residency. The following section discusses decision ownership in medical care from the perspective of "diffusion of responsibility." We question the quality of choices made within narrow decisional frames. We also compare isolated and interrelated choices, assuming that residents make more isolated decisions during their shifts. Lastly, we discuss the consequences of decreased decision ownership impacting the delivery of health care.

Effectiveness of very early workplace interventions to reduce sickness absence: a systematic review of the literature and meta-analysis

OBJECTIVE

The aim of this review was to investigate the effectiveness of workplace return-to-work (RTW) interventions delivered at very early stages (<15 days) of sickness absence (SA).

METHODS

A systematic literature search was conducted in PubMed, Health Management Information Consortium (HMIC), Cochrane library database, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsychInfo and Embase. Using pre-established criteria, independent pairs of researchers carried out the study selection, quality appraisal and data extraction. Workplace interventions before day 15 of SA, were included. Primary outcome measures included rates of and time until RTW, productivity loss, and recurrences of SA.

RESULTS

We found limited available evidence on the benefits of "very early" workplace interventions in terms of RTW after a SA episode compared to usual care. Only three randomized controlled trials classed as high or intermediate quality were identified. Early part-time sick leave together with appropriate job modifications led to a reduction in the duration and recurrence of SA. There is evidence of benefit of intervening during the first two weeks of SA for musculoskeletal disorders.

CONCLUSION

Our review has identified a lack of evidence from the literature at this time point to support "very early" intervention compared to usual care. The methodological design of the studies, notably the extent and timing of usual care provided and variable compliance/crossover between groups could however explain the lack of demonstrated benefit. Consensus is required on the definition of "early" and "very early" interventions, and further research is recommended to improve understanding of the factors influencing when and how best to intervene for maximum gain.

Associations of psychosocial working conditions and working time characteristics with somatic complaints in German resident physicians

PURPOSE

Somatic complaints (SC) are highly prevalent in working populations and cause suffering and extensive health-care utilization. Adverse psychosocial working conditions as conceptualized in the Job Demand-Control-Support Model (JDC-S) and adverse working time characteristics (WTC) are potential risk factors. This combination is particularly common in hospital physicians. This study examines associations of JDC-S and WTC with SC in resident physicians from Germany.

METHODS

A cross-sectional study was conducted among 405 physicians at the end of residency training. SC were measured using the Giessen Subjective Complaints List (GBB-24) containing the sub-categories exhaustion, gastrointestinal, musculoskeletal, and cardiovascular complaints. Data on working conditions were collected by a self-report method for work analysis in hospitals (TAA-KH-S) and by questions on WTC (i.e., working hours). Multivariable stepwise regression analyses were applied.

RESULTS

Workload showed the most pronounced relationship with all sub-categories of SC except gastrointestinal complaints. Job autonomy was not significantly related to any SC sub-category. Social support at work was inversely associated with all SC sub-categories except for cardiovascular complaints. Free weekends were associated with reduced SC except for exhaustion. Shift work was related to an increased SC total score and musculoskeletal complaints. Working hours showed no association with SC.

CONCLUSION

In resident physicians, high workload and shift work are associated with increased SC, while social support at work and free weekends are associated with decreased SC. These insights may inform the development of preventive measures to improve the health of this professional group. Prospective studies are needed though to corroborate our findings.