The residents in our program felt that most aspects of the three domains of the senior resident’ wellness, ability to deliver quality health care, and medical education experience were unaffected by the introduction of the SRRB, but reported four improved perception shifts and two that had worsened. The SRRB’s combination of innovations, namely educational sessions on sleep hygiene, an electronic handover tool and a simulation-based medical education curriculum, may have successfully targeted some of the perceived potential negative consequences of duty hour restrictions and night float systems.
Study participants felt that the senior residents were exposed to less personal harm as a result of the SRRB. This is consistent with previous research showing that prolonged duty hours for residents increase their personal harm risk including needle stick injuries, motor vehicle collisions post-call, and burnout [1, 6, 9, 18, 19]. Study participants also felt that the SRRB caused increased conflicting role demands by reducing the senior residents’ ability to spend time with family, perform research, and trade work shifts compared to the traditional system of call. Despite this, there was no perceived change in senior residents’ general wellbeing. Previous studies have reported mixed results in residents’ health, wellness and quality of life after implementation of night float systems [9, 12, 14, 30] with some reporting such improvements as more time available to study, as well as negative consequences, such as increased depression and feelings of isolation [20–22, 36].
Benefits in patient care and outcomes have been previously reported after the implementation of duty-hour restrictions [3, 9, 10, 12, 14, 16]. Our study results are consistent with these findings whereby participants felt that senior residents were less likely to commit a medical error with shorter duty hours. The resulting shorter shifts and increased number of patient care handovers between postgraduate trainees has been identified as a significant potential source of communication and medical errors [8, 24, 37–40]. Our participants did not feel there was a negative impact on continuity or quality of care provided by the senior resident as a result of the SRRB. The implementation of an electronic handover tool as part of the SRRB may have influenced these perceptions. A growing body of literature supports the use of such electronic tools in order to minimize this potential negative consequence [28, 29].
The majority of research published has reported either no change or an improvement in the overall quality of medical education with the implementation of duty-hour restrictions [9, 12, 14, 24, 30]. Study participants felt that the senior residents’ educational experience was enhanced after the implementation of the SRRB with improved teaching effectiveness. This may be due in part to decreased senior resident fatigue during teaching duties given shorter consecutive duty hours and the addition of the simulation-based medical education curriculum. Both high-fidelity and low-fidelity procedural simulation have been successfully used as medical education tools in post-graduate training [31–34]. The study participants felt that the implementation of the SRRB allowed less staff physician supervision for the senior residents but did not feel there was any significant difference in the senior residents’ ability to learn successfully after the implementation of the SRRB. These perceptions may reflect a balance between the benefits of the simulation curriculum against the loss of both daytime medical education experiences and resident/staff physician handover contact, and direct supervision for night float residents. Participants felt there were fewer disruptions in other rotations, possibly reflecting that the SRRB eliminated the need to pull residents from other rotations to fulfill MTU call shifts, allowing residents on subspecialty rotations to complete their duties with fewer interruptions.
Our study should be interpreted in light of the study design. First, this study reports changes in internal medicine residents’ perceptions rather than objective outcomes. Perceptions are often important determinants of the ultimate success of such resident-driven structural and scheduling changes. Second, we chose to include all the residents in the study cohort. We recognize that we thus asked residents who did not personally experience aspects of the bundle as well as those who did to offer their perspective on how it may have affected the senior residents. We felt it was essential to include the perceptions of all residents as they were all stakeholders in this quality improvement initiative, and the rotation changes we examined could be permanently adopted at our institution. The junior residents’ perceptions of the impact of the SRRB on their more senior colleagues is important in the context of their reliance on the seniors as clinical mentors and teachers, and their forthcoming transition into the senior role. Third, the timing of a 6-month intervention during an academic year makes it very difficult to ensure that every resident has had the same experience at the start of the intervention. This is another reason that we chose to include all the residents as our cohort in this study, recognizing that even some of the post-graduate year 2 senior residents would have had limited experience with the pre- and possibly post-intervention rotation schedule. Accordingly we acknowledge that at the time of initiation of the study pilot, the surveyed participants would have had varied rotations and clinical experiences. Fourth, this study was performed at a single institution. While the response rates were very high the generalizability of these study results may be limited as each individual institution is subject to its own culture and practice. We were limited by the size of our program and therefore our study may have been insufficiently powered to yield other statistically significant differences. Lastly, every institution and postgraduate training programs is a dynamic entity, and the results reported may have been influenced by changes within our site and residency program during the study period.