Taylor, Taryn S. MD; Nisker, Jeff MD, PhD; Lingard, Lorelei PhD
Duty hours reform is predicated on the assumption that working fewer consecutive hours will result in more and better-quality sleep hours, which will yield residents who will provide safer patient care.1–3 Existing research is focused primarily on interventions and outcomes related to residents’ on-duty experiences; results of these studies are conflicting and have been used variably to justify or criticize duty hours reform.2,4–8 With very little research into what residents actually do postcall and how they decide what to do, we do not know what influences residents’ decisions about their postcall time. Consequently, it is unclear whether postcall behaviors are particularly entrenched, or what educational or organizational strategies might be implemented to influence them. The lack of such insight is a critical gap in the literature, as researchers have recently found that residents were unlikely to change or improve their sleep habits based solely on an educational intervention to improve their knowledge of sleep physiology principles.9 This result begs the ubiquitous knowledge translation question: If improved knowledge is not influential in changing residents’ behavior, then what would be?
Answering this question requires research that explores not only what residents decide to do postcall but also how they understand these decisions. This knowledge is necessary to inform policy regarding residents’ duty hours restrictions; without it, policy risks being irrelevant and failing in its goal to optimize residents’ well-being, competency, and patients’ safety.
This study sought to describe residents’ postcall behaviors and to understand the dominant rationalizations that residents offered to justify their decisions to continue to work or leave the hospital.
We used a constructivist grounded theory approach, to acknowledge the socially situated nature of the studied phenomenon and the researcher’s insider role in shaping the resulting theory.10–12 Health sciences research ethics board approval was obtained for the study at the study institution.
We recruited 24 residents from a single Canadian institution, representing both sexes, all training years, and six specialties: general surgery, obstetrics–gynecology, orthopedic surgery, urology, pediatrics, and internal medicine. Participants worked clinically at three affiliated hospitals. Initially, purposive and convenience sampling included a balance of surgical and nonsurgical residents with comparable frequency of 24-hour call shifts. Theoretical sampling supported further development of concepts as iterative analysis proceeded.10 We determined sample adequacy by continuing data collection until saturation was achieved and no new theoretical insights were emerging.13
One of us (T.T.) conducted individual semistructured interviews with participants. As a resident in one of the sampled programs, she knew some participants and was introduced to others as a fellow resident conducting master’s research. Interviews were audio-taped and transcribed verbatim. Data analysis using NVivo proceeded iteratively, alongside data collection.10 All three of us held joint discussions throughout the analysis to refine emerging concepts, guide theoretical sampling, and develop new interview prompts as necessary. We conducted a member check to confirm resonance of findings and refine key themes.
The richest and most animated part of the interview discussions was not residents’ descriptions of their postcall behaviors but, rather, their rationalizations of why they chose these behaviors. Using representative quotations from both surgical and nonsurgical participants, we describe this finding in detail in this section.
Abiding by cultural norms characterizes the dominant rationalization that residents offered to justify their decisions. We defined cultural norms as shared postcall expectations of the postgraduate training environment, which were understood by residents through explicit messages (e.g., enforced rules) or tacit (e.g., role modeling or organizational structures) ones. This dominant rationalization cut across nearly all of the reported staying or going behaviors in our data set and, therefore, offers insight into how residents decided to act regardless of their particular actions. Abiding by cultural norms included three thematic subcategories: infrastructure, invoking values, and negotiating tension. Each of these is defined and illustrated with examples cited by resident participant code.
The infrastructure subtheme highlights the organizational elements of the clinical or educational environment that implicitly reinforced and reproduced cultural norms. Team structure was referenced recurrently in the interviews. A relay-team structure, with routines that clearly delineated the beginning and end of duty, supported residents in going home postcall:
All you need to do is hand over … before you leave. If there’s consults that need to be called in or anything like that, as soon as 8:30 hits, it’s not your responsibility anymore. (R007)
When teams did not have the “adequate redundancy in manpower” (R006) to permit a simple passing of the baton, the manpower arrangement created a cultural norm of team obligation to stay postcall:
So, even if you’re up operating all night, you’re kind of expected/needed the following day … you need to round on your patients, give your team something to do, come up with a plan for the day, and then either operate, scope, help run clinics. (R003)
Organizational characteristics of the educational environment also reinforced postcall cultural norms. When privileged learning opportunities were reserved for more senior trainees, going home was felt to negatively affect a resident’s education:
You only get a limited two-year span, as a senior, to really learn how to operate. Certainly, the impression I get from the current seniors is that they want to be there because this is all they get, training-wise and surgically, so they want to be there for every minute that they can. (R004)
Thus, team structures and perceived limitation of available learning opportunities had a substantial impact on how residents rationalized their enactment of postcall cultural norms.
Cultural norms are predicated on core values, which residents recurrently invoked as they reflected on their postcall decisions. Where the cultural norm was to go home, residents invoked the value of patient safety to rationalize their behavior. Going home, these residents argued, minimized the potentially negative impact of sleep deprivation on their clinical performance and patient care. Accordingly, perceptions of inherent risk meant that the choice to stay and provide patient care while postcall was deemed indefensible:
I just don’t see how it’s safe and don’t see how you can defend, like, I just wouldn’t be able to live with myself if I thought that I had made an error or missed something because I chose to work postcall, when it’s not my patient’s fault that I had been up all night. (R005)
Yet residents abiding by a cultural norm to stay postcall justified their decision by invoking the value of educational opportunities, which was offered by the chance to expand their clinical repertoire through extended work hours. Time spent outside of the hospital meant that educational opportunities were irrevocably lost. As one resident succinctly put it:
The educational incentive is huge. For example, tonight I’ll probably end up being awake for more than an hour after midnight. Realistically, I’ll get a few hours of sleep, but if I don’t go to work tomorrow, then I’m going to miss out on an entire operating day. Those are cases I don’t get to do. I’m never going to get to do those cases again. (R021)
The values of educational opportunity and patient safety were present, but invoked differently, in programs regardless of whether the cultural norm was to stay or go postcall. For instance, the value of educational opportunity was also recognized by residents abiding by the cultural norm of going home postcall; however, it was invoked to argue that their fatigue-related impairment would preclude any valuable learning during the postcall period and possibly well afterwards:
I know that for me, when I was postcall I was completely ineffective anyway, so staying would not be a learning opportunity, it would just be an opportunity not to rest and then you wouldn’t be efficient the following day. (R002)
For residents rationalizing the decision to stay postcall, the value of educational opportunity had another dimension. In addition to improving clinical skills and knowledge, residents asserted that long working hours were educationally necessary to prepare them for the realities of practice, including sleep deprivation:
… it’s one of those things where you learn in residency to function off little sleep, and you apply it for those rare circumstances where you’re staff and you’re up all night dealing with something. (R001)
A number of tensions were evident in residents’ rationalizations of whether to stay or go postcall. Tensions arose in three distinct situations: (1) when cultural norms conflicted with local institutional postcall policy, (2) when cultural values were in question, (3) and when cultural norms were in flux. This subtheme, negotiating tension, captures these tensions and how residents accommodated them in their thinking.
In circumstances where the cultural norm to stay conflicted with explicit local duty hours policies, residents defended an unwavering dedication to stay based on the value of educational opportunity:
Learning how to do procedural skills … is a very difficult thing, and I think you appreciate that more and more the more you actually learn because you realize it takes a lot of time and effort. To sit there and turn down a whole day of operating, I know personally, is something I don’t think I’ll ever do…. People who are making these policies, I don’t know if they actually get what’s involved in training to do a procedure. (R001)
Not only does the value of educational opportunity support the cultural norm of staying but, as this resident implied, anyone who doesn’t recognize this simply hasn’t learned enough to realize, or doesn’t “actually get what’s involved” (R001). Those inside the culture know; those outside do not.
However, not all residents who stayed postcall fully endorsed the value of educational opportunity to justify their decision. They expressed skepticism about the educational benefit of staying postcall and reservations about the effect on patient care. Yet these residents still chose to abide by cultural norms because to do otherwise would not “look good” (R018):
And then, I know myself, I’m terrified of making a mistake … when I’m postcall. And I’ll never know … would I have made that mistake on a regular day, or did I make that just because I was too tired and I was being careless?… I mean, I’ve been asked to do an operation and I’ve said no before because I was too tired. I said I would happily retract but there is no way that I’m going to operate. So, again, a total waste of a day operating, so not improving skills, just being a human retractor. (R018)
Residents experiencing a tension with the cultural norms of their context sometimes invoked values in unexpected ways to rationalize abiding by these norms. For example, the resident quoted below justified his decision to stay postcall based on the anticipated benefit for future patients:
You have to think to yourself, in these five years, if I do less call and am constrained to how many hours I do, am I going to be a competent surgeon when I come out? That’s the real question. Not how safe the patients are when you’re in a teaching hospital but how safe the patients are when you’re outside. And I don’t think you’re going to be a safe surgeon unless you operate enough. (R019)
This rationalization, in which the safety of current patients is weighed against that of future patients, is in stark contrast to the rationalization of residents who invoke the value of patient safety in favor of going home postcall. As the resident quoted below asserted, no amount of perceived risk to current patients was considered tolerable:
The patient should come first. Yes, we’re here to be educated, but we’re not here to be educated at the expense of others. Especially not people who trust us and are counting on us to make the right decisions and to think things through well. (R023)
Tensions also arose when residents belonged to a culture in flux. A recent change in local postcall policy meant that some junior residents abided by cultural norms contrary to the practices of their consultants and senior colleagues. Staying postcall was the predominant cultural norm modeled by consultants in these situations, which provoked residents to consider their future work hours. Many voiced intentions to work postcall as staff, regardless of their current cultural norms as residents. Furthermore, some residents were able to imagine a different future postcall behavior while continuing to uphold the value that supported their current postcall behavior. Referencing the value of patient safety, the resident quoted below rationalized why working postcall might be reasonable in the future:
The volume of what is expected of me when I am on call will be much less, and that is my preference compared to this type of a system. It will be 24-hour call and I will not necessarily have the following day off, but I think it will be few and far between that I’m actually up all night and then expected to work the following day. (R008)
Our study was designed to explore how residents spend their postcall day and why they make these choices—what Coverdil et al14,15 characterized as the “stay-or-go dilemma” for residents. Our results highlight residents’ rationale of abiding by cultural norms to support their inclinations to stay or go home postcall. Intriguingly, the same values of patient safety and education were used to support opposite behaviors.
Others have recognized that the postcall stay-or-go decision offers insight into residents’ professional values.14,15 Our multiprogram study confirms this finding previously described only in general surgery residents.14,15 Our unique contribution is the finding that residents perceive that they are demonstrating a commitment to patient safety and their education regardless of which postcall behavior they advocate—staying or going. As others have described, in situations where value conflict may potentially arise between two equally important values, individuals often remedy this tension by reasoning that the values are intimately linked.16 In this case, for residents who stay, educational value is seen as an instrumental value that is a means to achieving a terminal value of patient safety. This strategic application of professional values is a critically important insight because it calls into question the dominant rhetoric underpinning duty hours reform initiatives: the invocation of, in most cases, a single benefit of restricted duty hours—patient safety.9,17–20
Current rhetoric around duty hours reform tends to imply that there is one right culture to which all residents and training programs should aspire. As evidenced in our study, however, a simple right or wrong characterization does not ring true for residents when the same professional values can be—and are—used to justify opposing cultural norms. Although many have called for a shift in professional attitudes and values about sleep and work hours to facilitate duty hours reform,9,17–19 our results underscore Arora and colleagues’17 caution that “old values do not simply die in a new system.” Not only do values not die, but their persistence in both postcall cultures suggests there is something more at play. Previous studies indicate that although individuals may regard similar values as important, it is the relevance an individual assigns to a given value that defines that individual’s attitudes and subsequent behaviours.16 This suggests, for example, that residents who rationalized their decision to stay based on the value of educational opportunity may have felt that the value of patient safety was no less important, but simply less relevant to their actions. Thus, although initiatives focused on redefining residents’ values are unlikely to result in behavioral change, interventions that eliminate the need for residents to determine the relevance of particular values in the stay-or-go dilemma may lead to greater duty hours compliance.
Our findings may help to explain the disappointing results of recent duty hours initiatives. For instance, a previous educational intervention sought to teach residents about the impact of sleep deprivation and fatigue on performance, with negligible impact on residents’ off-duty sleeping habits.9 Our findings suggest why this and other similar interventions may prove ineffective: Knowledge-based facts are easily accommodated by residents who believe them to be irrelevant to themselves or to the values they choose to uphold. Similarly, initiatives to change attitudes, for which many have advocated,17,19,21 may fail because they rely on an appeal to values that tacitly assumes such values are stable entities. In contrast to this assumption, our findings suggest that values are versatile and, therefore, amenable to multiple applications and shifting perceptions of relevance. Finally, the creation of more stringent guidelines and punitive measures22 is unlikely to optimize duty hours compliance because residents may feel that values of professional autonomy, education, and patient safety are more relevant to their attitudes about duty hours than the value of abiding by policy.
We suggest that it might be productive to refocus our efforts away from individual residents having the right values or making the right postcall decisions, and towards removing the stay-or-go burden from residents’ shoulders. Changes to program curricula, team organization, and infrastructure would be instrumental towards such an end; for instance, offering off-duty procedural simulation skills training may help with the problem of residents feeling forced to choose between abiding by policy and obtaining valuable training opportunities. As well, relay team structures may better allow residents to leave the hospital postcall without fears of compromising patient care. Given that residents are unable to accurately self-assess their fitness for duty when faced with the stay-or-go decision,19,23,24 we may even need to consider more extreme infrastructural changes, such as electronic monitoring with swipe cards, to restrict access to active patient care areas beyond duty hours limits. Although such changes would conflict with strongly held values of physician autonomy and self-regulation, they should at least be debated in light of the pitfalls of a values-based approach to self-regulation suggested by our findings.
There are inherent limitations in drawing conclusions based on residents’ post hoc rationalizations. However, we believe these data provide useful insights into how residents understand their own decisions in context, and our member check suggested that our findings authentically represented the thinking that happens in stay-or-go dilemmas. We attempted to minimize any program-specific influences by sampling from six residency programs across three hospital settings; however, our results are likely influenced by the culture of the overarching institution in which all participants were enrolled. Future research will need to determine the transferability of our findings to other institutional settings. We deliberately chose a resident as the interviewer because of the anticipated benefit of encouraging participants to speak freely with one of their own.25 Although we recognized the potential for her to introduce her own perspective into the interviews and the analysis, our constructivist grounded theory methodology affords strategies for accounting for this influence, such as the inclusion of other analytical perspectives in the analysis.26 Researcher reflexivity, another grounded theory technique, involves the creation of memos and field notes that allow the researcher to engage in continuous self-awareness and acknowledgement of his or her role in co-constructing the emerging theory.26
Cultural norms strongly influence how residents enact shared professional values such as patient safety and education in their postcall decisions. These values appear to be versatile and amenable to multiple, even conflicting applications. Thus, we suggest that for duty hours reform initiatives to be successful, the current values-based rhetoric may need to shift in favor of organizational changes that reduce the circumstances in which postcall behavior is an individual, values-based decision.
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