Overnight Shift Work: A Faculty-Driven Staffing Strategy

Although much has been written about the effects of overnight shift work on aging workers, few articles examine the effects of overnight shift work on aging physicians.(1) Regardless the employment, recovery time after overnight shifts and circadian rhythm flexibility can worsen as shift workers age.(2) Increased on-shift sleepiness and lessened cognitive function have been associated with overnight shift work in older adults.(3,4)

Within the specialty of emergency medicine (EM), older emergency physicians (EPs) polled in past national surveys indicated that practice modifications, such as the reduction of overnight shift work, can prolong their careers and reduce burnout.(5) Academic EM departments have various strategies, both official and unofficial, of assigning overnight shifts related to age.(6)

Age-related policies may increasingly be viewed as discriminatory or at odds with institutional policies. A more cynical perspective holds that an EP’s age is not professionally earned, especially for those practicing EM as a second or third career. So, it is useful to consider alternative qualifications other than employee age on which to base adjustments to overnight shift work.

Rather than age, experience-based qualifications within the specialty, such as professional seniority (years after residency graduation) or group tenure (years worked for group) may be more acceptable to employers, since these factors are often a proxy for age but are based on professional experience.

Little has been written about EPs’ attitudes toward overnight shift adjustments based on professional seniority or on group tenure. Moreover, little has been shared about how physician groups have democratically self-determined their own overnight staffing models based on either of these two experience-based qualifications.

For this reason, we conducted a survey of EM faculty at our urban, academic department of emergency medicine to discern whether our faculty group had the appetite for an official overnight work policy and, if so, on what qualifications it should be sculpted.

Methods

This survey was conducted among full-time EM faculty in an academic emergency department of a large, urban, tertiary care hospital. To assess EM faculty attitudes surrounding the design and implementation of a departmental policy to reduce or eliminate overnight shifts for senior faculty, we developed a survey informed by the literature concerning overnight shift burden in the aging physician population.(4) A number of questions used for demographics and current practice were applicable to our primary objective; we implemented identical questions inquiring about decay in skills, empathy, and ability to recover from overnight shifts compared to five years ago. Questions were reviewed by research faculty for face validity and clarity before distribution.

The survey consisted of demographic information and questions designed to assess attitudes surrounding overnight shift burden. Response types consisted of both binary (“yes”/ “no”) and 5-point Likert-scale ranging from “strongly agree” to “strongly disagree.”

In the survey prompt, EM faculty recipients were alerted that their responses would be used to collect group consensus to develop a strategic plan to reduce overnight shifts for faculty with significant seniority or tenure. An anonymous, web-based format was used to mitigate response bias based on privacy concerns or influence, and recipients were informed that department leadership and individuals involved in scheduling would not have access to respondents’ potentially identifiable information.

The web-based survey (Qualtrics, Provo, UT) was distributed via anonymous email link to 57 full-time faculty members. After 14 days, an email reminder was sent to all original recipients requesting that the survey be completed. The data analysis was performed by a departmental statistician using Stata v14.0. Results are presented as frequencies with proportions and medians with interquartile ranges (IQR).

Results

Forty-five (79 percent) of 57 full-time faculty members responded to the survey; 28 (62 percent) were male with a median age of 43 (IQR, 38–51) years (see Table 1). Respondents had been practicing emergency medicine since completing their residency training for a median of 10 (5–18) years and at the current institution for a median of 5 (2–10) years.

Overall, 73 percent agreed that overnight shifts should be reduced based on years worked for their current faculty group (tenure) (see Table 2). Sixty-four percent of faculty with professional seniority of >15 post-residency years and 72 percent of those with 6–15 post-residency years supported this measure, while 85 percent of faculty with 0–5 post-residency years were in support.

Overall, a resounding majority of 87 percent agreed that overnight shifts should be reduced based on years after graduating from residency (professional seniority). Ninety-three percent of faculty with professional seniority of >15 post-residency years and 94 percent of those with 6–15 post-residency years supported this measure, while 69 percent of faculty with 0–5 post-residency years were in support.

In addition, 60 percent were willing to work a slightly higher percentage of overnight shifts to reduce the percentage of overnight shifts for faculty with significant tenure. Those most willing were those with 0–5 years post-residency (62 percent) and >15 years post-residency (79 percent). Faculty with 6–15 years post-residency were less willing (44 percent).

Eighty-four percent of respondents believed they would be more likely to continue working at their current institution if such an initiative were in place. Those most likely were >15 years post-residency (93 percent), followed by 6–15 years post-residency (83 percent) and 0–5 post-residency (77 percent).

Forty-seven percent reported that reducing overnight shifts would impact their job satisfaction “a great deal,” a response driven by 71 percent of faculty >15 years post-residency replying this way. Eighty-three percent of faculty 6–15 years post-residency believed it would impact job satisfaction “a great deal” or “a lot,” while 69 percent of faculty 0–5 years post-residency believed it would impact job satisfaction “a great deal,” “a lot,” or “a moderate amount.”

Of questions asking respondents to compare their current practice to five years prior, one focused on the effects of overnight shifts, for which 32 (71 percent) of 45 respondents reported that their ability to recover from an overnight shift was “less” compared to five years prior (see Figure 1). A slight but non-statistically significant trend reveals the most junior cohort recovering from overnight shifts the best: 7 (54 percent) of 13 reporting “less” ability to recover compared to five years prior.

Figure 1. Ability to recover from an overnight shift

Discussion

Overnight shifts have been noted to cause negative health effects and have been cited as a factor in retirement decisions from emergency medicine in Academic Board of Emergency Medicine (ABEM) surveys.(5) Forty-three percent of ABEM survey respondents (n = 344/809) indicated overnight shifts had caused them to think about leaving EM. Surveys by the American Academy of Pediatrics Section on EM and board-certified PEM physicians reveal that aging PEM physicians feel similarly.(7)

Goldberg, et al., assessed the burden of overnight shifts on EPs, showing 74 percent self-reporting “worse/much worse” recovery from overnight shifts compared to their recovery five years prior.(4) Our survey shows EM faculty reflecting similar experiences, with 71 percent reporting “worse/much worse” post-overnight recovery. Despite over a decade between surveys, it seems the effects of overnight shift work — an inherent part of work in emergency departments — have not changed.

Yet, only 60 percent of ED leaders reported a strategy for aging EPs in 2009’s ABEM surveys without follow-up data to signal any progress. Even worse for those seeking guidance, these strategies were wide-ranging without much commonality.

Our survey results reflect that our EM faculty were more in favor of overnight shift reductions based on the number of post-residency years (professional seniority), rather than based on the number of years working for the department (tenure). Though professional seniority and tenure both had majority support from EM faculty, it is worth noting that professional seniority had more support, driven by almost universal support from faculty with >6 years post-residency work.

Interestingly, faculty with 0–5 years post-residency work supported tenure over professional seniority as a qualification for reduced overnights. This variance likely reflects a perspective difference, albeit self-serving, since faculty 0–5 years post-residency are more likely to be in their first job and, thus, be most likely to benefit from a policy based on institutional tenure. Conversely, faculty 6+ years post-residency are less likely to be in their first job and more likely to have more academic commitments requiring conflicting business hour work.

It is notable that 62 percent of faculty 0–5 years post-residency replied that they would work a“slightly higher percentage of overnight shifts,” reflecting that junior faculty may view this initiative as “paying it forward” by working slightly more overnight shifts earlier in their career, in return for career longevity with fewer overnight shifts later. This willingness may also reflect a demographic that is younger, less burned out by years of emergency medicine shift work, or less burdened by daytime academic and administrative commitments.

Overall, the willingness to sacrifice (take less-desirable shifts in the near term for fewer overnight shifts in later years) reflects a faculty mindset with intent to stay within the department, supported by the 84 percent of respondents who confirmed such a policy to be a retention incentive that would impact job satisfaction “a great deal,” “a lot,” or “a moderate amount.”

As secondary endpoints, our survey also asked respondents to rate themselves in various categories of physical, cognitive, and emotional stressors of clinical practice and how they have evolved over the past five years. Overall, it appears the most senior cohort reflects that they have plateaued in their ability to manage heavy clinical burdens, while modestly declining in their cognition and dexterity. Albeit indirectly, these responses, too, seemed to support a reduction in overnight shifts that might be disproportionately burdensome to senior faculty.

In response to these survey results, our department launched an official operational wellness initiative in August 2019 that reduced overnight hours for EM faculty in three tiers of professional seniority: 15, 20, and 25 years post-residency, respectively, receiving 50 percent, 75 percent, and 100 percent reduction in overnight clinical hours from the general faculty.

As an example, our adult EM staffing model, which dedicates 10 percent of our faculty lines to nocturnist roles, would have staffed full-time general faculty on approximately 17–18 overnights annually. With this initiative, full-time general faculty are staffed on approximately 20 overnight shifts annually — an increase of one overnight shift per 4–6 months.

We believe in the upside: Faculty with 15 years of seniority work approximately 10 overnights annually, those with 20 years of seniority work five overnights annually, and those with 25 years of seniority are absolved from overnight shift work.

Any staffing model has the potential to crumble. This initiative’s Achilles heel would be a sudden exodus of nocturnists — EM faculty who primarily work overnight shifts — or the sudden need for increased overnight shift work. So, we added a self-imposed, protective measure for overall faculty well-being. These seniority-based overnight reductions are liable to be adjusted, though not necessarily completely reversed, if patient care requires full-time general faculty to work over 36 overnight shifts annually. We believe this reflects a sustainable model that respects experience-related (and often age-related) changes for senior faculty members, while concurrently protecting general faculty from undue overnight shift burden.

Through this democratically supported initiative, we hope to create an environment of increased physical and mental health not only for senior faculty, but also for the entire department. We believe this initiative may increase overall departmental academic productivity (i.e., teaching, publications, and funding) by reducing or eliminating overnight shifts from senior faculty, who would be most negatively affected and who often carry more academic responsibilities than junior faculty.

For a similar reason, overall departmental mentorship should increase, since senior faculty are more likely to serve as mentors to their departmental emergency physician colleagues, to residency trainees and medical students, and to those outside their institutions. Overall, this environment should enhance departmental success and morale.

The sustainability of this initiative highlights the importance of recruiting, hiring, and nurturing a strong team of EM faculty who primarily work overnight shifts. Creating an environment of fair compensation for our nocturnists that includes reduced clinical hours, shift choice, additional salary, and willingness to work with individuals’ family needs or circadian rhythm is of highest priority.

We recognize that another group’s demographics (e.g., age, seniority, cultural preferences) will dictate the specific details of a similar initiative. Regardless, we believe this survey-based process of creating visible consensus should be applicable to any undesirable shift type (e.g., late evenings, weekends, holidays) in any shift-based medical specialty (e.g., radiology, hospital medicine, critical care). In fact, an observational study in the field of diagnostic radiology shows physiologic and cognitive effects of overnight shift work, thus unveiling a subspecialty that may be ripe for a similar staffing strategy.(8)

Limitations

This survey was conducted as part of a departmental operations initiative and was limited to faculty who work in our adult EDs; our pediatric EDs are staffed separately. This survey intentionally did not present age-related response options for assigning overnight shifts, nor does it allow for retrospective analysis based on respondent age, since it was anonymous.

This survey and the resulting democratically supported initiative was conducted at a single site in an urban academic setting. As a result, the responses may not be generally applicable to all settings, and while we had a 79 percent response rate, it is possible that the 21 percent who did not respond could have differed systematically.

Conclusions

Through a democratic process, our faculty as a whole recognized the potential benefits of reducing overnight shifts based on professional seniority. Our results show that faculty appear willing to sacrifice working a slightly increased number of overnights as junior faculty in return for the reduction of overnight shifts in their futures as senior practitioners.

Regardless of a faculty member’s seniority or tenure, faculty perceive this operational wellness initiative as increasing job satisfaction and a reason to continue working in our faculty group.

With a strong team of nocturnists, a consensus-based overnight shift strategy was created to reward, recruit, and retain valuable senior faculty while developing junior faculty with more circadian plasticity.

References

1. Folkard S. Shift Work, Safety, and Aging. Chronobiol Int. 2008;25:183–98. doi: 10.1080/07420520802106694

2. Muecke S. Effects of Rotating Night Shifts: Literature Review. Adv Nurs. 2005;50:433–9. doi: 10.1111/j.1365-2648.2005.03409.x

3. Rouch I, Wild P, Ansiau D, Marquié J-C. Shiftwork Experience, Age and Cognitive Performance. Ergonomics. 2005;48:1282–93. doi: 10.1080/00140130500241670

4. Goldberg R, Thomas H, Penner L. Issues of Concern to Emergency Physicians in Pre-retirement Years: A Survey. J Emerg Med. 2011 Jun;40(6):706-13. doi: 10.1016/j.jemermed.2009.08.020.

5. Smith-Coggins R, Broderick KB, Marco CA. Night Shifts in Emergency Medicine: The American Board of Emergency Medicine Longitudinal Study of Emergency Physicians. J Emerg Med. 2014;47:372–8. doi: 10.1016/j.jemermed.2014.04.020

6. Takakuwa KM, Biros MH, Ruddy RM, FitzGerald M, Shofer FS. A National Survey of Academic Emergency Medicine Leaders on the Physician Workforce and Institutional Workforce and Aging Policies. Acad Med. 2013;88:269–75. doi: 10.1097/acm.0b013e31827c026e

7. Gorelick M, Schremmer R, Ruch-Ross H, Radabaugh C, Selbst S. Current Workforce Characteristics and Burnout in Pediatric Emergency Medicine. Acad Emerg Med. 2016;23:48–54. doi: 10.1111/acem.12845

8. Hanna TN, Zygmont ME, Peterson RT, Theriot D, Shekhani H, Johnson JO, Krupinski EA. The Effects of Fatigue from Overnight Shifts on Radiology Search Patterns and Diagnostic Performance. J Am Coll Radiol. 2018 Dec;15(12):1709–2016. doi: 10.1016/j.jacr.2017.12.019