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Trainee experience of ‘out of hours’ surgical working in the UK: A cross-sectional analysis
the surgeon xxx (xxxx) xxx
Trainee experience of ‘out of hours’ surgical working in the UK: A cross-sectional analysis P.G. Vaughan-Shaw a,b, B. Lineham a,c, K. Hurst a,d, O. McBride a,e, C. Honeyman a,d, S. Healy a,f, J. Banks a,g, N. Wickramasinghe a,h, D.M. Riding a,i,*, M. Moran a,j a
Trainees' Committee, Royal College of Surgeons of Edinburgh, Edinburgh, UK Department of Colorectal Surgery, Western General Hospital, Edinburgh, UK c Health Education England Yorkshire and the Humber, Leeds, UK d Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK e Department of Vascular Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK f Department of Ear, Nose and Throat Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK g Department of Breast Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK h Department of Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK i Health Education England North West, Manchester, UK j Pfizer Pharma GmbH, Berlin, Germany b
article info
abstract
Article history:
Background: Changes to working practices and increasing service demand have contributed
Received 30 August 2019
to low morale amongst UK surgical trainees, with pressures particularly acute ‘out of
Received in revised form
hours’ (OOH). Surgeons may be expected to be ‘on call’ for multiple hospitals, or to provide
2 October 2019
remote consultations, yet healthcare systems may undermine their professional safety and
Accepted 20 October 2019
patient care. This cross-sectional study sought to define the perceptions of UK-based Royal
Available online xxx
College of Surgeons of Edinburgh (RCSEd) affiliated trainees of OOH surgical care and training.
Keywords:
Methods: The RCSEd Trainees' Committee conducted a design-thinking exercise to produce
Patient safety
an online questionnaire. Non-consultant grade RCSEd Members and Fellows were invited
Surgical training
to participate. Quantitative data was analysed using descriptive statistics, and qualitative
Emergency surgery
data was coded to identify emergent themes.
Healthcare systems
Results: One hundred and fifty-five surgeons participated. Of those surgeons working in multiple hospitals OOH (n ¼ 16), many did not receive access cards (12[75%]) or site-specific induction (13[81%]), and 8(50%) were not confident in using local electronic investigation and records systems. Only 14/114 (12%) of the surgeons providing remote opinion had access to a consultation record system, and most perceived dissatisfaction with the system. Emergent themes from qualitative data revealed that trainee surgeons desire specific training in OOH working, concerns that OOH work experience is diminishing, and that hospital infrastructure such as IT and communications, rest facilities and catering were inadequate in facilitating safe care. Conclusions: The participants perceived that the systems supporting delivery of safe surgical care OOH were inadequate. Hospital leaders should ensure that systems minimise risk to staff and patients. © 2019 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Trainees' Committee, Royal College of Surgeons of Edinburgh, Nicolson St, Edinburgh EH8 9DW, UK. E-mail address: [email protected] (D.M. Riding). https://doi.org/10.1016/j.surge.2019.10.002 1479-666X/© 2019 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. Please cite this article as: Vaughan-Shaw PG et al., Trainee experience of ‘out of hours’ surgical working in the UK: A cross-sectional analysis, The Surgeon, https://doi.org/10.1016/j.surge.2019.10.002
2
the surgeon xxx (xxxx) xxx
Introduction The delivery of safe surgical care within the National Health Service (NHS) is increasingly difficult. Patients often have multiple comorbidities, polypharmacy, and can be amongst the sickest patients in the NHS. They may have a high risk of major complications and death.1 Emergency surgical patients present at any time of the day or night and require prompt assessment, timely investigation and appropriate management. Meanwhile, surgical inpatients who suddenly become unwell require timely ‘out of hours’ (OOH) assessment and management. The changing context of post-graduate medical training in the UK as a result of Calman reforms, the New Deal and the implementation of the European Working Time Directive (EWTD) led to a substantial reorganisation of surgical work patterns.2e4 Shift work has become normal for trainees, specialty and associate specialists (SAS) and consultants, as has the provision of cover across multiple specialties or hospital sites. Parallel service restructuring has resulted in many specialties working within a centralised system, where a major part of the ‘on call’ work is the provision of remote opinion from ‘hub’ tertiary level centres to ‘spoke’ hospitals. Recent survey data suggested low morale amongst surgical doctors. Poor communication, a lack of continuity of care and training, and increasingly burdensome service provision have contributed to this dissatisfaction.5 Recommendations from the Royal College of Surgeons of Edinburgh (RCSEd) proposed a focus on delivery of training, improved availability of senior support, sensible rota design and the development of an integrated multidisciplinary surgical team as interventions to mitigate these problems.6 Surgeons are increasingly aware of the role that human factors play in the provision of safe care. Healthcare professionals do not make errors in isolation, and the working environment should be optimised to maximise the probability of satisfactory outcomes.7 The OOH working environment presents unique challenges, including navigating to and accessing a remote hospital site out of hours, liaising remotely with a colleague in the emergency department without direct access to the patient and their imaging, and often working with colleagues for the first time without the reassurance of a pre-established professional relationship. This model of service provision has the potential to threaten patient safety and to compromise staff well-being. Recent, well-documented proceedings have led many doctors to be concerned that individual clinicians are being considered liable for errors induced by institutional systematic failures.8 To date, there has been limited direct engagement with the stakeholders on the front line of OOH surgical care. The current study defines the experience and opinions of UK-based RCSEd-affiliated trainees in relation to out of hours surgical care and training and asks: ‘How might we improve the out of hours surgical training landscape in the UK, so that RCSEd is a promoter of best practice?’
Methods The study group (Trainees' Committee of the RCSEd) undertook a design thinking exercise7 to explore the question: ‘How
might we improve the out of hours surgical training landscape in the UK, so that RCSEd is a promoter of best practice?’. Through this process a prospective, cross-sectional, focussed online questionnaire was developed. This was approved by the RCSEd Council and then transposed onto the commercial online survey platform ‘Survey Monkey’. The survey was distributed to RCSEd-affiliated trainees using the College's mailing list and was promoted on social media platforms. The email or social media post detailed the purpose of the survey and included a hyperlink that connected directly to the questionnaire on the ‘Survey Monkey’ website. The questionnaire was available for two months between 1st July and 31st August 2018. The survey was voluntary, and no identifiable data were collected or stored. The questionnaire design dictated mandatory completion of each question to unlock the proceeding question. In this study, all non-consultant, non-SAS (specialty and associate specialist) grade RCSEd Members and Fellows are referred to as ‘trainees’. Participants were asked to provide basic demographics including level of training (FY1/2, CT1/2, ST3/4 ST5þ) and specialty (Ear, Nose and Throat, General Surgery, Trauma & Orthopaedics, Neurosurgery, Cardiothoracic Surgery, Paediatric Surgery, Plastic Surgery, Urology, Oral and Maxillo-facial Surgery, Vascular Surgery, Transplant and Access and Hepatobiliary). Participants were invited to confirm their status as academic trainees (AFY2, ACF or ACL), less than full-time trainees, and their specialty cover (i.e. single specialty versus cross-specialty cover) and shift pattern (i.e. resident/shift, non-resident, single unit cover, multiple unit cover). Participants were invited to submit free text responses to describe examples of best practice or aspirations for out of hours (OOH) working. The responses were coded into four domains: education and training, staffing, morale and working conditions, and IT systems. These domains were identified during a post hoc analysis of the responses. Within each domain, specific emergent themes were coded. The draft analysis of the qualitative data was performed by DR and corroborated by the other authors, with coding differences settled by consensus. Data were exported from SurveyMonkey into Microsoft Excel (Microsoft, 2010, Redmond, Washington, USA) which was used to generate summary descriptive statistics.
Results Demographics There were a total of 155 participants. All training grades and surgical sub-specialties were represented, most commonly working in General Surgery (36%) and Trauma and Orthopaedics (18%). Sixty-eight percent (n ¼ 105) were higher surgical trainees, 16% (n ¼ 25) were core surgical trainees and 3% (n ¼ 5) were Foundation trainees. The remaining 20 participants (13%) were in non-training, non-consultant grade posts. Seventeen participants (11%) worked less than full time (LTFT). The majority of Plastic Surgery, Urology, OMFS, ENT and Vascular trainees reported non-resident on-call work. Of
Please cite this article as: Vaughan-Shaw PG et al., Trainee experience of ‘out of hours’ surgical working in the UK: A cross-sectional analysis, The Surgeon, https://doi.org/10.1016/j.surge.2019.10.002
3
the surgeon xxx (xxxx) xxx
these OMFS and Urology were most likely to work in systems covering multiple hospital sites simultaneously. For ease of understanding, the quantitative and qualitative data are presented separately.
investigations or records, and 63(52%) dissatisfied with training received in remote consultation. Seventy-five participants (63%) were dissatisfied with their understanding of the medicolegal aspects of providing remote consultation (see Fig. 2). Of the 119 who responded to the relevant question, 23(19%) participants were aware of electronic communication applications used to transfer confidential information within their hospital, with 10(8%) perceiving them to be useful. Meanwhile, 64(54%) felt institutional Wi-Fi provision was inadequate for working needs (e.g. accessing hospital guidelines or emails). Eighty three (70%) felt that weak or absent mobile phone signal had impacted communication during OOH working, and 40(34%) had witnessed at least one incident where safe patient care was perceived to be threatened by poor mobile phone/Wi-Fi coverage.
Quantitative responses Of the 126 participants responding to the question, the majority received their rota by email (n ¼ 96, 76%), with 19(15%) using web-based rotas and 9(7%) still working to paper rotas. Twenty-nine (30%) of those working from emailed rotas ‘always’ felt able to identify and contact junior members of the team, compared to 21% (n ¼ 4) of those using web-based rotas. Sixty-four (51%) felt that they were always able to identify and contact senior colleagues with no difference seen dependent on means of rota distribution. Twelve participants (10%) said they could ‘rarely’ or ‘never’ contact junior colleagues. Participants were invited to comment on aspects of multisite OOH working. Sixteen participants provided information and of these 12(75%) were not provided with access identity cards for relevant hospital sites, 13(81%) were not provided with site-specific induction including the location of emergency equipment, and 8(50%) did not feel confident in using the local electronic patient records and documentation systems. Six participants (38%) were required to undertake further training before being granted access to these systems (see Fig. 1). Finally, experiences in the provision of remote opinion and advice were explored. Of the 114 responses to this question, only 14(12%) participants had access to a formal consultation record system, while 30(26%) did not document remote advice anywhere, and 24(21%) requested that the parent team should document the advice. Amongst the 120 responses to a further question, there was a high level of dissatisfaction in particular aspects of remote consultation, with 34(28%) dissatisfied with the available communication systems, 50(42%) dissatisfied with documentation systems, 64(53%) dissatisfied with remote access to patient
Qualitative responses In total, 258 free text responses were received from 133 participants (86%). Twenty-two participants (14%) did not provide any free text responses. Initial analysis identified four domains: education and training, staffing, morale and working conditions, and information technology.
Education and training Emerging themes in this domain included a desire for training in how to manage the specific challenges of working OOH. Participants suggested that interventions focussing on the management of referrals from other hospitals, primary care centres or other healthcare providers would be useful. Participants also reported a desire to have better supervision and support from consultants, though some described experiencing ‘good’ or ‘excellent’ senior support during OOH work. There was also an aspiration to see clearer guidance on admission criteria for patients referred OOH, to ensure safe care. In general, OOH working was considered an important part of training:
Swipe card access to relevant clinical areas
Informed of locaƟon of emergency equipment
Provided with access to electronic invesƟgaƟon / records systems
Provision of addiƟonal training to enable systems access
0
10 Yes
20
30
40
50
60
70
80
90
No
Fig. 1 e Experiences of trainees with multi-site responsibility during out of hours working (by percentage, n ¼ 16). Please cite this article as: Vaughan-Shaw PG et al., Trainee experience of ‘out of hours’ surgical working in the UK: A cross-sectional analysis, The Surgeon, https://doi.org/10.1016/j.surge.2019.10.002
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the surgeon xxx (xxxx) xxx
CommunicaƟon
DocumentaƟon
Access to invesƟgaƟons / records
Training in providing remote consultaƟon
Understanding medicolegal aspects of remote consultaƟon
0 SaƟsfied
Neutral
10
20
DissaƟsfied
30
40
50
60
70
No answer
Fig. 2 e Trainee satisfaction by percentage with aspects of remote consultation during out of hours working (n ¼ 120).
‘[I aspire] to have a supportive team of consultants, easily contactable, who are willing to train and let me do the emergency operating myself (either independently or under supervision e as appropriate)’ ‘I feel that trainees think that because they aren't one to one with a senior permanently being taught that they are not being trained. However, it is OOH when you need to make decisions, manage patients is where you learn a lot about risk awareness, management etc therefore OOH is in my opinion a hugely important part of your training.’
Staffing Many participants reported concerns about the number of staff working OOH, and their level of experience. Most reported an acceptable level of consultant availability OOH, but there was a perceived deficit in the availability of more junior doctors such as Foundation or Core level trainees. As well as concerns regarding staffing, it was suggested that the reduction in OOH experience for junior staff (with some departments having no sub-registrar level doctor OOH), may lead to a reduction in the quality of OOH service in future, as doctors take on senior roles with little relevant experience: ‘I am concerned that in 10 years' time we will have senior doctors with no understanding of out of hours work.’ ‘OOH is woefully understaffed, with very low morale in the various centres in which I have worked.’
Morale and working conditions The dominant emergent theme in this domain was general dissatisfaction with the prevailing ‘in hospital’ conditions for those working OOH. In particular, there was a clear aspiration for on call rest rooms and showers, and ‘staff only’ areas such as the Doctors' Mess and private eating areas. The need for high quality hot food, rather than microwaveable vending
machine products was a common theme. Participants suggested that hospitals should do more to encourage the welfare and morale of OOH workers: ‘Better quality food (not just abysmal vending machine), a better doctors' mess with functioning TV, kitchen, Wi-Fi, computers with access to results. There should also be reserved parking close to the hospital rather than having to walk 500 metres across a deserted car park at 4am. Gym facilities would be good but not the obligation of NHS to provide this.’
Information technology Participants reported general dissatisfaction with the available information technology to support OOH working. Remote access to patient data, particularly imaging, was a common aspiration for participants, as was an online system for recording remote consultations that would be integrated into the patient's record. Although pager technology was not considered to be helpful, some participants suggested that hand held devices were time consuming and not a valid substitute for OOH referrals or requests for advice: ‘Better communication infrastructure is required. Mobile phone reception in the hospital is so poor that often outside consultants can't get through to the on call consultant, and so they call the registrar bleep, and we have to act as a secretary, taking the contact number and then walking to find the consultant and asking them to phone the referring hospital back. This is a poor service to the [referring] District General Hospitals and is a ridiculous waste of registrar training time. Good communications infrastructure should be a top priority for hospital management to optimise patient safety, efficiency of service delivery and junior doctor training.’
Please cite this article as: Vaughan-Shaw PG et al., Trainee experience of ‘out of hours’ surgical working in the UK: A cross-sectional analysis, The Surgeon, https://doi.org/10.1016/j.surge.2019.10.002
the surgeon xxx (xxxx) xxx
Discussion This cross-sectional study shows that RCSEd-affiliated nonconsultant grade Members and Fellows continue to report major concerns with the institutional systems and working conditions that underpin their ‘out of hours’ (OOH) practice. Despite these concerns it is recognised that OOH work is a fundamental and important part of training that hones decision making and organisational skills. As such, participants felt that specific training in managing patients OOH should be included in curricula, as the required skills can be very different from the usual day time duties. Curriculum designers may wish to mitigate these concerns by including specific syllabus points in future iterations. It is now appreciated that human factors and healthcare systems design influence patient care, and that formal training in these domains improves patient safety. There continues to be concern that as more junior colleagues are taken off OOH shifts, particularly overnight, there is an increasing deficit in the availability of support for the (often) registrar level surgeon on call, particularly in the smaller surgical specialties. The longer term concern is that the pool of collective knowledge of OOH working is steadily diminishing, and that future registrar level surgeons may not have sufficient experience to be able to safely manage patients OOH. If these perceptions are accepted, NHS institutions may need to consider how they deploy newly qualified and early years surgical doctors to ensure that they gain sufficient experience to preserve the cultural memory of OOH working. Failure to do so may threaten services' ability to provide safe care. One of the key findings of this study was the difficulty perceived by many participants in working across multiple sites OOH, either by travelling between different hospitals, or by being the point of contact for peripheral ‘spoke’ units seeking specialist advice from tertiary ‘hub’ units. The very high proportion of participants who did not have adequate security clearance and identification badges to allow them access to different hospitals and their data systems is alarming, as is the finding that many did not have site-specific inductions to inform them of local facilities and equipment. This represents a clear threat to patient safety OOH, and requires urgent amendment. Hospitals inviting specialist surgeons into their institution to treat patients have an obligation to ensure that they are adequately prepared and informed. Failure to do so conceivably impedes patient care. The task of providing remote consultations over the telephone, relying on the assessment of the referring nonspecialist clinician was also reported as potentially problematic. In the era of centralisation of services to ‘hub and spoke’ models of care, this may be increasingly common, yet there is a perception that there is a lack of specific training and formalised documentation systems to protect the advising surgeon. Management recommendations are often recorded in the patient's notes by the referrer, with medical records unavailable to the surgeon. There can often be difficulty in accessing required imaging in specialties where this is particularly important. The results of this study suggest that there appears to be a culture of informality in many units
5
despite the highly consequential advice given, such as patients rejected by vascular surgery units for repair of ruptured abdominal aortic aneurysm. In the design thinking exercise (see ‘Methods’), neurosurgical units were considered to be exemplars of best practice in remote consultation, with formalised systems of imaging review and decision making already in place. As services are increasingly centralised, other specialties may wish to consider how they should minimise the risk to both their colleagues and patients when providing remote opinion and advice. Participants also reported an increasing reliance on mobile technology to communicate between colleagues during OOH. Despite this, many hospitals continue to have either mobile phone ‘blackspots’ with no available mobile signal, or inadequate Wi-Fi internet provision. Importantly, 70% of participants reported that failure of this technology had impeded communication OOH, with around one third suggesting that this had directly contributed to threatened patient safety. In addition, much of the current communication hardware is provided by the individual surgeon at their own cost, usually their own smart phone. Hospitals may need to review their communication hardware and software technology to ensure that communications between team members is safe, effective and funded by the employer, not the employee. This cross sectional survey of 155 trainee surgeons provides a useful overview of OOH working in the UK National Health Service. As with all survey-based studies, a greater number of participants may have allowed firmer conclusions to be drawn. Further interrogation of qualitative responses (by deploying focus groups or semi-structured interviews) may have offered deeper understanding of the issues raised. In addition, given that the authors are themselves surgical trainees, there should be an acknowledgement of potential confirmation bias framed within their own experiences of working OOH. Despite these weaknesses, the findings corroborate non-academic discourse on working conditions that many surgeons will recognise, and (at least) offer evidence to stimulate further investigation of how working systems and conditions can be optimised to protect trainee surgeons and their patients.
Acknowledgements The authors wish to thank Richard McGregor and Juliana Fraser for their advice and assistance in preparing the survey, and Clare McNaught, Robin Paton, Janet Ross and Sai Vittal for reviewing the manuscript. We are grateful to The Royal College of Surgeons of Edinburgh, who supplied administrative support for this study.
references
1. The Royal College of Surgeons of England. Emergency surgery e standards for unscheduled surgical care. Available from: https://www.rcseng.ac.uk/search/#SearchTerm¼emergency% 20surgery [accessed 19.07.19].
Please cite this article as: Vaughan-Shaw PG et al., Trainee experience of ‘out of hours’ surgical working in the UK: A cross-sectional analysis, The Surgeon, https://doi.org/10.1016/j.surge.2019.10.002
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the surgeon xxx (xxxx) xxx
2. Calman K. Consultation on report of working group on specialist medical training. London: Department of Health; 1993. 3. Department of Health. New deal: working arrangements for doctors and dentists in training. Available from: https:// webarchive.nationalarchives.gov.uk/20120503153201/http:// www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@ dh/@en/documents/digitalasset/dh_4053893.pdf [accessed 19.07.19]. 4. European Community. Council Directive 93/104/EC. Off J Eur Commun 1993;L307:18e24. 5. Baggaley A, Robb L, Paterson-Brown S, McGregor RJ. Improving the working environment for the delivery of safe surgical care in the UK: a qualitative cross-sectional analysis. BMJ Open 2019;9(1):1e8.
6. The Royal College of Surgeons of Edinburgh. Improving the working environment for safe surgical care. Available from: https://www.rcsed.ac.uk/media/415574/rcsed-workingenvironment-web3.pdf [accessed 19.07.19]. 7. Catchpole K. Spreading human factors expertise in healthcare: untangling the knots in people and systems. BMJ Qual Saf 2013;22(10):793e7. 8. General Medical Council. Responding to the case of Dr Bawa Garba. Available from: https://www.gmc-uk.org/about/howwe-work/corporate-strategy-plans-and-impact/supporting-aprofession-under-pressure/responding-to-the-case-of-drbawa-garba [accessed 19.07.19].
Please cite this article as: Vaughan-Shaw PG et al., Trainee experience of ‘out of hours’ surgical working in the UK: A cross-sectional analysis, The Surgeon, https://doi.org/10.1016/j.surge.2019.10.002
Trainee experience of ‘out of hours’ surgical working in the UK: A cross-sectional analysis P.G. Vaughan-Shaw a,b, B. Lineham a,c, K. Hurst a,d, O. McBride a,e, C. Honeyman a,d, S. Healy a,f, J. Banks a,g, N. Wickramasinghe a,h, D.M. Riding a,i,*, M. Moran a,j a
Trainees' Committee, Royal College of Surgeons of Edinburgh, Edinburgh, UK Department of Colorectal Surgery, Western General Hospital, Edinburgh, UK c Health Education England Yorkshire and the Humber, Leeds, UK d Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK e Department of Vascular Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK f Department of Ear, Nose and Throat Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK g Department of Breast Surgery, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK h Department of Orthopaedic Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK i Health Education England North West, Manchester, UK j Pfizer Pharma GmbH, Berlin, Germany b
article info
abstract
Article history:
Background: Changes to working practices and increasing service demand have contributed
Received 30 August 2019
to low morale amongst UK surgical trainees, with pressures particularly acute ‘out of
Received in revised form
hours’ (OOH). Surgeons may be expected to be ‘on call’ for multiple hospitals, or to provide
2 October 2019
remote consultations, yet healthcare systems may undermine their professional safety and
Accepted 20 October 2019
patient care. This cross-sectional study sought to define the perceptions of UK-based Royal
Available online xxx
College of Surgeons of Edinburgh (RCSEd) affiliated trainees of OOH surgical care and training.
Keywords:
Methods: The RCSEd Trainees' Committee conducted a design-thinking exercise to produce
Patient safety
an online questionnaire. Non-consultant grade RCSEd Members and Fellows were invited
Surgical training
to participate. Quantitative data was analysed using descriptive statistics, and qualitative
Emergency surgery
data was coded to identify emergent themes.
Healthcare systems
Results: One hundred and fifty-five surgeons participated. Of those surgeons working in multiple hospitals OOH (n ¼ 16), many did not receive access cards (12[75%]) or site-specific induction (13[81%]), and 8(50%) were not confident in using local electronic investigation and records systems. Only 14/114 (12%) of the surgeons providing remote opinion had access to a consultation record system, and most perceived dissatisfaction with the system. Emergent themes from qualitative data revealed that trainee surgeons desire specific training in OOH working, concerns that OOH work experience is diminishing, and that hospital infrastructure such as IT and communications, rest facilities and catering were inadequate in facilitating safe care. Conclusions: The participants perceived that the systems supporting delivery of safe surgical care OOH were inadequate. Hospital leaders should ensure that systems minimise risk to staff and patients. © 2019 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Trainees' Committee, Royal College of Surgeons of Edinburgh, Nicolson St, Edinburgh EH8 9DW, UK. E-mail address: [email protected] (D.M. Riding). https://doi.org/10.1016/j.surge.2019.10.002 1479-666X/© 2019 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. Please cite this article as: Vaughan-Shaw PG et al., Trainee experience of ‘out of hours’ surgical working in the UK: A cross-sectional analysis, The Surgeon, https://doi.org/10.1016/j.surge.2019.10.002
2
the surgeon xxx (xxxx) xxx
Introduction The delivery of safe surgical care within the National Health Service (NHS) is increasingly difficult. Patients often have multiple comorbidities, polypharmacy, and can be amongst the sickest patients in the NHS. They may have a high risk of major complications and death.1 Emergency surgical patients present at any time of the day or night and require prompt assessment, timely investigation and appropriate management. Meanwhile, surgical inpatients who suddenly become unwell require timely ‘out of hours’ (OOH) assessment and management. The changing context of post-graduate medical training in the UK as a result of Calman reforms, the New Deal and the implementation of the European Working Time Directive (EWTD) led to a substantial reorganisation of surgical work patterns.2e4 Shift work has become normal for trainees, specialty and associate specialists (SAS) and consultants, as has the provision of cover across multiple specialties or hospital sites. Parallel service restructuring has resulted in many specialties working within a centralised system, where a major part of the ‘on call’ work is the provision of remote opinion from ‘hub’ tertiary level centres to ‘spoke’ hospitals. Recent survey data suggested low morale amongst surgical doctors. Poor communication, a lack of continuity of care and training, and increasingly burdensome service provision have contributed to this dissatisfaction.5 Recommendations from the Royal College of Surgeons of Edinburgh (RCSEd) proposed a focus on delivery of training, improved availability of senior support, sensible rota design and the development of an integrated multidisciplinary surgical team as interventions to mitigate these problems.6 Surgeons are increasingly aware of the role that human factors play in the provision of safe care. Healthcare professionals do not make errors in isolation, and the working environment should be optimised to maximise the probability of satisfactory outcomes.7 The OOH working environment presents unique challenges, including navigating to and accessing a remote hospital site out of hours, liaising remotely with a colleague in the emergency department without direct access to the patient and their imaging, and often working with colleagues for the first time without the reassurance of a pre-established professional relationship. This model of service provision has the potential to threaten patient safety and to compromise staff well-being. Recent, well-documented proceedings have led many doctors to be concerned that individual clinicians are being considered liable for errors induced by institutional systematic failures.8 To date, there has been limited direct engagement with the stakeholders on the front line of OOH surgical care. The current study defines the experience and opinions of UK-based RCSEd-affiliated trainees in relation to out of hours surgical care and training and asks: ‘How might we improve the out of hours surgical training landscape in the UK, so that RCSEd is a promoter of best practice?’
Methods The study group (Trainees' Committee of the RCSEd) undertook a design thinking exercise7 to explore the question: ‘How
might we improve the out of hours surgical training landscape in the UK, so that RCSEd is a promoter of best practice?’. Through this process a prospective, cross-sectional, focussed online questionnaire was developed. This was approved by the RCSEd Council and then transposed onto the commercial online survey platform ‘Survey Monkey’. The survey was distributed to RCSEd-affiliated trainees using the College's mailing list and was promoted on social media platforms. The email or social media post detailed the purpose of the survey and included a hyperlink that connected directly to the questionnaire on the ‘Survey Monkey’ website. The questionnaire was available for two months between 1st July and 31st August 2018. The survey was voluntary, and no identifiable data were collected or stored. The questionnaire design dictated mandatory completion of each question to unlock the proceeding question. In this study, all non-consultant, non-SAS (specialty and associate specialist) grade RCSEd Members and Fellows are referred to as ‘trainees’. Participants were asked to provide basic demographics including level of training (FY1/2, CT1/2, ST3/4 ST5þ) and specialty (Ear, Nose and Throat, General Surgery, Trauma & Orthopaedics, Neurosurgery, Cardiothoracic Surgery, Paediatric Surgery, Plastic Surgery, Urology, Oral and Maxillo-facial Surgery, Vascular Surgery, Transplant and Access and Hepatobiliary). Participants were invited to confirm their status as academic trainees (AFY2, ACF or ACL), less than full-time trainees, and their specialty cover (i.e. single specialty versus cross-specialty cover) and shift pattern (i.e. resident/shift, non-resident, single unit cover, multiple unit cover). Participants were invited to submit free text responses to describe examples of best practice or aspirations for out of hours (OOH) working. The responses were coded into four domains: education and training, staffing, morale and working conditions, and IT systems. These domains were identified during a post hoc analysis of the responses. Within each domain, specific emergent themes were coded. The draft analysis of the qualitative data was performed by DR and corroborated by the other authors, with coding differences settled by consensus. Data were exported from SurveyMonkey into Microsoft Excel (Microsoft, 2010, Redmond, Washington, USA) which was used to generate summary descriptive statistics.
Results Demographics There were a total of 155 participants. All training grades and surgical sub-specialties were represented, most commonly working in General Surgery (36%) and Trauma and Orthopaedics (18%). Sixty-eight percent (n ¼ 105) were higher surgical trainees, 16% (n ¼ 25) were core surgical trainees and 3% (n ¼ 5) were Foundation trainees. The remaining 20 participants (13%) were in non-training, non-consultant grade posts. Seventeen participants (11%) worked less than full time (LTFT). The majority of Plastic Surgery, Urology, OMFS, ENT and Vascular trainees reported non-resident on-call work. Of
Please cite this article as: Vaughan-Shaw PG et al., Trainee experience of ‘out of hours’ surgical working in the UK: A cross-sectional analysis, The Surgeon, https://doi.org/10.1016/j.surge.2019.10.002
3
the surgeon xxx (xxxx) xxx
these OMFS and Urology were most likely to work in systems covering multiple hospital sites simultaneously. For ease of understanding, the quantitative and qualitative data are presented separately.
investigations or records, and 63(52%) dissatisfied with training received in remote consultation. Seventy-five participants (63%) were dissatisfied with their understanding of the medicolegal aspects of providing remote consultation (see Fig. 2). Of the 119 who responded to the relevant question, 23(19%) participants were aware of electronic communication applications used to transfer confidential information within their hospital, with 10(8%) perceiving them to be useful. Meanwhile, 64(54%) felt institutional Wi-Fi provision was inadequate for working needs (e.g. accessing hospital guidelines or emails). Eighty three (70%) felt that weak or absent mobile phone signal had impacted communication during OOH working, and 40(34%) had witnessed at least one incident where safe patient care was perceived to be threatened by poor mobile phone/Wi-Fi coverage.
Quantitative responses Of the 126 participants responding to the question, the majority received their rota by email (n ¼ 96, 76%), with 19(15%) using web-based rotas and 9(7%) still working to paper rotas. Twenty-nine (30%) of those working from emailed rotas ‘always’ felt able to identify and contact junior members of the team, compared to 21% (n ¼ 4) of those using web-based rotas. Sixty-four (51%) felt that they were always able to identify and contact senior colleagues with no difference seen dependent on means of rota distribution. Twelve participants (10%) said they could ‘rarely’ or ‘never’ contact junior colleagues. Participants were invited to comment on aspects of multisite OOH working. Sixteen participants provided information and of these 12(75%) were not provided with access identity cards for relevant hospital sites, 13(81%) were not provided with site-specific induction including the location of emergency equipment, and 8(50%) did not feel confident in using the local electronic patient records and documentation systems. Six participants (38%) were required to undertake further training before being granted access to these systems (see Fig. 1). Finally, experiences in the provision of remote opinion and advice were explored. Of the 114 responses to this question, only 14(12%) participants had access to a formal consultation record system, while 30(26%) did not document remote advice anywhere, and 24(21%) requested that the parent team should document the advice. Amongst the 120 responses to a further question, there was a high level of dissatisfaction in particular aspects of remote consultation, with 34(28%) dissatisfied with the available communication systems, 50(42%) dissatisfied with documentation systems, 64(53%) dissatisfied with remote access to patient
Qualitative responses In total, 258 free text responses were received from 133 participants (86%). Twenty-two participants (14%) did not provide any free text responses. Initial analysis identified four domains: education and training, staffing, morale and working conditions, and information technology.
Education and training Emerging themes in this domain included a desire for training in how to manage the specific challenges of working OOH. Participants suggested that interventions focussing on the management of referrals from other hospitals, primary care centres or other healthcare providers would be useful. Participants also reported a desire to have better supervision and support from consultants, though some described experiencing ‘good’ or ‘excellent’ senior support during OOH work. There was also an aspiration to see clearer guidance on admission criteria for patients referred OOH, to ensure safe care. In general, OOH working was considered an important part of training:
Swipe card access to relevant clinical areas
Informed of locaƟon of emergency equipment
Provided with access to electronic invesƟgaƟon / records systems
Provision of addiƟonal training to enable systems access
0
10 Yes
20
30
40
50
60
70
80
90
No
Fig. 1 e Experiences of trainees with multi-site responsibility during out of hours working (by percentage, n ¼ 16). Please cite this article as: Vaughan-Shaw PG et al., Trainee experience of ‘out of hours’ surgical working in the UK: A cross-sectional analysis, The Surgeon, https://doi.org/10.1016/j.surge.2019.10.002
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the surgeon xxx (xxxx) xxx
CommunicaƟon
DocumentaƟon
Access to invesƟgaƟons / records
Training in providing remote consultaƟon
Understanding medicolegal aspects of remote consultaƟon
0 SaƟsfied
Neutral
10
20
DissaƟsfied
30
40
50
60
70
No answer
Fig. 2 e Trainee satisfaction by percentage with aspects of remote consultation during out of hours working (n ¼ 120).
‘[I aspire] to have a supportive team of consultants, easily contactable, who are willing to train and let me do the emergency operating myself (either independently or under supervision e as appropriate)’ ‘I feel that trainees think that because they aren't one to one with a senior permanently being taught that they are not being trained. However, it is OOH when you need to make decisions, manage patients is where you learn a lot about risk awareness, management etc therefore OOH is in my opinion a hugely important part of your training.’
Staffing Many participants reported concerns about the number of staff working OOH, and their level of experience. Most reported an acceptable level of consultant availability OOH, but there was a perceived deficit in the availability of more junior doctors such as Foundation or Core level trainees. As well as concerns regarding staffing, it was suggested that the reduction in OOH experience for junior staff (with some departments having no sub-registrar level doctor OOH), may lead to a reduction in the quality of OOH service in future, as doctors take on senior roles with little relevant experience: ‘I am concerned that in 10 years' time we will have senior doctors with no understanding of out of hours work.’ ‘OOH is woefully understaffed, with very low morale in the various centres in which I have worked.’
Morale and working conditions The dominant emergent theme in this domain was general dissatisfaction with the prevailing ‘in hospital’ conditions for those working OOH. In particular, there was a clear aspiration for on call rest rooms and showers, and ‘staff only’ areas such as the Doctors' Mess and private eating areas. The need for high quality hot food, rather than microwaveable vending
machine products was a common theme. Participants suggested that hospitals should do more to encourage the welfare and morale of OOH workers: ‘Better quality food (not just abysmal vending machine), a better doctors' mess with functioning TV, kitchen, Wi-Fi, computers with access to results. There should also be reserved parking close to the hospital rather than having to walk 500 metres across a deserted car park at 4am. Gym facilities would be good but not the obligation of NHS to provide this.’
Information technology Participants reported general dissatisfaction with the available information technology to support OOH working. Remote access to patient data, particularly imaging, was a common aspiration for participants, as was an online system for recording remote consultations that would be integrated into the patient's record. Although pager technology was not considered to be helpful, some participants suggested that hand held devices were time consuming and not a valid substitute for OOH referrals or requests for advice: ‘Better communication infrastructure is required. Mobile phone reception in the hospital is so poor that often outside consultants can't get through to the on call consultant, and so they call the registrar bleep, and we have to act as a secretary, taking the contact number and then walking to find the consultant and asking them to phone the referring hospital back. This is a poor service to the [referring] District General Hospitals and is a ridiculous waste of registrar training time. Good communications infrastructure should be a top priority for hospital management to optimise patient safety, efficiency of service delivery and junior doctor training.’
Please cite this article as: Vaughan-Shaw PG et al., Trainee experience of ‘out of hours’ surgical working in the UK: A cross-sectional analysis, The Surgeon, https://doi.org/10.1016/j.surge.2019.10.002
the surgeon xxx (xxxx) xxx
Discussion This cross-sectional study shows that RCSEd-affiliated nonconsultant grade Members and Fellows continue to report major concerns with the institutional systems and working conditions that underpin their ‘out of hours’ (OOH) practice. Despite these concerns it is recognised that OOH work is a fundamental and important part of training that hones decision making and organisational skills. As such, participants felt that specific training in managing patients OOH should be included in curricula, as the required skills can be very different from the usual day time duties. Curriculum designers may wish to mitigate these concerns by including specific syllabus points in future iterations. It is now appreciated that human factors and healthcare systems design influence patient care, and that formal training in these domains improves patient safety. There continues to be concern that as more junior colleagues are taken off OOH shifts, particularly overnight, there is an increasing deficit in the availability of support for the (often) registrar level surgeon on call, particularly in the smaller surgical specialties. The longer term concern is that the pool of collective knowledge of OOH working is steadily diminishing, and that future registrar level surgeons may not have sufficient experience to be able to safely manage patients OOH. If these perceptions are accepted, NHS institutions may need to consider how they deploy newly qualified and early years surgical doctors to ensure that they gain sufficient experience to preserve the cultural memory of OOH working. Failure to do so may threaten services' ability to provide safe care. One of the key findings of this study was the difficulty perceived by many participants in working across multiple sites OOH, either by travelling between different hospitals, or by being the point of contact for peripheral ‘spoke’ units seeking specialist advice from tertiary ‘hub’ units. The very high proportion of participants who did not have adequate security clearance and identification badges to allow them access to different hospitals and their data systems is alarming, as is the finding that many did not have site-specific inductions to inform them of local facilities and equipment. This represents a clear threat to patient safety OOH, and requires urgent amendment. Hospitals inviting specialist surgeons into their institution to treat patients have an obligation to ensure that they are adequately prepared and informed. Failure to do so conceivably impedes patient care. The task of providing remote consultations over the telephone, relying on the assessment of the referring nonspecialist clinician was also reported as potentially problematic. In the era of centralisation of services to ‘hub and spoke’ models of care, this may be increasingly common, yet there is a perception that there is a lack of specific training and formalised documentation systems to protect the advising surgeon. Management recommendations are often recorded in the patient's notes by the referrer, with medical records unavailable to the surgeon. There can often be difficulty in accessing required imaging in specialties where this is particularly important. The results of this study suggest that there appears to be a culture of informality in many units
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despite the highly consequential advice given, such as patients rejected by vascular surgery units for repair of ruptured abdominal aortic aneurysm. In the design thinking exercise (see ‘Methods’), neurosurgical units were considered to be exemplars of best practice in remote consultation, with formalised systems of imaging review and decision making already in place. As services are increasingly centralised, other specialties may wish to consider how they should minimise the risk to both their colleagues and patients when providing remote opinion and advice. Participants also reported an increasing reliance on mobile technology to communicate between colleagues during OOH. Despite this, many hospitals continue to have either mobile phone ‘blackspots’ with no available mobile signal, or inadequate Wi-Fi internet provision. Importantly, 70% of participants reported that failure of this technology had impeded communication OOH, with around one third suggesting that this had directly contributed to threatened patient safety. In addition, much of the current communication hardware is provided by the individual surgeon at their own cost, usually their own smart phone. Hospitals may need to review their communication hardware and software technology to ensure that communications between team members is safe, effective and funded by the employer, not the employee. This cross sectional survey of 155 trainee surgeons provides a useful overview of OOH working in the UK National Health Service. As with all survey-based studies, a greater number of participants may have allowed firmer conclusions to be drawn. Further interrogation of qualitative responses (by deploying focus groups or semi-structured interviews) may have offered deeper understanding of the issues raised. In addition, given that the authors are themselves surgical trainees, there should be an acknowledgement of potential confirmation bias framed within their own experiences of working OOH. Despite these weaknesses, the findings corroborate non-academic discourse on working conditions that many surgeons will recognise, and (at least) offer evidence to stimulate further investigation of how working systems and conditions can be optimised to protect trainee surgeons and their patients.
Acknowledgements The authors wish to thank Richard McGregor and Juliana Fraser for their advice and assistance in preparing the survey, and Clare McNaught, Robin Paton, Janet Ross and Sai Vittal for reviewing the manuscript. We are grateful to The Royal College of Surgeons of Edinburgh, who supplied administrative support for this study.
references
1. The Royal College of Surgeons of England. Emergency surgery e standards for unscheduled surgical care. Available from: https://www.rcseng.ac.uk/search/#SearchTerm¼emergency% 20surgery [accessed 19.07.19].
Please cite this article as: Vaughan-Shaw PG et al., Trainee experience of ‘out of hours’ surgical working in the UK: A cross-sectional analysis, The Surgeon, https://doi.org/10.1016/j.surge.2019.10.002
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2. Calman K. Consultation on report of working group on specialist medical training. London: Department of Health; 1993. 3. Department of Health. New deal: working arrangements for doctors and dentists in training. Available from: https:// webarchive.nationalarchives.gov.uk/20120503153201/http:// www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@ dh/@en/documents/digitalasset/dh_4053893.pdf [accessed 19.07.19]. 4. European Community. Council Directive 93/104/EC. Off J Eur Commun 1993;L307:18e24. 5. Baggaley A, Robb L, Paterson-Brown S, McGregor RJ. Improving the working environment for the delivery of safe surgical care in the UK: a qualitative cross-sectional analysis. BMJ Open 2019;9(1):1e8.
6. The Royal College of Surgeons of Edinburgh. Improving the working environment for safe surgical care. Available from: https://www.rcsed.ac.uk/media/415574/rcsed-workingenvironment-web3.pdf [accessed 19.07.19]. 7. Catchpole K. Spreading human factors expertise in healthcare: untangling the knots in people and systems. BMJ Qual Saf 2013;22(10):793e7. 8. General Medical Council. Responding to the case of Dr Bawa Garba. Available from: https://www.gmc-uk.org/about/howwe-work/corporate-strategy-plans-and-impact/supporting-aprofession-under-pressure/responding-to-the-case-of-drbawa-garba [accessed 19.07.19].
Please cite this article as: Vaughan-Shaw PG et al., Trainee experience of ‘out of hours’ surgical working in the UK: A cross-sectional analysis, The Surgeon, https://doi.org/10.1016/j.surge.2019.10.002