Home Working Time Directive 2009 Calling Time Calling Time Summer 2006 How we can ensure safe shift working for surgeons in training

How we can ensure safe shift working for surgeons in training

The progressive implementation of the WTD has and will continue to haveprofound effects on the delivery andcontinuity of acute surgical care and thetraining of tomorrow’s surgeons.

In particular full shift solutions to the working time limits have had a deleterious effect on training especially in the craftspecialties and this has been demonstratedby a series of surveys conducted by theRoyal College of Surgeons of England[RCS(Eng] in liaison with the surgicaltrainee organisations ASiT (Association of Surgeons in Training) and BOTA (British Orthopaedic Trainees Association).Innovative working practices introduced for example under the Hospital at Nightscheme following research have shown a significant reduction in acute surgicalintervention (except for life or limbthreatening conditions) between 22.00and 08.00 and also that much of the workundertaken by surgical staff during thisperiod is devoted to the management of medical co-morbidities.

The RCS(Eng) EWTD Working Party becameincreasingly concerned two years ago about the work schedules of many doctors in training and convened a multiprofessional task group including key stakeholders fromthe Royal College of Physicians, the Royal College of Anaesthetists, the Faculty of Occupational Health, national traineeassociations, postgraduate deaneries andthe Department of Health (DH). Last Julythis group received evidence from amongstothers Professor Simon Folkard and ProfessorCharles Czeisler both internationally recognised experts on shift working in24/7 organisations, body rhythms andsleep medicine. Subsequently the RCS Eng Council agreed to recommend that:

  • Wherever possible senior surgicaltrainees should be removed from nightshifts in order to consolidate learningand maximise daytime training opportunities
  • Surgical specialist registrars should notbe required to undertake inappropriate cross-cover nor to work a full shift pattern. However if full shift working is requiredon training grounds this should be in theform of a single night shift followed bya day off duty
  • Early year trainees working towards acareer in surgery may gain significantvalue from shift working during modulartraining for example in critical care
  • Further 24/7 modelling is required tomatch skill mix with workload demands
  • Work should, wherever possible, be broughtinto the extended day to ensure optimumtraining opportunities with only life or limb-threatening conditions scheduled for emergency operative proceduresoutside this period
  • The need for fully staffed emergencyoperating theatre facilities as recommendedby NCEPOD (National Confidential Enquiry into Patient Outcome and Death)cannot be underestimated
  • The increasingly recognised value ofextended roles for non-medical healthcare professional to diminish service gaps, opportunities for the use of new and emerging technologies such as telemedicine and remote monitoring of patients should be explored.

Should further in-depth assessment of demand in specific locations preclude the reintroduction of on-call arrangementsfor surgical trainees evidence suggeststhat in order to maximise patient andstaff safety:

  • The length of shifts should be nolonger than 12-13 hours
  • Night shifts should not exceed 2-3consecutive nights and be followed bytwo uninterrupted nights sleep beforereturning to day time working
  • Adequate rest breaks must be available (every 4 hours according to the enactmentof the WTD in the United Kingdom)with provision of appropriate facilities. These should address issues of postureand comfort, appropriate lighting, sounddampening, privacy, hygiene and catering
  • Terms and conditions of employment should be reviewed to ensure safe shift working for example in the provision of accommodation and facilities for takingappropriate rest including short periods of sleep. The Royal College remainsanxious that every effort be made to explore the potential for surgicaltrainees to be able to negotiate ‘optout’ arrangements. In addition that proposals put forward by DH officials to secure adjustments to the definitionof ‘work’ in response the SiMAP and Jaeger judgements including theintroduction of a category of ‘inactiveon-call’ be further pursued under the Finnish Presidency. The College also strongly supports the notion of the separation of on-site training from service (unless on-call) as agreed in the Republic of Ireland

    • Further Reading

    The Royal College of Surgeons ofEngland. Safe Shift Working forSurgeons in Training. January 2006 www.rcseng.ac.uk/rcseng/content/publications/docs/Shift_working_for_surgeons_in_training.html

    Statement by the Department of Health & Children and the Irish Higher Surgical Trainees Group on therequirements of the implementationof the European Working TimeDirective for doctors in higher surgicaltraining programmes. Dublin 2004 www.dohc.ie/issues/european_working_time_directive/joint_statement.pdf?direct=1

    The Royal College of Surgeons of England website provides advice and information for surgeons on how best to implement the requirements of the Directive whilst protecting training and education and ensuring patient safety: www.rcseng.ac.uk/service_delivery/ewtd

     
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