Abstract
Introduction:
Clinical learning during night call has been shown to be less efficient and effective than during the day among residents. Strategies are needed to address the gap between night-time and daytime learning. We conducted a survey study to examine perceptions of night-time compared with daytime learning among Internal Medicine interns, and asked for suggestions to address this gap.
Method:
This is a cross-sectional survey study conducted on a single class of 47 interns from Singapore General Hospital in December 2013. Interns anonymously completed a modified previously published 25-item survey. A total of 23 items asked for ratings of learning during the day versus the night using a 5-point Likert scale. The remaining two open-ended questions invited respondents to suggest improvements for teaching and learning. Analysis was done by descriptive statistics for the Likert-scale items, and thematic coding by two coders for narrative responses.
Results:
Response rate was 70% (33/47). Interns rated learning during the day more positively than during night call for 23 of 23 (100%) items, with 22 out of 23 items showing significant difference. Among the 33 respondents, 20 provided narrative responses. Three major themes emerged: increasing manpower, allowing patient follow-up after night call, and more time for bedside teaching in the daytime.
Conclusion:
Our study confirms that learning during night call is perceived as less effective than during the day. We further extended this finding to offer alternate strategies to enhance clinical learning among interns.
Introduction
One important goal of residency training is to provide clinical learning opportunities to develop resident competencies while delivering patient care. 1 However, learning on the job is variable and affected by factors such as fatigue, patient volume, availability of attending physicians, teaching style and stress. 2 Past studies have generally found negative opinions regarding the educational value of night rotations.3–6 One study conducted for residents found that residents perceived a greater emphasis on service than on education during night call. 7 This may be attributed to reduced availability of attending physicians and increased resident fatigue during night hours.4,5 However, few suggestions were found in the literature as to how to improve learning during the night. The purpose of this study is to confirm whether Internal Medicine interns in Singapore have the same perception of learning during the night compared with the day, and to identify potential strategies to improve the gap. We conducted a survey study to determine perceptions, underlying reasons and strategies. The study had ethics committee approval.
Methods
Internal Medicine is one of 20 residency programs in Singapore Healthcare (Singhealth) Group, the largest healthcare cluster in Singapore. Singapore General Hospital is the major training hospital within Singhealth. The Internal Medicine Residency Program is a three-year programme designed to provide residents with the clinical skills and knowledge to become competent clinician practitioners. Interns undergo four months’ rotation in Internal Medicine in their first year of training. The typical night call refers to the working hours of 5 pm to 8 am the following day, and interns work under supervision of medical officers and Registrars; however, interns also work from 7 am to 5 pm the first day and 8 am to 12 noon the second day. Each intern is assigned an average of 4–6 night calls per month during their rotation in Internal Medicine. Study participants were a single class of 47 interns starting their programs in July 2013. They were aged between 24 and 28 years, with a male:female ratio close to 1:1. This cross-sectional survey was conducted in December 2013.
We adapted a previously published 25-item survey assessing resident perceptions of daytime compared with night-time teaching. 4 The survey consisted of 23 questions addressing the following areas: availability of teaching (questions 1–15), supervision (questions 16–19), patient care (questions 20, 21), and clinical skills (questions 22, 23). Responses were rated on a Likert scale (with strongly disagree = 1, disagree = 2, neutral = 3, agree = 4, and strongly agree = 5). All items were phrased so that an ‘agree’ rating was positive. We omitted two items from the original survey (‘usually attend didactic sessions and conferences’; ‘receive effective patient sign-outs’) as they were not relevant to our setting. We added two open-ended questions inviting respondents to suggest improvements for teaching and learning, as follows: “Do you have any suggestions regarding how to improve night call teaching and learning?” and “Do you have any suggestions regarding areas of improvement of daytime teaching so as to better supplement the night call experience?”.
Interns were sent an email and invited to respond anonymously. A reminder was sent once by email after two weeks. The data were converted to an Excel file and descriptive analysis (means and SDs) was applied. Further, a paired t-test was used to compare responses about night call versus day work for items 1–23. Thematic analysis was performed manually by two independent coders for narrative responses to the open-ended questions. Themes extracted from both questions were examined in aggregate. The coders met to reach agreement on final major themes.
Results
The overall response rate was 70% (33/47). Demographic data pertaining to age and gender of respondents was not collected in this survey. Interns rated teaching and learning during the day more positively than during night call for 23 of 23 items, with 22 out of 23 items showing statistically significant differences (p<0.001 for questions 1–20, p=0.003 for question 22 and p=0.004 for question 23; Table 1). The only item on which day and night did not differ was ‘independence for patient care decisions’ (question 21). The greatest difference was seen for the question on ‘adequate rest’ (question 20), with a difference of 2.39 points between night and day (p<0.001).
23-item survey of Internal Medicine Interns’ a perception of learning during night call versus day work, Singapore General Hospital, 2013.
pt: patient; H & P: history and physical examination.
N = 33 of 47 (response rate 70%).
Mean score is calculated from rating on a Likert scale (1 = strongly disagree, 5 = strongly agree); maximum = 5.00.
Paired t-test.
The perceived gap by interns between night call and day work learning was wider in areas of ‘availability of teaching’, ‘supervision’ and ‘patient care’, compared with area of ‘clinical skills’. There were ten items for which the score differences were 1 or greater. Among these ten items, seven items addressed the availability of teaching (questions 1, 4, 5, 6, 9, 12, 14; Table 1), two items addressed supervision (questions 18, 19) and one item addressed patient care (question 20).
Among the 33 respondents, 20 provided narrative responses. The major themes derived were: ‘improve manpower for night call’; ‘allow protected time after night call to follow up on own patients’; and ‘provide dedicated consultant bedside teaching during the day to supplement formal teaching’ (see Table 2 for illustrative quotes).
Major themes and illustrative quotes selected from Internal Medicine intern narratives, Singapore General Hospital, 2013.
Discussion
We believe this is the first study in Singapore to explore perceptions of interns regarding clinical learning during night call compared with during day work. Our study, similar to published studies, found that interns perceived clinical learning during the day more positively than during night call. We also identified key areas to address the learning gap.
Our study found similar results to Bricker and Markert. 4 The major differences were that in our study we found the gap to be even wider than in the original study. Furthermore, in that study 17 of 25 items showed significant differences between day and night, while in our study 22 of 23 items showed a significant difference. We speculate that this difference could be related to the respondent type (our respondents were interns while the previous study respondents came from all three years of training) and systemic differences in the clinical work itself.
The open-ended questions in our study added to our understanding of reasons (implied from suggestions made by interns) for the less than optimal learning experience during night call, enabling future action. Interns asked to ‘improve manpower for night call’ to address the item of ‘adequate rest’ (question 20), reflecting greatest mean difference of 2.39 points between night and daytime learning. Improving manpower is a realistic and feasible solution which has now been implemented. The maximum night calls per month for interns have reduced from six in 2013 to four in 2014 in Singapore General Hospital. They also suggested ‘allowing protected time after night call to follow up on own patients’, and ‘providing dedicated consultant bedside teaching during the day to supplement formal teaching’ to address the area of decreased availability of teaching during night call. This comment echoes the recommendation of bedside teaching as the best vehicle to impart clinical skills (e.g. history and examination skills and professionalism). 8
Our study is strengthened by a high response rate from a homogenous respondent group, and a reasonable response rate for narrative questions. We also used a survey that has been previously successfully deployed. 4 We identified some realistic strategies which could be employed to enhance clinical learning during night call among interns.
Our study has some limitations. Because our respondents were interns from only one programme, the findings may not be generalizable to other residencies. Also, this is a cross-sectional survey without an intervention. Thus, future studies will include multiple residency programs, and assess the impact of interventions such as reduced number of nights on call and supplementary teaching during daytime on resident perceptions of learning. Although the previously published 25-item survey adapted in this study was not validated, we attempted to choose questions compatible with our local context, and modified the survey by adding two open-ended questions. Finally, performing qualitative analysis on written responses from anonymous respondents has significant limitations compared with interviews or focus groups, as the themes identified might not be representative if saturation was not reached.
Conclusion
Our study showed that Singapore Internal Medicine interns perceived clinical learning during night call as less effective than during the day time, similar to other published studies. We contributed to the literature by exploring reasons for the differences of clinical learning between daytime and night-time. This identified realistic strategies that could be employed to enhance night call learning among interns. These strategies may be implemented by other residencies. Future studies will examine the effectiveness of such strategies at reducing the gap between daytime and night-time learning among residents.
Footnotes
Conflicts of Interest
None declared.
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.