To assess residents' perceptions of the impact of resident work hour restrictions on patient care, education, and job satisfaction.
Four focus groups of internal medicine residents at Barnes-Jewish Hospital at the Washington University School of Medicine were conducted during February and March 2004. Twenty-six housestaff from the first three years of residency participated; all were volunteers. Transcripts were analyzed for major themes.
Both residents and interns supported work hour limitations and enjoyed the benefits of working fewer hours. However, they had difficulty complying with the restrictions, particularly if they felt patient care, teaching, or their own education would be compromised. Participants perceived that restricted work hours diminished the continuity of patient care and increased the likelihood of medical errors such as those resulting from delayed follow-up of diagnostic tests. Both interns and residents found it difficult to attend conferences, and residents found fewer opportunities to teach. Effects on job satisfaction were mixed as a result of work hour restrictions.
Residents in the sample favored work hour restrictions but had serious concerns about the effects of the restrictions on patient care and medical education. The findings suggest that imposing rigid work hour restrictions has significant consequences for patient care and medical education and that the most effective ways to balance work hour limitations with the demands of patient care and necessary educational components to train competent physicians have yet to be identified.
"In many circumstances, important information is being lost in the transition of care from shift to shift. Recent data suggests that because housestaff work restricted work hours, shift hand-over errors exceed the number of errors due to fatigue . This finding suggests critical elements of the patient's story are not being communicated. "
[Show abstract][Hide abstract] ABSTRACT: For better or worse, the imposition of work-hour limitations on house-staff has imperiled continuity and/or improved decision-making. Regardless, the workflow of every physician team in every academic medical centre has been irrevocably altered. We explored the use of cognitive task analysis (CTA) techniques, most commonly used in other high-stress and time-sensitive environments, to analyse key cognitive activities in critical care medicine. The study objective was to assess the usefulness of CTA as an analytical tool in order that physician cognitive tasks may be understood and redistributed within the work-hour limited medical decision-making teams.
After approval from each Institutional Review Board, two intensive care units (ICUs) within major university teaching hospitals served as data collection sites for CTA observations and interviews of critical care providers.
Five broad categories of cognitive activities were identified: pattern recognition; uncertainty management; strategic vs. tactical thinking; team coordination and maintenance of common ground; and creation and transfer of meaning through stories.
CTA within the framework of Naturalistic Decision Making is a useful tool to understand the critical care process of decision-making and communication. The separation of strategic and tactical thinking has implications for workflow redesign. Given the global push for work-hour limitations, such workflow redesign is occurring. Further work with CTA techniques will provide important insights toward rational, rather than random, workflow changes.
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