Findings

Eleven focus groups and 30 telephone interviews were conducted with 82 junior doctors.

See table 1 for details of the training grades of participants.

Thirty-six participants were male and 46 female. Specialty trainee participants were training in a wide range of medical and surgical specialties, and psychiatry.

An overview of the Findings from the data is presented in table 2 below.

Perceived effects of the WTR on working hours

There was general agreement that working hours were much improved under the WTR, and that intended benefits in terms of reduced trainee fatigue and improved work-life balance had been achieved to some extent. Many trainees felt that the 48 h limit was appropriate and enabled sufficient training experience, albeit with a perceived lack of flexibility. I think, speaking to people who didn't have the forty-eight hour working time directive thing, we get a lot more time to go home and enjoy ourselves and be outside the hospital than they ever did and I think that's a good thing, I feel like I've got a bit more of a life. (Tel. Int. 22, Foundation)

Implementation of the WTR in practice: effects on fatigue

However, some participants did report still working long hours and experiencing fatigue despite the 48 h limit, and this was found to be related to a number of factors, including the way in which the Regulations were implemented and other organisational and contextual factors.

The WTR have not entirely eliminated long hours, with some trainees giving examples of working up to 100 h in a week. However, fatigue did not necessarily arise just from the long hours worked, but also from the organisation of work within those hours, for example, the mixture of day and night shifts, and long shifts straddling day and night (eg, 14:00 to 2:00). Rotas could involve 5 consecutive days at work with 13 h shifts, and working up to 12 consecutive days or, for some, 7 consecutive nights (despite Royal College recommendations to the contrary). Trainees reported that averaging meant that a working week could exceed 70 h and remain compliant. I don't think the hours are long, so doing a 12 hour day or 13 hour day is fine, I think doing 12 days in a row you hit delirium about day ten and then you over-ride it…so I don't think it's the shift I think it's the number of days you work in a row. (Focus group 3, Foundation) There's no continuity in terms of predictability of, right this is what I'm doing and, for example, my rota you run an eight cycle rota so you've got eight weeks to get through and none of those eight weeks are the same at all, and you jump around with longs and lates in-between and I think that from my side is what creates fatigue. (Focus group 10, Specialty) That was a particularly difficult shift on the assessment suite because you would go from five long days with maybe two days off, or a day off sometimes, and then onto a period of nights, you are constantly swapping from nights to days which was tiring, and 12 hour shifts and 13 hour shifts were always a bit of a drag. (Tel. Int. 22, Foundation)

There was also a perception that 12 h shifts were more fatiguing, with less ‘down-time’ than longer but less intense on-call sessions. Work intensity was also increased by rotas involving cross-cover out of hours. My personal opinion is [the WTR have] actually increased fatigue and stress in the fact that you feel you have to get an increased amount of work done in a shorter amount of time. (Tel. Int. 16, Foundation)

Provision of facilities for taking rest during a night shift was also being reduced which, alongside less capacity to take breaks or compensatory rest, added to the fatigue experienced. Rest periods were also lost in half days—sometimes inserted into rotas to balance hours—not always being taken, sometimes because senior clinical staff were unaware of them, so workload did not respond to working hours. The trouble with night shift is being able to sleep during the day and most hospitals have no facility to actually catch a nap while on nights. The last time I worked in a hospital with bedrooms for on-call staff was in 2007 and that's despite guidance from the Royal College of Physicians that it should be possible for someone to have a short nap. (Tel. Int. 23, Specialty) The difficulty is you may be entitled to various half days but the chances of them actually materialising are very slight … unless these things are really formalised and recognised they just don't happen. I mean you can just about get your half day off before nights because everyone understands that you're about to start nights … but the rest of them just don't happen. (Tel. Int. 19, Foundation)

Drivers to work long hours

Fatigue did not just arise from hours specified in rota design. There were many reasons, including some voluntary, for trainees working beyond their rostered (scheduled) hours.

Some reasons for working longer hours than scheduled stemmed from the capacity to fit workload into the working period. This was more evident in shift work, where there was a feeling that incoming doctors in the evening may not have the capacity to perform non-urgent tasks, so the present doctor would finish those tasks before leaving. In contrast, in on-call rotas, a trainee would simply pass the bleep to the incoming doctor and so have a cleaner handover. You kind of know yourself if I was to leave this work it's only going to be there for me in the morning and there's a ward round in the morning, so I will have to get loads more work handed my way. So you want to get things finished. (Tel. Int. 2, Foundation)

Other drivers came from missing educational opportunities if trainees did not attend work outside the rota, including going to work on rostered days off. These opportunities included attending ward rounds and observing in theatre. While benefits of the WTR for work-life balance were perceived, there was a sense that some educational activity that had been part of the ‘work’ domain was now being taken home. This included portfolio completion and reading that may have been done in the workplace during slack periods on-call. If you haven't got enough time to eat or go to the toilet, you can't leave work on time, then you definitely don't have time to go to clinics, you definitely don't have time to do audits or anything like that during work, it basically means that anything that is exclusively for your own training is basically done in your own time and the amount of time available to you is really diminished. (Tel. Int. 7, Specialty)

Although this increased their working hours and reduced time for rest and recuperation, the benefit of taking up such opportunities was often seen to outweigh this. I've got no problems with the fact that I work a little bit over and take the extra time to get training opportunities and that increases my hours to get better at my job. That's personal sacrifice, personal advancement type stuff to get a better job to become a consultant. (Focus group 11, Specialty)

There were also professional and cultural reasons for working beyond rostered hours. These related to the expectations and norms perceived among their professional group and the workplace. Trainee doctors often worked beyond rostered hours due to a sense of commitment and responsibility, both to patients and to colleagues. There were cases of trainees staying late to hand over the care of a patient, rather than force two handovers (eg, where a junior doctor would stay to complete an admission in A&E, rather than hand over to another FY2 doctor, who would then have to hand over to the specialty where the patient was being admitted), owing to concern for continuity of care and the risk of information being lost. There was also a strong sense of collegiality, expressed as a responsibility not to burden colleagues with routine tasks, particularly as they were likely to face other immediate demands at the handover time. We have just never taken the half days because we're so busy, you know; we could have done, but would have screwed over our colleagues. (Focus group 2, Foundation)

At times, however, this could be perceived as a cultural expectation that some jobs would not be left—so less a choice, more an imposition. There were references to a negative culture where trainees could experience pressure from senior doctors, and other professions, to stay beyond their rostered hours, with an implication of unprofessionalism if they left on time. There was also a perception among trainees that their professional reputation was at risk, with implications for an employment reference and future career.

Concerns about working hours were often not recognised or appreciated by seniors, with some respondents identifying a dismissive attitude towards the WTR, and a feeling that such limitations were counter to medical professionalism. Some trainees also agreed that limited hours undermined professional autonomy, a feeling exacerbated if hours were enforced during the periodic 2-week monitoring process. If you clicked that you started at 8.00 and you were meant to start at 9.00, you had to explain…why did you do it, so quite a lot of the time I wouldn't put down that I started before 9.00 because I knew I was going to have to justify that I came in before 9.00. (Focus group 5, Foundation)

Trainees reported that, as the WTR compliance is derived from these New Deal monitoring reports, there was no objective record of hours worked, and there were also no formal measures for health and well-being. However, few trainees kept their own record of hours worked despite their being conscious of working beyond rostered hours. This was partly due to their view of medicine and the nature of their work, meaning that working to limited hours was not an issue to them. We are treated usually like we are working late due to our own failings which is not a nice atmosphere to work in, I think it's very important that you feel you are working, especially as a junior in a new career, you're working somewhere you are appreciated, valued and not being looked at suspiciously. (Tel. Int. 21, Foundation)

Gaps in rotas also placed additional pressure on the system, and so on individual doctors. These arose from staff shortages caused by under-recruitment, as well as absences. This often meant providing informal cover, for example in extended shifts. While locums were used, external locums were felt to be sometimes unreliable, meaning last minute cover was often necessary. Formal internal locum shifts were sometimes used and cross-referenced against rotas to ensure an individual did not exceed the WTR hours, and there was no reported pressure to undertake locum shifts. The trainees reported that there was a shortage of available doctors to fill rotas, even without the need to comply with the WTR. Some trainees felt that even fully staffed rotas would be stretched because the workload had increased since the staffing levels were initially put in place. The fundamental issue is trying to do a decent job and you can't do a decent job if there aren't enough of you on the ground, so you are always working many hours in excess of what you should be doing, you end up tired and exhausted and jaded and then you're not doing a good job for your patient. (Tel. Int. 29, Foundation)

Effects of fatigue

Trainees identified effects of fatigue arising from their working hours. While detriments to their skills and judgement were identified, these were mostly felt to affect efficiency rather than safety—however, risks to patient safety cannot be discounted. Some reported that fatigue affected their ability to retain new information. I think when you were getting to the end of a thirteen hour shift you found that your technical skills, like your ability to put a cannula into someone and stuff like that, it certainly decreases, I find it gets a lot harder to do things that require more concentration, things like that, but I think you're also quite aware of that, so patient safety wise you are aware that you are not at your best so you often check more of your decisions with other people and things like that. (Tel. Int. 22, Foundation) I think 12 days in a stretch is too long without a day off, I just think it's a really long stretch…I think [the effect] is fatigue really and I suppose you learn less towards the end of those days really because you are just tired. (Tel. Int. 26, Foundation)

Fatigue was also reported to affect mood, particularly when switching between different working patterns, with consequences for their professional manner. This may have consequences for teamworking and interprofessional communication, as well as for interactions with patients. You become more irritable sometimes as well, I noticed I was a bit more snappy [when switching between long days and nights] (Focus group 5, Foundation) You don't make as good decisions and you're more grumpy, you're less likely to be good with the patients, you know, you're more likely to just go in there and take the blood rather than actually you know being a doctor to them … so you have to be a lot more careful when you're tired I suppose. (Tel. Int. 9, Foundation)

These issues were sometimes compounded by hunger and discomfort arising from not achieving rest breaks during long shifts. I think when I'm hungry my fuse is shorter and I think my compassion towards others is not as what it should be. (Tel. Int. 2, Foundation)