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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 4  |  Page : 548-556

Nigerian resident doctors' work schedule: A national study


1 Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria
2 Department of Obstetrics, Gynecology and Perinatology, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria
3 Department of Paediatrics, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria
4 Department of Internal Medicine, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria
5 Department of Oral Medicine, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria
6 Department of Anaesthesia, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria
7 Department of Morbid Anatomy and Forensic Medicine, Federal Medical Centre, Umuahia, Abia State, Nigeria
8 Department of Radiology, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria
9 Department of Morbid Anatomy and Forensic Medicine, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria
10 Department of Community Medicine, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria
11 Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria; Department of Colorectal Surgery, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, United Kingdom
12 Department of Medicine, Howard University Hospital, Washington, DC, United States
13 Department of Obstetrics, Gynaecology and Perinatology, University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria

Date of Submission22-Oct-2021
Date of Acceptance06-Dec-2021
Date of Web Publication19-Apr-2022

Correspondence Address:
Dr. S A Balogun
Department of Surgery, Obafemi Awolowo University Teaching Hospitals Complex, PMB 5538, Ile-Ife, Osun State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_1901_21

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   Abstract 


Background and Aim: The deleterious effects of Resident Doctors' (RDs') long duty hours are well documented. Driven by concerns over the physician's well-being and patient safety, the RDs' duty hours in many developed countries have been capped. However, in Nigeria and many African countries, there are no official regulations on work hours of RDs. This study evaluated the work schedule of Nigerian RDs and its impact on their wellbeing and patient safety. Subjects and Methods: A national survey of 1105 Nigerian RDs from all specialties in 59 training institutions was conducted. With an electronic questionnaire designed using Google Forms, data on the work activities of RDs were obtained and analyzed using the IBM SPSS software version 24. The associations were compared using Chi-squared test with the level of significance set at < 0.05. Results: The mean weekly duty hours (h) of the RDs was 106.5 ± 50.4. Surgical residents worked significantly longer hours than non-surgical residents (122.7 ± 34.2 h vs 100.0 ± 43.9 h; P < 0.001). The modal on-call frequency was two weekday on-calls per week (474, 42.9%) and two weekend on-calls per month (495, 44.8%), with the majority of RDs working continuously for up to 24 hours during weekday on-calls (854, 77.3%) and 48–72 hours during weekend on-calls (568, 51.4%), sleeping for an average of only four hours during these on-calls. The majority of RDs had post-call clinical responsibilities (975, 88.2%) and desired official regulation of duty hours (1,031, 93.3%). Conclusion: The duty hours of Nigerian RDs are currently long and unregulated. There is an urgent need to regulate them for patient and physician safety.

Keywords: Burnout, Nigeria, physician and patient safety, resident doctors, work-related hazards


How to cite this article:
Balogun S A, Ubom A E, Adesunkanmi A O, Ugowe O J, Idowu A O, Mogaji I K, Nwigwe N C, Kolawole O J, Nwebo E E, Sanusi A A, Odedeyi A A, Ogunrinde O V, Adedayo O O, Ndegbu C U, Ojo A S, Anele C O, Ogunjide O E, Olasehinde O, Awowole I O, Ijarotimi O A, Komolafe E O. Nigerian resident doctors' work schedule: A national study. Niger J Clin Pract 2022;25:548-56

How to cite this URL:
Balogun S A, Ubom A E, Adesunkanmi A O, Ugowe O J, Idowu A O, Mogaji I K, Nwigwe N C, Kolawole O J, Nwebo E E, Sanusi A A, Odedeyi A A, Ogunrinde O V, Adedayo O O, Ndegbu C U, Ojo A S, Anele C O, Ogunjide O E, Olasehinde O, Awowole I O, Ijarotimi O A, Komolafe E O. Nigerian resident doctors' work schedule: A national study. Niger J Clin Pract [serial online] 2022 [cited 2022 May 22];25:548-56. Available from: https://www.njcponline.com/text.asp?2022/25/4/548/343467




   Introduction Top


Residency training has traditionally been associated with long duty hours and inadequate sleep due to overwhelming clinical and academic responsibilities.[1] Long work hours was traditionally argued to facilitate continuity of patient care, more opportunity of seeing rare cases, gaining requisite experience and skills, follow-up of disease progression, as well as the effects of medications and interventions.[2] It is now however increasingly recognized that the intense work schedules of resident doctors (RDs) have deleterious effects on their occupational health and well-being, patient safety, and quality of care.[1],[3] This was demonstrated in the case of an 18-year-old college student named Libby Zion, who died in a New York City hospital in 1984, under the care of overworked and tired RDs.[4] Her death prompted regulations of the hitherto unrestricted duty hours of RDs worldwide.

In Europe, the European Working Time Directive (EWTD), adopted in 1998, capped duty hours of RDs in the European Union (EU) member countries at 48 hours per week.[5] This was followed in 2003 (with revisions in 2011) by the Accreditation Council for Graduate Medical Education (ACGME) limiting the weekly resident duty hours in the United States to a maximum of 80 hours.[6] In China and the United Kingdom, the stipulated legal limits are 44 and 52 duty hours per week, respectively.[7] Despite these regulations, RDs worldwide continue to work long hours, beyond the maximum recommended limits.[7]

In many parts of Africa, the narrative is not different as several countries either lack or do not enforce work limit regulations. Earlier reports from Nigeria have highlighted the lack of work time directive and the potential harms of prolonged work hours on RDs.[8],[9] As part of a global community and in line with international best practices, African nations need to adopt the concept of work limit regulations and contextualize it to the African environment. Such interventions should however be driven by relevant data which is currently limited. From a national survey, this study sought to evaluate the current work schedule of Nigerian RDs, the impact on their well-being, their perception of regulated work hours as well as to compare the work schedules of different specialties. This study is the second phase of an earlier study by some of the authors on the work schedule of Nigerian surgical trainees.[10]


   Materials and Methods Top


A nationwide survey of Nigerian RDs in the surgical specialties (cardiothoracic surgery, general surgery, neurosurgery, obstetrics and gynecology, ophthalmology, oral and maxillofacial surgery, orthopedic surgery, otorhinolaryngology, pediatric surgery, plastic surgery, urology), internal medicine (cardiology, dermatology, endocrinology, gastroenterology, infectious diseases, nephrology, neurology, pulmonology); pediatrics; laboratory medicine (chemical pathology, hematology, microbiology, morbid anatomy); anesthesia; community/public health; dentistry (community dentistry, conservative dentistry, oral medicine, oral pathology, oral radiology, orthodontics, pediatric dentistry/child dental health, periodontics, prosthodontics); family medicine; mental health/psychiatry; and radiology, was conducted in two phases.

The first phase, which studied the work schedule of Nigerian RDs in the surgical specialties, was conducted between 8 and 22 November 2020.[10] The second phase was conducted between 25 January and 24 March 2021, with the aim of evaluating the work schedule of RDs in the non-surgical specialties (all other specialties aside from the surgical specialties mentioned above). The study respondents were selected by convenience sampling. The work schedules of RDs in the surgical and non-surgical specialties were compared.

The data collection tool was a 43-item purpose-designed electronic questionnaire that was designed using Google Forms. The questionnaire was electronically distributed via emails and social media platforms, including WhatsApp and Telegram, to 1,250 RDs in 59 residency training institutions (comprising of federal and state teaching hospitals, federal medical centers, as well as specialist, general and private hospitals) across the six geopolitical zones of Nigeria.

The questionnaire gathered information on sociodemographic characteristics such as age, gender, marital status, specialty, designation, year of training, and current work schedule. The outcome measures were the impact of the current work schedule on quality of life and patient care, as well as the knowledge and perception of RDs toward capped duty hours.

The data was analyzed using IBM SPSS version 24 (Chicago®). Frequencies and percentages were presented in tables, and associations between categorical variables were tested for statistical significance using the Chi-squared test with the level of significance set at P < 0.05.

Participation in the study was voluntary, and no incentive was offered for participation. The questionnaire was anonymous, with no personal identifying information. Consent to participate in the study was implied by completing the questionnaire and submitting responses.


   Results Top


Sociodemographic characteristics of Nigerian RDs

There were 1,105 respondents in various years of training spread across the earlier-mentioned specialties and representing an 88.4% response rate. Of this number, 565 were in the surgical (51.1%) and 540 were in the non-surgical (48.9%) specialties. The respondents were predominantly men (809, 73.2%), married (867, 78.5%) and 30–39 years of age (835, 76.6%). There were more men in surgical specialties compared with non-surgical specialties (79.5% vs 66.7%). On the other hand, women accounted for 33.3% of RDs in non-surgical specialties and 20.5% in surgical specialties. Other sociodemographic characteristics of the RDs are shown in [Table 1].
Table 1: Sociodemographic characteristics of Nigerian RDs (n=1,105)

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Overview of Nigerian RDs' work hours

Overall, the RDs worked a mean of 106.5 ± 50.4 hours weekly, comprising of routine work hours (40.0 ± 13.2 hours), on-call hours (56.5 ± 33.0 hours) and overtime (10.0 ± 4.2 hours). Surgical residents had significantly higher mean weekly duty hours compared with non-surgical residents (122.7 ± 34.2 h vs 100.0 ± 43.9 h; P < 0.001). Amongst the non-surgical residents, those in the infectious diseases units (apparently working in the COVID-19 isolation wards and centers) reported the longest average duty hours of 143.9 hours per week, whereas RDs in conservative dentistry reported the shortest average weekly duty hours of 56.1 hours. Amongst the surgical residents, neurosurgery residents reported the longest average duty hours per week (156.9 hours), whereas the shortest average duty hours of 88.5 hours per week was reported by oral and maxillofacial surgery residents. Further details of specialty-specific work hours are presented in [Table 2].
Table 2: Mean weekly duty hours of Nigerian RDs across different specialties

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Nigerian RDs' routine work hours

The mean weekly routine work hours and overtime were respectively 40.0 ± 13.2 hours and 10.0 ± 4.2 hours. The most common identified reason for working overtime was inadequate staffing (861, 77.9%) [Table 3]. Only four RDs (0.4%) reported being paid for overtime.
Table 3: Pattern of work schedule of Nigerian RDs (n=1,105)

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Nigerian RDs' on-call schedule

The mean weekly on-call duration was 56.5 ± 33.0 hours. Registrars reported significantly more on-call hours than senior registrars (P < 0.001). A total of 474 (42.9%) and 495 (44.8%) RDs had an on-call frequency of two week-day on-calls per week and two weekend on-calls per month respectively. About three-quarters (854, 77.3%) of the respondents reported an on-call duration of up to 24 hours on weekdays, while 568 (51.4%) worked between 48–72 hours during weekend on-calls. The RDs reported sleeping an average of four hours during on-calls. The majority of RDs reported rarely or never having protected breaks during routine work hours (512, 46.3%), and only occasional protected breaks during on-calls (469, 42.4%).

Comparing across specialties, surgical residents had significantly more on-calls than their non-surgical counterparts (mean frequency of weekday on-calls per week: 2.5 vs 2.0, P < 0.001; mean frequency of weekend on-calls per month: 1.9 vs 1.7, P < 0.001). Most RDs had post on-call clinical duties (975, 88.2%) without a break between the end of the on-call period and the start of routine clinical duties. Surgical residents were significantly more likely than non-surgical residents to have post–on-call clinical responsibilities (98.8% vs 77.2%; P < 0.001). These findings are depicted in [Table 3] and [Table 4].
Table 4: Association between subspecialty and work schedule characteristics of Nigerian RDs

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Effects of Nigerian RDs' work hours on their quality of life

The majority of the respondents (594, 53.8%) reported that sleep deprivation from long work hours always or usually affected their work, while 870 of them (78.7%) reported fatigue even when not post on-call. There was a significant association between long duty hours and fatigue (P = 0.002). About a quarter of the respondents (290, 26.2%) needed sick leaves in the preceding year, with mean annual absenteeism from work of eight days. A total of 573 RDs (51.9%) had either not taken their annual leaves within the preceding year or had never taken an annual leave since their assumption of residency training, with surgical residents being more affected than non-surgical residents (57.7% vs 45.7%; P < 0.001). The most common reason for the inability to take an annual leave was inadequate staffing as reported by 263 RDs (45.9%).

Most of the RDs (794, 71.9%) reported hazards from prolonged work hours. Prolonged duty hours and fatigue were significantly associated with reported hazards and medical errors (P = 0.003 and P < 0.001 respectively). Amongst the non-surgical residents, RDs in community dentistry, periodontics, and pulmonology reported no hazards, whereas all the RDs in endocrinology and nephrology reported hazards. On the other hand, amongst surgical residents, RDs in cardiothoracic surgery reported the most hazards (8/10, 80%), whereas those in urology reported the least hazards (9/23, 39.1%). The most common hazards reported were sleeping on duty (460, 57.9%), and falling asleep while driving (298, 37.5%). Surgical residents were more likely than non-surgical residents to report hazards from long duty hours (74.2% vs 69.4%; P < 0.001).

Owing majorly (591, 64.7%) to the frequency and duration of on-calls, nearly one-half of the RDs (546, 49.4%) rarely or never looked forward to their on-calls. A total of 443 of the RDs (40.1%) reported that they were or would probably reconsider their specialties because of their current work schedules. Though not significant, surgical residents were more likely than non-surgical residents to report a reconsideration of specialty (44.8% vs 35.2%, P = 0.163). These findings are shown in [Table 4] and [Table 5].
Table 5: Impact of work schedule on the quality of life of Nigerian RDs (n=1,105)

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Nigerian RDs' knowledge and perception of official capping of duty hours

The majority of RDs (849, 76.8%) were unaware of the existence of limits on work hours in other countries. However, an overwhelming majority of them (1,031, 93.3%) desired official capping of work hours. The most common reasons cited for desiring official work hour limits included fatigue and reduced performance or work output associated with long duty hours (735, 66.5%). The most common reason cited by surgical residents who did not desire official limits on duty hours was the desire to acquire more surgical skills or experience (16, 2.8%). On the other hand, non-surgical residents who did not want duty hours capped cited continuity of patient care as their most common reason (19, 3.5%). The majority of respondents (846, 76.6%) desired to be free of clinical responsibilities post on-calls, as shown in [Table 6].
Table 6: Knowledge and perception of Nigerian RDs toward official capping of duty hours (n=1,105)

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   Discussion Top


The mean duty hours of 107 hours per week reported in our study is higher than the 88.7 hours reported in a previous study conducted in Nigeria.[11] It is also higher than the duty hours reported in other African and non-African countries.[2],[12],[13] The lack of official regulation of the work hours of RDs in Nigeria is likely the reason why the work hours reported in our study is significantly higher than the 48-hour and 80-hour limits recommended by the EWTD and ACGME respectively.[5],[6] The need for regulation may therefore be the most important first step toward achieving a safer and more effective work environment for Nigerian RDs. Our study found that surgical residents worked significantly longer hours than non-surgical residents. The higher physical demand, including long theatre hours, of surgical specialties has been cited as a reason why they are less attractive to women within the African setting.[14] Regulating work hours might encourage more women to venture into the so-called more difficult specialties as is the case in developed countries.

Our study corroborated the findings of other authors who have documented adverse effects of long duty hours and sleep deprivation on the well-being of RDs.[8],[10],[15] Aside from the deleterious effects of long duty hours on RDs' well-being and safety, our study also documented harmful effects on patient care and safety, such as wrong prescriptions, patient data mix-up, and missed steps in patient management as reported by more than one-half of the respondents. Medical errors, as those reported by the RDs in our study, are a leading cause of patient deaths worldwide, causing more deaths than breast cancer, AIDS, and motor vehicle accidents in the United States.[16]

There exists a significant relationship between fatigue and medical errors.[17],[18] The medical errors reported in our study were significantly associated with prolonged duty hours and fatigue amongst RDs. More than two-thirds of the RDs in our study reporting varying degrees of fatigue even when not on post–on-call duties indicates that the effects of long work hours tend to linger beyond the work period. A recent joint study by the World Health Organization (WHO) and the International Labour Organization (ILO) found that working for 55 hours or more per week increases the risk of death from ischemic heart disease and stroke.[19]

Furthermore, the long duty hours reported by the RDs in our study puts them at a high risk of burnout and its attendant adverse sequelae. A previous study found a relationship between burnout and the area of specialization, frequency of on-calls per week, and weekly duty hours, amongst others.[20] Surgical residents in our study, who reported significantly longer duty hours, a higher likelihood of post–on-call clinical responsibilities, and forfeiture of annual leave in the preceding year may be at a higher risk of burnout, as reported by an earlier study.[8] One of the consequences of burnout amongst RDs is the desire to quit their jobs,[21] as reported by more than a third of the RDs in our study. This is against the backdrop of the current doctor-to-physician ratio of 4:10,000 in Nigeria, made even worse by the massive brain drain presently plaguing the country.[22],[23] The unmitigated long duty hours of Nigerian RDs no doubt portends grave danger for both patient and physician well-being and safety.

The poor state of the primary and secondary healthcare systems in Nigeria plays a significant role in compounding the workload of RDs who are mostly employed in tertiary institutions.[24],[25] Strengthening the capacity of the lower building blocks of our health institutions will alleviate a significant amount of workload on RDs. The government should ensure that primary and secondary health institutions function appropriately through proper funding and staffing. Furthermore, apart from making available more residency training slots across the country, improving the welfare of RDs will go a long way in boosting their morale and discourage them from emigrating to other countries in want of greener pastures. Additionally, at the institutional level, employers should pay close attention to the health of residents by encouraging scheduled medical checkups, ensuring doctors go on annual leave, and making the workplace as conducive as possible. Call rooms where residents spend long hours should be made as comfortable as possible as proper welfare will further boost productivity.

The findings from this study will be useful for policy makers and agencies regulating residency training in Nigeria. The national spread of this survey, its large sample size, and the representation across different specialties give the survey a national outlook, and make the data obtained quite robust and valid. To the best of the authors' knowledge, this is the largest national study of RDs' work schedule conducted in Nigeria. That said, the authors acknowledge that the convenience sampling of respondents in this study creates the possibility of selection bias. There also exists the possibility of recall bias as the reported duty hours were based entirely on the respondents' recall of their work activities in the preceding year. In addition, the questionnaire used did not assess the different domains of quality of life (that is, physical, psychological, independence, social relations, environment, and spirituality) or how the reported work hours affected marriage, parenthood, relationships, finances, spirituality, and even tendency for affairs of the RDs, nor the impact of renumeration on quality of life of the RDs. These themes should be evaluated in future research. These limitations notwithstanding, the study provides important data for all relevant stakeholders to begin the process of regulating work hours for RDs in the Nigerian workspace.

Informed consent

Informed consent was obtained from all participants in this study.

Ethical approval

N/A. As the research was completely anonymized, without infringement on participants' rights, and the data was neither sensitive nor confidential in nature, research approval was not sought.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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