European Working Time Directive Research Articles

Fatigue among anaesthesiologists in Europe: Findings from a joint EBA/NASC survey.

Anaesthesiologists deliver an increasing amount of patient care and often work long hours in operating theatres and intensive care units, with frequent on-calls and insufficient rest in between. In the long term, this will negatively influence mental and physical health and well being. As fatigue becomes more prevalent, this has predictable implications for patient safety and clinical effectiveness. 1. This study aimed to evaluate the prevalence, severity, causes and implications of work-related fatigue amongst specialist anaesthesiologists. An online survey of specialist anaesthesiologists. The survey was sent to anaesthesiologists in 42 European countries by electronic mail. Responses from a 36-item online survey assessed work-related fatigue and its impact on anaesthesiologists in European countries. Work-related fatigue was experienced in 91.6% of the 1508 respondents from 32 European countries. Fatigue was caused by their working patterns, clinical and nonclinical workloads, staffing issues and excessive work hours. Over 70% reported that work-related fatigue negatively impacted on their physical and mental health, emotional well being and safe commuting. Most respondents did not feel supported by their organisation to maintain good health and well being. Work-related fatigue is a significant and widespread problem amongst anaesthesiologists. More education and increased awareness of fatigue and its adverse effects on patient safety, staff well being and physical and mental health are needed. Departments should ensure that their rotas and job plans comply with the European Working Time Directive (EWTD) and introduce a fatigue risk management system to mitigate the effects of fatigue.

Employment Factors Associated With Long Working Hours in France

The objectives of the study were to explore the employment factors associated with long working hours, known as a risk factor for various health outcomes. The study relied on the national representative data of the 2013 French working conditions survey and a study sample of 23,378 full-time employees. Long working hours were defined by the threshold of 48 hours a week following the European Working Time Directive. The prevalence of long working hours was higher among men (13.5%) than among women (8.5%). Employees of the private sector, with permanent work contract, in small companies, and men in the services had a higher prevalence of exposure. This prevalence increased with educational and occupational levels. Our findings may help decision-makers to define preventive strategies. More research is needed to improve our knowledge of the employment factors associated with long working hours, as there may be strong differences between countries.

861 Getting the Surgical Handover Right: A Closed-Loop Audit

Abstract Aim The European Working Time Directive has led to a reduction in hours worked by junior doctors and subsequently increased the number of handovers between colleagues. Ineffective handovers introduce the opportunity for clinical error and adversely affect patient safety. We sought to improve the quality of patient handovers in a busy surgical department, by assessing compliance with a twelve-point guideline from the Royal College of Surgeons (RCS) as the gold standard. Method An audit was performed across a seven-day period. For each patient discussed during the morning or evening handover, compliance was measured according to twelve domains pertaining to a patient’s admission as per RCS recommendations (e.g., diagnosis, location, relevant investigation results). Following intervention with a ‘safe handover’ checklist, we repeated the audit across a subsequent seven-day period. Secondary outcomes, such as environmental and human factors, were also assessed by a junior team member. Results A total of 28 handovers, incorporating 337 patients, were included. Following implementation of the checklist, compliance improved across most domains—particularly with highlighting the necessity for an additional review (33.3% vs. 91.0%) and the handover of outstanding tasks (31.5% vs. 84.3%). Compliance with discussion of resuscitation status remained low (7.0% vs 9.2%). Improvements were noted with environmental and human factors, including performance of team introductions and the opportunity to raise concerns. Conclusions We have demonstrated an improvement in the quality of patient handovers as per RCS guidance following the implementation of a handover checklist. Further interventions are warranted to improve handover of resuscitation status.

Resident physician duty hours, resting times and European Working Time Directive compliance in Spain: a cross-sectional study

BackgroundThere is a growing interest in understanding the impact of duty hours and resting times on training outcomes and the well-being of resident physicians. However, to this date no state-wide analysis exists in any European country.ObjectivesOur aim is to describe the shift work scheduling and to detail the degree of compliance with the Spanish legislation and the European Working Time Directive (EWTD) of Spanish resident physicians, focusing on territorial and specialty distribution.Material and methodsA descriptive cross-sectional analytical study was designed through an online survey adapted from the existing literature.ResultsOut of the 2035 surveyed resident physicians undergoing PGT in Spain, 80.49% exceeded the 48 h per week limit set by the EWTD and 13% of them did not rest after a 24-h on-call shift. The mean number of on-call shifts in the last 3 months was 15.03, with the highest mean reported in Asturias, La Rioja, and Extremadura. 51.6% of respondents had a day-off after a Saturday on-call shift. Significant differences are observed by region and type of specialty.ConclusionResident physicians in Spain greatly exceed the established 48 h/week EWTD limit. Likewise, non-compliance with labor regulations regarding mandatory rest after on-call duty and minimum weekly rest periods are observed.

A national survey of surgical training in gynaecology: 2014–2021

ObjectivesOver the last decade barriers to surgical training have been identified, including reducing access to theatre lists, reducing numbers of major surgical procedures being performed, increasing numbers of trainees and reduction in working hours since the introduction of the European Work Time Directive (EWTD). We aimed to assess the impact of these challenges on training in gynaecology over time.Study Design.We designed a study which aimed to assess both trainers and trainees perception of gynaecological surgical training in Ireland. The purpose of this was to identify confidence levels and challenges and to highlight potential areas for future improvement of surgical training in gynaecology.A a cross-sectional survey was distributed to all trainees and trainers registered with the Royal College of Physicians of Ireland Obstetrics and Gynaecology higher specialist training programme in 2014, 2017 and again in 2021. ResultsDuring the study period trainees’ confidence that the training programme prepared them to perform gynaecological surgery fell significantly. This fall in confidence was most evident for trainees’ ability to perform abdominal hysterectomy (40.9% vs 15.2%, χ2 = 4.61, p =.03) and vaginal hysterectomy (31.8% vs 12.1%, χ2 = 4.58, p =.03) when comparing 2014 with 2021. All trainees reporteded that gynaecology was not given adequate time in the training programme to prepare them to practice independently as consultants. Themes identified by participants to improve training included dedicated access to theatre time with a named trainer, increased simulation training and subspecialisation at later stages of training. ConclusionOur findings show an overall decrease in trainees’ and trainers’ confidence in the surgical training available in gynaecology over an eight-year period.. This is particularly true for major gynaecology procedures. Efforts must be made to ensure trainees have improved access to surgical training in gynaecology. Potential solutions include improving access to simulation and incorporation of subspecialist training into later stages of training.

Changes in weekly working hours, proportion of doctors with hours above the limitations of European Working Time Directive (EWTD) and time spent on direct patient care for doctors in Norway from 2016 to 2019: a study based on repeated surveys

ObjectivesTo compare the total weekly working hours, proportions with work hours above the limitations of European working time directive (EWTD) and time spent on direct patient care in 2016 and...

Surgical training in the 21st century: Are we limited by training time or are we just distracted?

The aim of any surgical training programme is to produce competent, effective, and safe individuals, who will go on to deliver high quality patient care, for a prolonged period at an affordable cost. The fundamental principles of surgical training have remained unchanged for years, despite there being increasing concerns relating to trainee recruitment, retention, and morale. There is no benefit in ascribing shortcomings of surgical training to uncontrollable factors such as the European Working Time Directive, unprecedented NHS service demand following COVID-19 and economic uncertainty. Instead, we must look introspectively at existing opportunities for improvement in order to continue to produce high quality surgeons in the NHS.

The implementation of the European Working Time Directive in Europe and its impact on training in obstetrics and gynaecology: A ten year follow-up

ObjectiveTo reassess the compliance with the European Working Time Directive (EWTD) in the member countries of the European Network of Trainees in Obstetrics and Gynaecology (ENTOG) and to investigate the impact of the EWTD on training. Study designIn this observational, cross-sectional study, an online questionnaire, containing multiple-choice questions and open questions, was distributed among Obstetrics and Gynaecology trainees in 33 ENTOG member countries. The questionnaire was designed as a follow-up of a similar survey conducted by ENTOG in 2009 and assessed the overall compliance with the EWTD, the adaptations needed to achieve this compliance, the impact of the EWTD on the quality of training and the well-being of trainees. The answers were analysed using descriptive statistics in Microsoft Excel. Results59 responses from 28/33 (84.8%) ENTOG member countries were collected. Only 5 out of 28 (17.9%) countries were found to be nationally compliant with EWTD. There were no clear differences in the compliance between different types of the hospitals (university/teaching/district), but a trend was observed towards higher rate of implementation in smaller hospitals (<1500 deliveries per year). Regarding the changes needed to become EWTD-compliant and yet maintain high-quality training, the most common suggestions were: hiring extra junior doctors, restructuring training, having less doctors on duty simultaneously, consultants performing more hands on work, dedicated training sessions, reduction of administrative tasks and simulation training for surgical skills. The majority of trainees, 7 out of 12, (58.3%) in the EWTD-compliant hospitals experienced a positive effect on their training, whereas the majority of trainees in non-compliant hospitals, 31 out of 47, (66%) were uncertain about the impact of the EWTD on the quality of training. Among the positive changes, better work-life balance and more consultants available out of the daily working hours were listed. ConclusionsDespite the introduction and implementation of the EWTD over two decades ago, the compliance rates across Europe remain low and seem not to have altered in the last ten years. In order to ensure the quality of training and, most importantly patient safety, we suggest that European nations keep striving to implement the EWTD for doctors in training. We also suggest for nations that have yet to implement this directive to use the strategies as an exemplar in countries that follow EWTD.

363 A Comparative Analysis of Night-Time General Surgical Training

AimThe aim of surgical training is to ensure trainees acquire competencies to perform as a Day 1 Consultant. The last decade has seen the introduction of European Working Time Directive, NELA guidelines and the revised Junior Doctor Contract. All of these, as well as the COVID 19 pandemic, have caused concerns regarding training. Our aim was to examine any changes to night-time on call activity during this time.MethodWe retrospectively analysed prospectively collected data from 2011, 2018, and 2021, in a busy District General Hospital. The data collection period was 31 days, looking at night-time (8pm to 8am) operative experience, supervision, and non-operative activity. A regression analysis was conducted to compare outcomes. A qualitative survey was used to assess attitudes and confidence.ResultsOn average, trainees spent 11% of their time operating independently, 2% operating supervised, 11% attending trauma-calls and 73% clerking/non-educational activities. There was a significant difference between the hours spent on operative versus non-operative activity (P 0.00046) with no differences over the years. Junior trainees did not feel confident operating at night and only 33% of all trainees found night-time training effective.ConclusionsNightshifts comprise a substantial proportion of potential training opportunities and managing the unselected emergency take is one of the Capabilities in Practice. Effective solutions must be implemented to help improve night-time surgical experience and confidence in order for this time to be effective for training of both operative and non-operative competency attainment.

The European Working Time Directive: Will Modern Surgical Training in the United Kingdom Be Sufficient?

PurposeThe introduction of the European Working Time Directive in 2009 limits doctors in the United Kingdom to a 48-hour working week. The reduction in surgical training time raises concern over the ability of future surgeons to deliver safe and effective care.MethodsThis interview-based qualitative study was conducted within a tertiary referral centre in the United Kingdom. Nine consultant general surgeons were interviewed with the aim of investigating how surgical trainees can comply with the European Working Time Directive whilst gaining sufficient knowledge, skill and experience to be safe surgeons.ResultsConsultants felt that the European Working Time Directive has impacted surgical training, patient care, service provision, and the professional attitudes of trainees. They felt that current surgical trainees have a relative lack of experience compared to previous generations, which has impacted their ability to manage complex patients. The consultant-trainee relationship was felt to have suffered due to shorter working hours. Furthermore, the move towards shift work has resulted in a lack of continuity of care for patients. Consultants suggested reconfiguring theatre lists to maximise opportunities for trainees. They also recommended that trainees seek out alternative learning methodologies such as simulation, and consider clinical fellowships at the completion of their training to maximise their experience and surgical skills prior to consultancy.ConclusionThis study highlights the concerns that senior surgeons working in a busy tertiary referral centre have towards the European Working Time Directive and modern surgical training. The authors recommend that both trainees and consultants have a responsibility to maximize opportunities during training, and that mentorship will need to continue at the consultant level. Further research in other centres can determine whether these sentiments are widespread, and whether institutional steps should be taken to change the way that modern surgeons are trained.

Core training and surgical opportunities: a UK-based analysis

The COVID-19 pandemic, the new Intercollegiate Surgical Curriculum Programme curriculum and the European Work Time Directive significantly reduced surgical exposure for trainees. This study analyzed the operative experience of Phase 1 trainees (CT1/ST1 vs. CT2/ST2) against the Annual Review of Competence Progression (ARCP) criterion of 120 procedures yearly. National survey research in October 2021. Study end-point was the completion of >4 weekly procedures, equivalent to 120 cases per year. Chi-square test and multivariate regression analysis were performed. 205 participants from 5 Deaneries were included, 48.3% were CT1/ST1 and 51.7% were CT2/ST2. About 54.5% of year-1 and 50% of year-2 trainees were 28 30 years old, 55.6% and 50.9% were male, and 39.4% and 38.7% were White British. About 39.4% of CT1/ST1 and 22.6% of CT2/ST2 performed <4 weekly procedures (P = 0.01), with no difference in the "Observed" (P = 0.6) or "Assisted" (P = 0.3) number of cases. CT2/ST2 recorded more "ST-S" (p 0.04), "S-TU" (P = 0.03), and "Performed" (P = 0.02) operations. For CT1/ST1, older age (HR 2.4, 95% CI [1.1; 5.3], P = 0.02) and southern deaneries (HR 1.7, 95% CI [1.2; 2.4], P = 0.004) were independent factor for <4 weekly procedures. For CT2/ST2, northern regions were associated with more favorable training (HR 1.4, 95% CI [1.1; 1.7], P = 0.01). Over one third of Phase 1 trainees do not meet the ARCP requirement of >120 procedures annually. Age and region of training are independent factors in the number of logbook cases. This research focuses on training opportunities for junior surgical residents across the United Kingdom. The degree and type of exposure to the operating theatre have a significant impact on the development of surgical competencies. These are undoubtedly related to patient outcomes, as the quality of care delivered to patients and relatives greatly relies on the training background of future consultant surgeons.

1231 A Full-Cycle Audit Of ‘Safe’ Surgical Handovers in A Tertiary Centre

Abstract Aim 1. Assess performance in surgical handovers at Southampton General Hospital (SGH) against RCS ‘Safe Handover’ guidelines Identify any areas for improvement to ensure safe and effective handover of surgical patients Method 10 evening surgical handovers were anonymously audited In October 2019 against RCS ‘safe handover’ guidelines. The results were subsequently analysed and circulated amongst the surgical department. Handovers were then led consistently by surgical registrars and advanced nurse practitioners (ANPs). A prompt including the RCS handover guidelines was made and distributed to all members of the surgical team and included in departmental inductions. Following this, a further 10 evening handovers were anonymously audited between July and August 2020. Results Many aspects of handover performance descriptors described by the RCS in the re-audit improved following the circulation of our prompt including RCS handover guidelines and examples of minimum or good standards of practice for handover. Specifically, handover timeliness, the briefings provided (100% from 70%), the audibility of a single speaker (70% from 30%), the number of educational discussions held during handovers (100% from 50%) and awareness of the on-call overnight consultant (100% from 80%) all vastly improved. Conclusions Emphasis on undertaking effective handovers needs to continue as ‘safe' handovers between shifts can protect both patient and doctor safety. This is especially true following the implementation of the European Working Time Directive (EWTD) and a move to full shift working. Handovers are also proposed as opportunities for training which may be helpful especially in an era of reduced hours of surgical training.

How to Implement a Simulation-Based Education Programme: Lessons from the UK Urology Simulation Boot Camp.

The operative and non-technical skills exposure of urology trainees has reduced due to a number of factors, including the European Working Time Directive, and the COVID-19 pandemic. Simulation-based education (SBE) is an innovative addition to clinical experience which can begin to address the skills-based learning deficiency in order to help trainees meet their curriculum requirements and optimise the exposure required for a trainee to become a competent general urology consultant. Surgical simulation is an effective training tool but has a complex implementation process, requiring considerable planning tailored to specific educational targets, to ensure it is sustainable and reproducible. Methodology from the field of implementation science offers an invaluable approach to design an effective simulation-based training adjunct, as exemplified by the example of the UK Urology Simulation Boot Camp (USBC), a comprehensive training course which incorporates core technical and non-technical skills based on the current Joint Committee on Surgical Training (JCST) urological training curriculum to equip newly appointed urology trainees to work as competent junior registrars. Delivered annually in Leeds since 2015, the course has had excellent feedback and results in improving the urological knowledge of trainees, as well as increases in trainees’ confidence. This paper will provide a summary of how the course was designed, delivered, reproduced, sustained and evaluated. Its success is demonstrated by its incorporation into the UK urology training programme, and since 2018, it is now recommended to all new urology residents in the UK. The course implementation model would be applicable to other surgical specialties.

Where's the emergency? Improving emergency psychiatry experience for core trainees in Bath and North East Somerset (BaNES) and Gloucestershire Health and Care (GHC) localities

AimsThe Royal College of Psychiatry advises that core trainees should be involved in 50 first-line emergency assessments during their core training. This includes assessment of suicidal risk following self-harm at least monthly. Trainees in Bath and Gloucester are not meeting these requirements. We set up an emergency experience rota, with the aim of increasing trainees’ experience and confidence in assessment and management of emergency psychiatry.MethodAn emergency experience rota was implemented in Bath in September 2017. Trainees were surveyed before and after their 6 month rotations. In cycle 1, trainees spent two weeks with the Crisis team and an additional three days with the Liaison team per rotation. In cycle 2, we made some modifications to the rota so that it was more flexible. This system was then adopted in Gloucester where trainees were encountering similar difficulties. We hope to complete cycle 3 across the two localities by July 2021.ResultFrom the initial two cycles conducted in Bath, post-change surveys showed an increase in trainees’ confidence in assessments in acute settings and completing risk assessments in cases of self-harm and suicidal ideation. All of the trainees who took part would recommend the experience to other trainees (100% (7/7)). In Gloucestershire, only pre-change data have been collected so far. A full analysis of all the results will be presented.ConclusionThe introduction of working time regulations such as the European Working Time Directive (2003) as well as local service reconfigurations leading to nurse-led liaison services and home treatment teams, have reduced the opportunity for trainees to undertake emergency assessments. Across the Severn Deanery, there is a discrepancy in the opportunity core trainees’ have to undertake emergency assessments – depending on their rota, stage of training, and services available. This difference in trainee experience, depending on locality, has been further impacted by COVID-19 and the introduction of cohorted wards.Trainees in Bath and Gloucester are predominantly covering the wards during on-calls and, therefore, we set out to ensure that they are regularly rostered to obtain emergency experience, helping them meet their core training competences. Initial results from two cycles of an emergency / out-of-hours experience rota suggest increased experience and confidence in first-line emergency assessments, enabling them to work towards meeting their core training requirements.

AB061. SOH21AS058. Evaluating the use of a proximal femoral nail module using a virtual reality orthopaedic simulator: a face and construct validity study

Background: Changing surgical practice due to the European Working Time Directive, shorter training times, and novel technological advancements compel current surgical curricula to find innovative methods of training to ensure adequate development and retention of surgical skills in our trainees. Virtual reality simulation as a learning tool to transcend current training methods have been of recent interest. This study aimed to identify the face and construct validity of the Precision OS trauma module proximal femoral nail procedure.

Factors relating to working hours restriction that have impacted the professional identity of trainees in the last decade.

Ever-developing changes to the working hours of junior doctors by the European Working Time Directive, the junior doctor contract of 2019 and most recently the COVID-19 pandemic have impacted the professional identity of doctors. There has been little investigation into its influence on the multifaceted aspects of postgraduate medical training, which feeds into how trainees consider themselves professionally and the concept of professional identity or 'being a doctor'. A review of the medical, socio-political and educational literature reveals that the impact on the professional identity development of trainees is influenced by several perspectives from the trainee, trainer and the public. Gross reduction in working hours has no doubt decreased the raw volume of clinical experiences. However, to counteract this, smarter learning processes have evolved, including narrative reflection, supervised learning events, and a greater awareness of coaching and training among trainers.

Do obstetrics trainees working hours affect caesarean section rates in normal risk women?

ObjectivesThe rate of caesarean section (CS) is increasing globally. The nulliparous, term, singleton, vertex presentation, spontaneously labouring woman (Robson Group 1/RG1) is considered low risk for CS. It has been hypothesized that more CS occur at nighttime or at weekends due to doctor fatigue. The European Working Time Directive (EWTD) was implemented in our institution in 2013 to limit doctor working hours, which aimed at reducing fatigue but arguably fractures continuity of care. This study aimed to determine the effect of nocturnal hours and weekend on-call as well as the implementation of EWTD on our RG1 CS rates. Study designThis was a population-based study in a tertiary referral centre from 2008−2017. The inclusion criteria for our study were limited to RG1. Data were analysed from an established clinical database, including mode and time of delivery. Descriptive statistics are presented as number and percent for categorical variables. Relative frequencies were tested using chi-squared test. All statistical analyses were performed using SPSS Version 26. Statistical significance was defined as p < .05. ResultsThere were 86,473 deliveries over the 10-year study period. There were 18,761 women in RG1. Overall the RG1 CS rate was 12.9 % (n = 2415). Rates of CS in the RG1 were not statistically different between those delivering on weekdays (12.9 %, n = 1726/13,430) and weekends (12.9 %, n = 689/5,331, OR 0.99, 95 % CI = 0.90–1.09, p = .89). During daytime hours the CS rate was 12.1 % (n = 777/6411) and at nighttime was 13.3 % (n = 1638/12,350, OR 1.10, 95 % CI = 1.01–1.21, p = .03). Comparing the time periods pre and post EWTD implementation, there was a significant increase in CS rates (12.1 % n = 1319/10,873 V 13.9 % n = 1096/7,888, OR 1.17, 95 % CI = 1.07–1.27 p < .001). With respect to other modes of delivery in RG1 pre and post EWTD, there was a statistically significant decrease in operative vaginal delivery (OVD) rates (40.1%, n=4,360 V 37.7%, n=2,973, OR 0.90, 95% CI = 0.85-0.95, p = .001) ConclusionThis study shows an association between obstetric trainee working practices, RG1 CS and OVD rates; this is most pronounced at night and after the introduction of the EWTD. It is unlikely that obstetric trainee working practices are the only factor related to the increasing CS rate and reduced OVD rate. Consideration should be giving to addressing the needs of obstetric trainees in relation to achieving their competencies with now reduced labour ward exposure. Further study is required to see if alternate arrangements in relation to simulation training could increase the OVD rate and reduce the CS rate.

Challenges and satisfaction in Cardiothoracic Surgery Residency Programmes: insights from a Europe-wide survey.

The increasing complexity of surgical patients and working time constraints represent challenges for training. In this study, the European Association for Cardio-Thoracic Surgery Residents' Committee aimed to evaluate satisfaction with current training programmes across Europe. We conducted an online survey between October 2018 and April 2019, completed by a total of 219 participants from 24 countries. The average respondent was in the fourth or fifth year of training, mostly on a cardiac surgery pathway. Most trainees follow a 5-6-year programme, with a compulsory final certification exam, but no regular skills evaluation. Only a minority are expected to take the examination by the European Board of Cardiothoracic Surgery. Participants work on average 61.0 ± 13.1 h per week, including 27.1 ± 20.2 on-call. In total, only 19.7% confirmed the implementation of the European Working Time Directive, with 42.0% being unaware that European regulations existed. Having designated time for research was reported by 13.0%, despite 47.0% having a postgraduate degree. On average, respondents rated their satisfaction 7.9 out of 10, although 56.2% of participants were not satisfied with their training opportunities. We found an association between trainee satisfaction and regular skills evaluation, first operator experience and protected research time. On average, residents are satisfied with their training, despite significant disparities in the quality and structure of cardiothoracic surgery training across Europe. Areas for potential improvement include increasing structured feedback, research time integration and better working hours compliance. The development of European guidelines on training standards may support this.

A little less autonomy? The future of working time flexibility and its limits

The European Court of Justice has recently issued rulings on the interpretation of the European Working Time Directive 2003/88, which appear to restrict flexible working time arrangements (especially Matzak C-518/15, Syndicat C-254/18 and CCOO C-55/18). Only a few months prior to the latter ruling of the CJEU, the Austrian legislator amended the Working Time Act in order to make it more flexible. The article argues that the measures taken by the Austrian legislator to enable more flexibility and autonomy can still be regarded as compatible with Union law. In general, the article tackles the question of possible further legislative developments in order to strike a balance between autonomy and the need for security of both parties to the employment relationship. Among other suggestions, the article introduces the concept of molecularisation of working time and examines whether work intensity should be introduced as a qualitative dimension to the concept of working time, thus deviating from the current European Working Time Directive. Finally, the article suggests security measures – often referring to Austria as a best practice example – in order to safeguard workers in view of working time flexibility.

'Slepen al the nyght with open ye': Personal reflections after 35 years of being on-call.

The European Working Time Directive (2003) has had a significant impact in reducing the total number of hours worked per week, as well as shift-lengths. There is, however, no agreement on optimal shift-lengths and day/night work balance in different medical specialities. Given the time it takes for clinical events to unfold, particularly in relation to labour, there may be advantages in retaining the 24 hours on-call shift for obstetricians--in the interests of patient care and training. Increasingly seen as a relic of the past, this shift-length merits further research, which should include the impact on clinician well-being.