Dear Editor, An 80-hour duty limit for residents was first introduced by the Accreditation Council for Graduate Medical Education (ACGME) in 2003, with the further addition of a 16-hour continuous duty period limit for first-year residents in 2011. Prior studies1 have demonstrated an association between longer working hours and increased risk of mental illness,2 attentional

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.

ABSTRACTSocial media and the data it produces lend itself to being visualised as a network. Individual Twitter users can be represented as nodes and retweeted by another Twitter user, thereby forming a relationship, an edge, between users. However, an unbounded network is a sprawling mass of nodes and edges. Boundary settings are typically applied, for example, a time period, a hashtag, a keyword search or a network substructure of a phenomenon of interest. Thus, the particular visualisation created is dependent upon the boundaries applied, enabling productive visual consumption, but concealing its social shaping. To explore this question of boundary setting and its associated issues, we draw on an example from the Twitter discussions about the UK Minister for Health, Jeremy Hunt, and the media debate surrounding the contractual hours of junior doctors during 2015–2016. We discuss the role and impact differing stakeholders have in setting these boundaries. We seek to provide a set of ‘questioning lenses’ in which we ask why these boundary settings were selected, what effect they have, and what are the potential implications of these boundary setting techniques on the visualisation consumer.

Aim: To create the first evidence-based risk management tool that balances productivity with the likelihood of breeching the European Working Time Directive (EWTD) and band 1 of the current UK junior doctor contract. Thus, providing reassurance to HR managers and junior doctors that a working pattern will not breech contractual and legislative hours limits. Methods: Twenty-one North West England NHS Trusts allowed access to their junior doctor hours monitoring data from 2012/13. Examination of the variance between the anticipated hours of work and that actually worked in practice facilitated the production of a risk-management tool for rota designers. Results: Valid monitoring returns were obtained for 256 full-shift and 47 non-resident on-call rotas. Full-shift specialties with >10 rotas in the dataset, and normally distributed, were used to produce a look-up table that allows rota designers to choose an acceptable percentage likelihood of breeching a pay banding/EWTD. This would be achieved by incorporating a specified minimum number of minutes under/over the 48-hour limit into the template rota as designated by the tool.

IntroductionThere is a well-established role of specialist nurses in on-going management of chronic diseases in specialist clinics. With the reduction in junior doctor hours, advanced nurse clinicians (ANC) are taking...

BackgroundA major reform of junior doctor training was undertaken in 2004–5, with the introduction of foundation training (FT) to address perceived problems with work structure, conditions and training opportunities for postgraduate doctors. The well-being and motivation of junior doctors within the context of this change to training (and other changes such as restrictions in working hours of junior doctors and increasing demand for health care) and the consequent impact upon the quality of care provided is not well understood.ObjectivesThis study aimed to evaluate the well-being of foundation year 2 (F2) doctors in training. Phase 1 describes the aims of delivering foundation training with a focus on the role of training in supporting the well-being of F2 doctors and assesses how FT is implemented on a regional basis, particularly in emergency medicine (EM). Phase 2 identifies how F2 doctor well-being and motivation are influenced over F2 and specifically in relation to EM placements and quality of care provided to patients.MethodsPhase 1 used semistructured interviews and focus groups with postgraduate deanery leads, training leads (TLs) and F2 doctors to explore the strategic aims and implementation of FT, focusing on the specialty of EM. Phase 2 was a 12-month online longitudinal study of F2 doctors measuring levels of and changes in well-being and motivation. In a range of specialties, one of which was EM, data from measures of well-being, motivation, intention to quit, confidence and competence and job-related characteristics (e.g. work demands, task feedback, role clarity) were collected at four time points. In addition, we examined F2 doctor well-being in relation to quality of care by reviewing clinical records (criterion-based and holistic reviews) during the emergency department (ED) placement relating to head injury and chronic obstructive pulmonary disease (COPD).ResultsPhase 1 of the study found that variation exists in how successfully FT is implemented locally; F2 lacks a clearly defined end point; there is a minimal focus on the well-being of F2 doctors (only on the few already shown to be ‘in difficulty’); the ED presented a challenging but worthwhile learning environment requiring a significant amount of support from senior ED staff; and disagreement existed about the performance and confidence levels of F2 doctors. A total of 30 EDs in nine postgraduate medical deaneries participated in phase 2 with 217 foundation doctors completing the longitudinal study. F2 doctors reported significantly increased confidence in managing common acute conditions and undertaking practical procedures over their second foundation year, with the biggest increase in confidence and competence associated with their ED placement. F2 doctors had levels of job satisfaction and anxiety/depression that were comparable to or better than those of other NHS workers, and adequate quality and safety of care are being provided for head injury and COPD.ConclusionsThere are ongoing challenges in delivering high-quality FT at the local level, especially in time-pressured specialties such as EM. There are also challenges in how FT detects and manages doctors who are struggling with their work. The survey was the first to document the well-being of foundation doctors over the course of their second year, and average scores compared well with those of other doctors and health-care workers. F2 doctors are benefiting from the training provided as we found improvements in perceived confidence and competence over the year, with the ED placement being of most value to F2 doctors in this respect. Although adequate quality of care was demonstrated, we found no significant relationships between well-being of foundation doctors and the quality of care they provided to patients, suggesting the need for further work in this area.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Evolving Trauma and Orthopedics Training in the UK

Anaesthetic training: not better, not worse, just different

A main objective of restricting working time for residents, whether it is the Accreditation Council for Graduate Medical Education (ACGME) regulation or the European Working Time Directive (EWTD), is to protect patients from exhausted doctors. However, in the Netherlands, legislation enacted in 1993 to reduce working hours for junior doctors, as residents are termed, and midwives was prompted by trainees in a teaching hospital who complained to members of parliament about long working hours and miserable personal lives. At the time, public working hours were mandated to no more than 38 h/wk. An arbitrary 10 hours was added for education and training: thus, trainees were allowed to work 48 hours a week. In the first years, the Dutch Department of Labor took a more or less lenient position but, in 1997, started to enforce the law. Site visits to hospitals are made routinely, resident schedules are inspected, and hospitals are fined if they do not comply with the rules. Initially the surgical community fiercely opposed the new regulation and argued that a work week of 48 hours would not suffice to adequately train young surgeons. However, their plea for a 60-hour work week was politically unacceptable to the Dutch government, which had already accepted the limits of the European Working Time Directive. In 1995, the yearly survey of the Dutch Association of Surgical Trainees reported a work week of 57 hours. This number decreased to 55 hours in 2005 and has remained unchanged since.1

The trend, in the last few years, of shorter working hours for junior doctors has been driven by the need for safer working conditions. This has led to the loss of continuity of care and the introduction of shift work for residents and registrars, resulting in up to three handovers per 24-h period. Many sentinel events occurring in hospitals can be attributed to a breakdown in communication. Clinical handover is important because it not only facilitates continuity in the transfer of patient information between healthcare professionals but also helps identify potential problems that may occur in upcoming shifts. Methods of handover include verbal-only reports, verbal reports with note-taking and the use of printed handouts containing relevant patient information. This paper presents an exposition of a working model for morning surgical handovers in a tertiary teaching hospital that uses a printed handover sheet, is consultant-led and conference-based, and with an educational focus. A survey of resident staff confirmed the morning handover as important in both patient care and education. There was a marked improvement in tertiary trauma survey completion rates after the introduction of the morning handover. It is now an accepted and important part of the working day in the surgical unit of the hospital.

The work hours of junior doctors have been in the spotlight since the mid-1980s. Rostering and the structure of surgical units aim to balance quality and continuity of patient care with reasonable working hours. Actual hours worked during two 12-week surgical registrar rosters were compared. Compliance of each roster with fatigue recommendations was assessed with Fatigue Audit InterDyne (FAID, InterDynamics Pty Ltd, Adelaide, Australia) software. Workload was determined from an electronic prospective surgical audit. Impact of the roster change was discussed with consultants and registrars. The traditional roster started on 16 July 2007 and the fatigue-friendly roster on 14 July 2008. The total number of hours worked reduced by 11% (from 5085.17 h in 2007 to 4530.85 h in 2008). Fatigue was eliminated (from 133.25 h in 2007 to 0 h in 2008). Over the 12-month period, the operative workload for the Department of General Surgery increased by 18%. FAID compliance improved from 67.3 to 91.2%. Consultant and registrar satisfaction with the new roster was high. Safe working hours have been achieved for surgical registrars by restructuring the surgical units and implementing a new on-call rota without a perceived effect on patient care.

Address correspondence to Prof. F.P. Cappuccio, Clinical Sciences Research Institute, University of Warwick, Warwick Medical School, U.H.C.W. Campus, Clifford Bridge Road, Coventry CV2 2DX, UK. email: f.p.cappuccio@warwick.ac.uk The Modernization of the National Health Service (N.H.S.) and medical careers have brought over the last 10 years or more growing pressures and demands for radical changes in the way we deliver safe and effective healthcare and train new doctors to fit these changes. At the same time, there has been increasing awareness at a European level that both patients and doctors are exposed to health risks due to excessive working hours of junior doctors. A legislative framework to reduce average working hours to no more than 48 h/week was then introduced in Europe (with the view to be implemented fully on 1 August 2009), which has added to the challenges and has sparked a much heated debate.

SummarySpecialist training in the UK has been affected by changes in recent years aimed at a reduction in junior doctors' working hours to comply with employment regulations and the introduction of structured training with specified duration. The Calman reforms implemented in 1996 introduced a focussed system with defined competencies and a shorter training period. The previous system was based on experience gained in an apprentice-type setting with no defined duration of training. The European Working Time Directive (EWTD) regulates the number of working hours for junior doctors and aims for a 48-h working week by 2009. In the surgical disciplines a reduction in working hours and shorter duration of training could adversely affect the acquisition of operative skills. The concern among trainees and their trainers was that surgical exposure has been reduced and therefore trainees have limited surgical experience by the time they complete training. We conducted this study in a teaching district hospital to determine the effect of recent changes on gynaecological surgical training. We found that there was a 27% reduction in surgical activity between 1995 and 2005 from 3,789 to 2,781, whereas the number of trainees had increased by 67% from 6 to 10. The proportion of operative procedures performed by trainees decreased from 55% (2,078/3,789) in 1995 to 34% (951/2,781) in 2005 (p < 0.001). The average number of procedures performed by each trainee in 2005 was 95 compared with 346 in 1995, a 73% reduction (p < 0.001). Innovative approaches to surgical training in gynaecology are required to produce a competent surgeon in a shorter time, or the risk of future consultants having limited surgical experience will increase.

The implementation of the European Working Time Directive, from the Council of the European Union (93/104/EC), in August 2004 has provoked a change in the working hours of junior doctors in the United Kingdom. With the evolution of the subsequent cross-cover arrangements combined with the modernising of medical careers,(1) training is becoming increasingly important. Here we present a simple method of teaching junior doctors the skills and competencies required to aspirate a peritonsillar abscess or 'quinsy'. The model is easy to construct, low cost and reusable.

The European Working Time Directive and training in cardiothoracic surgery in the United Kingdom: A report of the Specialty Advisory Board in Cardiothoracic Surgery of The Royal College of Surgeons of Edinburgh

By 2009 doctors in training will have to reduce their working hours to 48 per week. One strategic health authority estimates that they will lose 8,000 junior doctor hours per week. How will the service manage? What effects will the reduction in hours have on training? This article gives an overview of current developments in negotiations on the European Working Time Directive (ETWD) and urges readers to start planning for 2009 implementation now. The newly launched College web area on the EWTD (http://www.rcseng.ac.uk/service_delivery/ewtd/) provides more information and updates.

The implementation of the European Working Time Directive and the compulsory reduction in junior doctors hours provided the main driver and background for this project. The project aim was to implement Hospital Emergency Care Teams (HECT) on three District General Hospitals (DGHs) to provide emergency out-of-hours care. The project strategy centred on the recruitment, training and preparation of critical care nurses to undertake advanced assessment roles. Methods used to monitor and evaluate activity include the use of innovative hand-held computers. Main outcomes include, the conclusion that a multidisciplinary HECT of five could manage the overnight workload and level of acuity in a DGH of 420-500 beds, and that critical care nursing staff can be prepared for advanced supporting roles. Experiences gained provide valuable learning that could be used to influence similar projects. Implications for practice include the development of a national framework to inform areas such as multidisciplinary competency-based education and training. Scientific evidence is required to evaluate the effect of HECT on hospital mortality and morbidity and quantify the staff, inpatient experiences.

Advanced nursing roles such as the night nurse practitioner (NNP) have been introduced into NHS trusts in response to the reduction in junior doctors hours. The NNP role is diverse and constantly evolving to meet patient need. The NNP undertakes advanced clinical assessment of patients and undertakes interventions to facilitate optimum patient care. Is the step towards nurse prescribing a natural progression or are professional working boundaries being destroyed= Recent controversial developments surrounding the nurse prescribers role will have a significant impact on the NNP. This article looks at the potential implications for practice development considering the ongoing changes within the nurse prescribing arena.

Objectives: To determine what measures were introduced by emergency departments in response to the national monitoring week in March 2003, and which, if any, of these were most effective in...

Postpartum haemorrhage (PPH) is a worldwide problem. The historical background dates back to William Smelley's in the seventeenth century in his famous treaty of the theory and practice of midwifery in 1752. Changes in clinical factors and surgical expertise compel the modern day midwife and obstetrician to be vigilant in identifying risk factors and apply appropriate solution early. The recent confidential enquiry into maternal death (why mothers die (2000–2002)) identifies areas of substandard care. The rising caesarean section rate adds to the rising incidence of PPH. The reduction in junior doctor's hours may limit the pool of experienced obstetric surgeons available to manage severe PPH competently. There can be major complications following radical surgery for PPH. These include loss of fertility, other morbidity and even maternal death. The invention of the B-Lynch surgical technique for the conservative management of PPH was first performed and reported by a consultant obstetrician and gynaecological surgeon in Milton Keynes NHS Trust publishing the first series of cases in BJOG 1997. This has made a significant impact on the conservative surgical management of massive PPH. There are now over 1300 successful applications of this technique worldwide (CB-Lynch personal communication). Other similar or modified techniques such as Cho's Square Suture and Haymen's modification of the B-Lynch Suture Technique have been introduced adding to more available methods of conservative surgery. The current list of publications of successful application of the B-Lynch compression technique is encouraging and more outcome data can be reported by a letter or e-mail to enquiries@cblynch.com. Obstetricians and midwives both in developed and underdeveloped countries should seek training and attend fire drills in PPH control to avoid maternal morbidity and death. There should be special concentration on effective conservative surgery such as uterine compression techniques to avoid major morbidity and loss of fertility.