Key words workload - specialization - obstetrics - work-life balance - duty roster - perinatal
center
Introduction
Since 2005, all perinatal centers (PNCs) in Germany are classified into one of four
levels of care, based on the complexity of the care provided at the center and on
the regional provision of care and health services: level I perinatal centers I (PNC
I), level II perinatal centers (PNC II), obstetric departments offering secondary
care and short-term perinatal care (PC), and maternity hospitals which offer standard
maternity care (MH). Level I and level II perinatal centers provide high-level tertiary
or quaternary care for mother and child, with level I centers offering the most specialized
treatment. This classification into four levels of care was done to ensure that comprehensive,
high quality obstetric care is available across all of Germany [1 ]. The “Quality Assurance Agreement on the Care of Premature and Full-term Babies”
on which this classification was based has been revised several times, most recently
on 20. 11. 2014 [2 ]. The Agreement defines the criteria for medical care. A PNC I must ensure that at
least one physician is always on duty in the obstetric department for all of the 24
hours and that a further physician is on call in the hospital. At least one of these
physicians must be a specialist for “special obstetric care and perinatal medicine”
or a physician with this specialization must be on-call by telephone. The Agreement
did not give any further specifications on how work should be distributed or what
form the duty rosters of obstetricians should take; full-time work and on-call duty
are both possible. PNC I facilities are additionally expected to function as recognized
training centers for the medical specialty “specialized obstetric care and perinatal
medicine” to ensure that high-quality medical care will continue to be available in
the future. According to the German Working Hours Act [3 ], the average hours of work per week must not exceed 48 hours and the maximum number
of hours worked per week must not exceed 60 hours. For reasons of health protection,
the hours spent on-call are classified as working time [4 ], [5 ]. Employees are only allowed to opt out of this protection at their own request within
the scope of so-called opt-out regulations which permit them to increase their average
working hours up to a collectively agreed higher limit without compensatory time off.
The professional and legal requirements for obstetric care facilities and the laws
on health and safety at work pose special challenges for the systems used to compile
duty rosters. The increasing numbers of women working in the field of gynecology and
obstetrics, where the percentage of female physicians is 64.8%, rising to 82.3% in
the age group up to 34 years [6 ], [7 ], and the family commitments of some mothers are some of the reasons why the percentage
of physicians working part time is increasing. This creates an additional challenge
when scheduling the roster [8 ].
The aim of this national survey of obstetricians working in Germany was to obtain
a realistic picture of the models currently utilized in different hospitals to schedule
the duty rosters. Secondary goals included collecting data on the current workloads
in obstetrics in Germany relative to the level of care provided by the respective
healthcare facility and identifying the resulting differences in the planning of shifts
and duty rosters.
Methods
Questionnaire
The survey was conducted using an online questionnaire developed by the authors themselves
which consisted of 95 items (Supplement 1), of which 93 were questions and two were
comment fields. The first part (20 questions) collected basic data on demography and
professional work and training. The second part collected data on part-time work [9 ], working hours, and the structure of working hours. A third part evaluated the participantʼs
satisfaction. Survey questions considered to be essential for the study were marked
as mandatory. The survey was compiled using www.surveymonkey.de and distributed along with its URL via the newsletter of the Young Forum of the German
Society of Gynecology and Obstetrics (DGGG) to its 2770 members currently training
to become specialists or doing additional advanced training. Information on how to
participate in the survey was also published in the Thieme specialist journal “Geburtshilfe
und Frauenheilkunde” and via the Thieme online network “Thieme Gyn-Community”. Data
were collected over a period of 3 months, from 17.02.2015 to 16.05.2015 with potential
participants given the opportunity to participate in the survey during that period.
Every study participant was required to actively give their consent to the evaluation
of their data at the beginning of the study and to confirm that they were working
in obstetrics at the time of the survey, otherwise they were excluded from the study.
Statistical analysis
Statistical analysis of the data was done using the open source software GNU PSPP
version 0.8.5 and GraphPad Software Inc., San Diego US, Prism 5.0a. Unpaired samples
and non-normally distributed samples were analyzed using the Mann-Whitney test and
the t-test for paired samples. Categorical variables were analyzed using the χ2 -test.
Results
Selection of datasets
A total of 481 (17%) out of the 2770 contacted persons participated in the study.
Of these, 437 were working in obstetrics at the time of the survey and gave their
consent to their data being analyzed. In the subsequent analysis, these 437 respondents
were taken as the total population with the figure of 437 set at 100%. Responses to
all survey questions are set against this figure, and the number or percentage of
participants who declined to answer a specific question is reported (n. s. = not specified).
Characteristics of participants
The majority of participants were German (89%, n = 392, n. s. = 61) and female (77%,
n = 326, n. s. = 59). At the time of the survey all of them were in training to become
specialists in gynecology and obstetrics (52%, n = 230, n. s. = 78). Detailed characteristics
of the participants are given in [Table 1 ]. The majority of participants worked full time (FT 64%, n = 297, n. s. = 80). Detailed
data on part-time working schedules (PT) were part of a subgroup analysis and have
already been published elsewhere [9 ]. The distribution of respondents according to the level of perinatal care offered
by their facility is shown in [Fig. 1 ].
Table 1 Characteristics of participants.
Total
Women
Men
437 physicians working in obstetric departments who consented to data analysis
Gender
n =
437
326
74.60%
96
21.97%
15
3.43%
Age
n =
437
n =
326
n =
96
83
18.99%
73
22.39%
10
10.42%
201
46.00%
155
47.55%
46
47.92%
66
15.10%
54
16.56%
12
12.50%
44
10.07%
32
9.82%
12
12.50%
20
4.58%
11
3.37%
9
9.38%
8
1.83%
1
0.31%
7
7.29%
15
3.43%
Nationality (n = 438; 1 × dual nationality, therefore 101%)
n =
437
n =
326
n =
96
392
89.70%
307
94.17%
85
88.54%
29
6.64%
19
5.83%
11
11.46%
16
3.66%
How many children below the age of 17 years live in your household?
n =
437
n =
326
n =
96
250
57.21%
190
58.28%
60
62.50%
74
16.93%
55
16.87%
19
19.79%
74
16.93%
61
18.71%
13
13.54%
19
4.35%
16
4.91%
3
3.13%
3
0.69%
2
0.61%
1
1.04%
2
0.46%
2
0.61%
0
0.00%
15
3.43%
Extent of employment
n =
437
n =
312
n =
89
104
23.80%
100
32.05%
4
4.49%
297
67.96%
212
67.95%
85
95.51%
36
8.24%
Professional position
n =
437
n =
313
n =
90
230
52.63%
199
63.58%
31
34.44%
81
18.54%
63
20.13%
18
20.00%
3
0.69%
1
0.32%
2
2.22%
57
13.04%
34
10.86%
23
25.56%
12
2.75%
7
2.24%
5
5.56%
17
3.89%
7
2.24%
10
11.11%
3
0.69%
2
0.64%
1
1.11%
34
7.78%
Interns/residents (n = 230): which year of training as a specialist are you currently
in?
n =
230
n =
199
n =
31
Year of training to become a specialist:
20
8.70%
18
9.05%
2
6.45%
38
16.52%
29
14.57%
9
29.03%
40
17.39%
37
18.59%
3
9.68%
62
26.96%
51
25.63%
11
35.48%
56
24.35%
50
25.13%
6
19.35%
6
2.61%
6
3.02%
0
0.00%
8
3.48%
8
4.02%
0
0.00%
0
0.00%
Level of care provided by the facility
n =
437
n =
302
n =
83
82
18.76%
69
22.85%
13
15.66%
22
5.03%
17
5.63%
5
6.02%
54
12.36%
45
14.90%
9
10.84%
225
51.49%
170
56.29%
55
66.27%
1
0.23%
0
0.00%
1
1.20%
1
0.23%
1
0.33%
0
0.00%
52
11.90%
Fig. 1 Distribution of respondents according to the level of care provided by the hospital.
Types of duty rosters
In obstetrics, all conceivable combination of full-time work with and without shift
work (SW), internal on-call duty (IOC) and external on-call duty (EOC) were reported
across all levels of care, from general maternity hospitals to facilities offering
tertiary and quaternary care. [Fig. 2 ] shows the organization of duty rosters in the different hospital types. Twenty-one
participants (5%) reported that night duty was not scheduled as shift work or internal
on-call duty. Across all levels of care, in-hospital work outside of normal working
hours was usually organized either as purely on-call duty or as a combination of regular
working hours and on-call duty. In this survey, on-call duty was the most common form
of roster used to cover night shifts during the week and to cover all weekend shifts
(day and night shifts). A total of 75% (n = 329, n. s. = 56) of respondents reported
that their duty roster included standby duty to cover the night shift. At the same
time, 63% (n = 277, n. s. = 113) reported that all on-call duty rosters included night
shifts from 9 p. m. to 6 a. m.
Fig. 2 Organization of duty rosters according to the level of care provided in the facility
(percentage per type of facility). 359 participants provided usable data = 100%. The
statement “neither SW (shift work) nor OC (on-call duty)” is not shown, n = 21. Not
specified (n. s.) = 57.
Shift work was much rarer: a shift work roster (only shift work or a combination of
on-call duty and shift work) was only used in 20% (n = 88, n. s. = 71) of cases. There
was no clear correlation between the extent of shift work scheduled and the level
of care provided by the hospital facility. However, combinations of both systems increased
as the numbers of physicians present in hospital increased. Similarly, a high number
of births was found to be correlated with shift work: participants (n = 366, n. s. = 71)
reported that on average 20% of scheduled work was shift work across all groups. If
the facility provided care for > 1500 births annually (n = 207), 29% reported working
in shifts; in those facilities which provided care for > 2000 births (n = 114) annually,
43% worked in shifts. Participants also reported that shift work was significantly
more common in facilities which had previously carried out a job analysis (p < 0.01).
External standby duty was part of the duty roster of 30% (n = 132) of participants
(n = 362, n. s. = 75). In this group (n = 132), external on-call duty was often used
as a way of organizing so-called back-up on-call duty (n = 168) and less often when
organizing (additional) standard on-call duty (n = 71).
Participants reported differences between the duty rosters on weekends and those for
the regular working week (defined here as Monday to Friday): shift lengths on the
weekend were significantly longer than in the week. This difference was less pronounced
in departments which had only shift work (n = 31) compared to departments with only
on-call duty or a combination of shift work and on-call duty (n = 324).
In departments where duty rosters were scheduled only as shifts, weekends were almost
exclusively covered by 2 12-hour shifts (n = 27). This was also the most common schedule
(n = 22) during the regular week as well. Because of the limited numbers, further
statistically reliable differentiations were not possible.
In departments which used on-call rosters (n = 324) there was a difference between
weekend and workday shifts: on-call shifts of 20 to 24 hours were the most common
(n = 162), followed by 12 – 14 hour on-call shifts (n = 62) or shifts of other duration
(n < 7, respectively). Shifts during the week tended to be shorter (n = 99 for 20 – 24
hour shifts).
329 of all participants reported that their duty roster included standby duty on a
pro rata basis. In 192 cases the duty roster mandated the highest possible level of
on-call duty permitted by the respective labor agreements. 104 of the participants
(24%) reported that they worked up to four on-call duty shifts, 203 participants (46%)
worked between five and nine, and 5 respondents worked ten or more on-call shifts
every month. More than half of the participants (55%) reported that on average, it
was not possible to do only the amount of work expected for their on-call duty roster:
the deviation from the envisaged amount of work was most striking in level I perinatal
centers and differed significantly from departments offering standard maternity care
(p = 0.01) and those offering advanced secondary and short-term perinatal care (p = 0.03).
90% (n = 290) of all respondents (n = 324, n. s. = 113) reported that tasks which
were supposed to be carried out during normal working hours (normal working time tasks)
were regularly carried out whilst on call.
Working hours
[Fig. 3 ] shows the real number of hours worked per week (the sum of all hours worked full
time including overtime and internal on-call duty but excluding external on-call duty)
compared to the data of the Marburger Bund (MB) Monitor 2015, the publication of the
professional medical association and trade union for physicians in Germany [10 ]. 43% of respondents (n = 189) had agreed to an opt-out arrangement, 34% (n = 150)
had rejected such an arrangement, 11% (n = 48) were not sure whether or not they had
agreed to such an arrangement (n. s. = 49; 11%).
Fig. 3 Average weekly working hours. Comparison of the survey by Young Forum (YF) (377 participants
answered the question = 100%, not specified [n. s.] = 60) with the data from the Marburger
Bund (MB) Monitor 2015.
Just under half of the participants (48%, n = 207, n. s. = 76) reported that their
employer systematically recorded their working hours, either by documenting the hours
manually (online) or by using an electronic timekeeping system. 11% (n = 49) of participants
reported that they were not able to record all of the hours they effectively worked,
although the majority (53%, n = 230) did not supply any information on this point.
In the free-text answers (n = 22), participants stated that the hours they worked
over and above their regular planned working times could not be entered into the registration
system or that the system automatically logged them out once they had worked the permitted
maximum number of working hours. The majority of respondents (71%, n = 311, n. s. = 121)
reported that they regularly worked overtime, irrespective of the type of care provided
by their department; in 24% of cases (n = 104, n. s. = 77) they were ordered to do
overtime. In departments which handled up to 1000 births annually, physicians worked
significantly less overtime than in centers which handled > 1000 births (74% vs. 89%,
p < 0.01). There was no significant difference between the groups “1001 – 2000 births”
and “> 2000 births”. Likewise, there were no significant differences between groups
with regard to the type of employer, the level of care provided by the facility, whether
or not the work was shift work, the amount of in-hospital on-call duty, whether working
times were recorded prior to deciding on the type of duty rosters, or the number of
children up to the age of 17 living in their household. The survey did not explicitly
ask about the reasons for overtime. Common reasons listed in the free-text answers
mentioned unfilled positions and staff shortages.
Personnel planning for the respective care levels
The overwhelming majority of participants reported that at least one physician was
present in the department outside normal working hours; there was only one case where
the duty physician was only on external on-call duty. The number of physicians present
in hospital varied greatly, depending on the number of births handled by the facility
and the type of care provided ([Fig. 4 ]). The higher number of physicians present in secondary and tertiary care facilities
and in PNCs compared to the number in general hospitals was statistically significant
(p ≤ 0.0001). A sub-analysis of PNCs according to the level of care offered by the
respective facility showed a significantly higher number of on-duty physicians in
level I PNCs compared to facilities offering short-term perinatal care and level II
PNCs (p = 0.0002 and p = 0.0001). We found no significant differences between facilities
offering short-term perinatal care and level II PNCs (p = 0.42). 31% of all participants
(n = 137) reported that no specialist physician was on duty in the hospital during
the night shift. Of the 44 participants who had less than one yearʼs experience in
obstetrics, ten were on duty at night with no specialist physician present; six of
them were working in level I PNCs. 269 participants (62%) felt that the distribution
of working hours in their hospital negatively affected their health.
Fig. 4 Physicians on duty in hospital relative to the number of births and the level of
care provided by the facility.
Discussion
This survey aimed to investigate working times and workloads in obstetric departments
across Germany. The data showed that differences in duty rosters were largely determined
by the number of births handled by the facility and the level of perinatal care it
provided. Duty rosters on weekdays differed from those of weekends, with the most
common working times consisting of combinations of on-call/standby duty. The most
important predictors for shift work were a high number of births in the facility and
a prior job analysis with recording of working times. A number of free-text comments
worried about potential financial losses following the introduction of shift work,
which could lead to a reluctance to implement shift work. Combinations of both systems
tended to increase with higher numbers of physicians on standby in hospital. The free-text
comments suggest that the real staffing needs could be met better by using different
types of duty systems.
The overwhelming use of systems with only a few shifts on weekends (2-shift system,
long on-call hours) raises the question whether the duty system used on weekends is
driven more by the wish to reduce the number of hours on duty on weekends rather than
by the actual staffing requirements. This was suggested by the free-text comments.
In contrast, weekday working hours appeared to correspond more closely to the real
staffing needs.
The majority of respondents reported that the amount of work they performed while
on standby exceeded the amount prescribed for their level of on-call duty. This is
illegal for the highest level of standby duty, because, according to the definition,
the percentage of time during which no work is performed must be greater than the
hours worked while on standby, otherwise regularly scheduling standby duty is not
permissible. In practice, there appears to be some difficulty in differentiating between
permissible demands to perform work while on standby (up to an average of 50% of the
time) and the system of remuneration (assessment as working time with up to 100% per
hour). Even departments with only one physician on duty in hospital on weekends stated
that sometimes the scheduled work roster consisted only of standby duty. Such reports
need to be evaluated critically as they point to a potential misunderstanding. In
addition to standard tasks such as planned visits to specific patients or being summoned
to perform check-ups or operations, enough time must be left for unplanned tasks to
ensure that the average time actually worked while on standby duty is < 50% [11 ]. As can be inferred from the free-text comments, such work is nevertheless regularly
carried out. The introduction of a shift system or a combination of full time work/regular
working hours and standby duty would be best practice.
The average hours worked per week determined in our study largely correspond to the
data collected by the Marburger Bund in the same year, although with a tendency to
be even higher than reported by the Marburger Bund [10 ]. The differences may be due to the fact that in our study a higher percentage of
respondents worked in university hospitals (30% [n = 133, n. s. = 96] vs. 18% Marburger
Bund [MB] Monitor 2015) and the number of interns/residents was also higher in our
study (53% of responses vs. 40% MB Monitor 2015). The high number of overtime hours
worked by the respondents suggests that personnel planning in obstetric departments
may not be in line with demand.
The surprising finding was that notwithstanding the increasing use of electronic timekeeping
systems and collective agreements and despite significant penalties for non-compliance
with the Working Hours Act (ArbZG), only 47% (n = 207, n. s. = 121) of employers in
obstetric medicine appeared to systematically record all of the time worked (compared
to the figure of 73% reported in MB Monitor). Proper recording would allow changes
in staffing requirements to be identified early and adjustments to be made. This is
suggested by the findings of this study: facilities which had previously undertaken
a job analysis were significantly more likely to have shift work systems in place.
In addition to the above-mentioned labor law considerations, this survey has also
revealed safety-related problems: obstetric work requires a maximum of concentration,
as the right life-changing decisions have to be made within the space of just a few
minutes to ensure the safety of mother and child. Long average working hours, frequent
overtime and inadequate choice of duty roster systems can have far-reaching consequences.
It is well known that increased workloads lead to higher transmission rates of multi-resistant
pathogens [12 ] and longer working times lead to an increase in the frequency of accidents und the
probability of mistakes [13 ]. Recent occupational research has modelled patient risk with regard to medical malpractice
and accidents as a function of the duty roster system and shift system used in medical
centers and suggested that safety needs to be optimized across all levels of medical
training [14 ]. Moreover, high workloads at night increase the individualʼs health risk over the
longer term [15 ]. This survey showed a high subjective perception that work schedules had an adverse
effect on health. The findings are comparable with the data of MB Monitor 2015 (61%
[n = 269, n. s. = 132] vs. 72%).
Treatment in hospital must at all times comply with the standards expected of medical
specialists. According to the quality standards proposed by the Federal Joint Commission
(Gemeinsamer Bundesausschuss, G-BA), specialized obstetric care must be available
in PNCs. According to the data in our survey no specialist physician was on site in
17% (n = 37) of level I PNCs.
However, it should be noted that, given the current relative shortage of doctors,
it is important to ensure that training for obstetricians and further training in
“specialized obstetric care and perinatal medicine” is available to provide comprehensive
specialist obstetric care in the future as well.
Strengths and limitations of this survey
This survey is the first national assessment of duty roster systems and workloads
in obstetrics in the Federal Republic of Germany. Physicians at all levels working
in obstetric departments participated in the study. This survey was primarily aimed
at physicians training to become specialists or in advanced training. Other subgroups
were also included, but these subgroups (e.g. chief physicians) were very small. This
means that great caution should be used before using individual findings as a basis
for further deliberations. Nevertheless, the distribution was sufficiently homogeneous
across all types of in-hospital care and across all levels of medical training. With
437 respondents, the number of participants in our study corresponds to the usual
group size of cohorts reported in articles on workloads used for comparative analysis
[16 ], [17 ], [18 ], [19 ]. The small sample sizes mean that bias is possible. The data presented here on duty
roster systems and workloads are in accordance with the expected findings anticipated
by the study group of the Young Forum when they designed the study and also reflect
the authorsʼ daily experience. The authors considered that the number of respondents
who worked in level I PNCs was disproportionately high. One reason for this could
be the composition of the Young Forum study group; a further reason could be the membership
structure of the DGGG as a scientific society which attracts more research-oriented
physicians. This could have resulted in a negative selection. A personalized survey
code was not sent out. In theory, repeat participation can therefore not be excluded.
However, a manual review of the datasets found no double entries (> 90% agreement).
In the opinion of the authors, the statements made by a few respondents that their
duty roster schedule comprised neither shift work nor standby duty (n = 21) are not
plausible. Differentiating between shift work and standby duty is done based on collective
bargaining agreements which can vary greatly. After considering the free-text comments,
the authors therefore assume that – despite the explanatory notes next to the respective
questions – for some of the participants the differences in work roster systems was
not clear enough for them to give correct answers. This could have led to a slight
underrepresentation of shift-work models. But if the respondents who did not provide
data on the work roster system used in their facility were included in the group doing
shift work, there would still be no significant change in the respective distributions
shown.
The same applies to the term “medical specialist”. On the one hand this was understood
to refer to the status of the physician as a medical specialist; it was also understood
to refer to the organizational structure of the department. This could lead to differences
in the understanding of the term “intern/resident physician”. To avoid misunderstandings
and ambiguities, future studies should clearly differentiate between the status of
medical specialist and working in the capacity of an intern/resident physician with/without
specialist training.
As it was an anonymized survey, no data on the location and the number of physicians
working in the respective healthcare facility was included. Using the questionnaire
it was not possible to infer what work the individual performed based on the type
of duty roster. It was not possible to determine whether the obstetric work performed
should be classified as standby duty or shift work. This would require a survey which
differentiated according to the type of work performed. The long list of questions
covering several topics and the expected time to complete the survey of around 15
minutes may have deterred prospective participants from taking part in the survey.
Outlook
The results of our survey point to some clear deficiencies in the structure and organization
of obstetric departments which may have potentially serious consequences for the quality
of care. Given the current trend of centralization and the increased closures of obstetric
departments because of unfavorable expenditure/revenue ratios as well as the known
fluctuations in patient flows in obstetrics, staffing needs should be regularly determined
based on the actual amount of work carried out (recording of tasks). After taking
legal, medical and structural conditions into account, identifying some (problematic)
key areas could help to adapt the duty roster systems used in obstetric departments
so as to improve the health of the physicians working there and reduce the liability
risk for the persons responsible for the duty roster. The management usually delegates
the responsibility for scheduling duty rosters to the departmental heads. The medical
directors or departmental heads who ultimately approve the duty roster and tolerate
departures from the planned schedule (e.g. overtime) are personally liable for violations
of the German Occupational Safety and Health Act (ArbSchG) and the Working Hours Act.
As the demands made of obstetric departments vary greatly according to regional, structural
and traditional differences, there can be no single, universally transferable solution
for obstetric working hours. We were not able to deduce the ideal duty roster model
for obstetrics from our data. There are different equally valid answers to organizational
questions which comply with the law and with collective bargaining agreements. For
example, the need for 100% coverage by a doctor could be met by either one doctor
working a shift or two doctors on standby.
It would also be sensible to include foreseeable influencing variables such as illness
and absences due to pregnancy/parental leave in the planning process. Planning would
need to start by reviewing the requirements for medical staff (determination of the
range of services offered) and the requirements laid down in current labor legislation
(permissible duty roster models) and reconciling them with the current conditions
in the facility (job analysis). This could be a way forward which, over the longer
term, would improve the safety of the care environment where we treat the patients
and children entrusted to our care.
