Neobook — clinical reference

Categories of staff and level of hospital

Staff-to-workload ratios

Background

The basis for consideration of working hours in anaesthesia care is the need for clinical services to be provided 24 hours a day, 7 days a week. This necessitates a shift system with regular and after-hours work, as well as work on weekends and public holidays.

For clinical platforms training specialists, the hours of work must also accommodate the teaching and learning responsibilities to ensure sustainable practice.

For all clinical staff, opportunities must also be provided for CPD as this is a requirement by the regulatory authority for maintaining one’s licence to practice. Service planning must be mindful of these non-clinical obligations.

Importantly though, the allocation of duties and scheduling of providers must ensure the maintenance of work-life balance for all categories of departmental staff.

In scheduling providers for clinical services, consideration must be given to shift duration and frequency, periods of rest between shifts, whether elective or after-hours scheduling, and the complexity of the tasks being undertaken.

Recommendations

Working hours

Providers should not work for continuous periods exceeding 12 hours or more than 16 hours in a 24-hour period as this has been shown to result in fatigue, and, if unchecked, leads to burnout of clinicians and compromises patient safety.

A minimum 8-hour period should be allowed between shifts for rest and personal needs.

The cumulative hours worked in a one-week cycle should not exceed 60 hours.

Elective procedures should be scheduled for completion within the normal 8-hour working day.

Providers must be allowed to take bio-breaks after every four to five hours of continuous service.

Context

The following recommendations assume that provision has been made for all providers, regardless of rank, to take vacation leave due to them as per the contract with their employer.

The guidelines are also predicated on the assumption that providers would be discouraged from routinely accepting additional clinical shifts for financial gain, as such practice undermines the purpose of the protections being advocated in these guidelines.

For purposes of these guidelines, the same meaning shall be given to the concepts of commuted overtime and after-hours emergency scheduling, and implies work undertaken outside the regular working hours, i.e., nights, weekends and public holidays.

Frequency of scheduling

The frequency of scheduling for after-hours shifts should not exceed once every four days as a higher frequency is associated with burnout risk and carries the potential to compromise patient safety. More specifically, providers should not be scheduled for more than two calls per week as frequent night shifts preclude effective participation in the training programme and related professional activities.

Categories of staff and level of hospital

These guidelines apply to all categories of staff in the current public sector healthcare delivery model, irrespective of service rank or the hospital level where they are employed, as recent evidence suggests a similar negative impact irrespective of the hospital level. Some of the responsibilities do apply to the private sector with regards to self-management of work hours and wellbeing.

The recommendations hereunder are premised on the current South African healthcare delivery model, in which delivery at the point of care defaults to medical officers and registrars, with specialists providing direct or remote supervision depending on the circumstances.

Department heads

The head of department is primarily responsible for the effective and efficient functioning of the department as it pertains to the provision of clinical services and delivery of its academic and professional mandates. The balance of their responsibilities entails their own contribution to clinical service provision and supervision of junior staff.

For heads of departments, it is recommended that 30–50% of non-clinical time is allowed for this management function.

In clinical departments with academic programme responsibilities, up to 50% of total time should be dedicated to non-clinical time. Non-clinical time should be allowed for the training programmes’ administration, professional development, and academic management.
In service departments without teaching responsibilities at undergraduate and postgraduate levels, up to 30% of total time should be dedicated to non-clinical time. Non-clinical time should be allowed for administration, training, and professional development.

Specialist staff

Specialist consultant staff share the clinical service, academic and professional responsibilities of the department, but with a lesser administrative load compared to the head of department. They are largely responsible for the clinical supervision of junior staff, the daily scheduling of staff and allocation of duties, delivery of the training programme and assessment of performance, and undertaking related professional activities within and outside the clinical department, e.g., societal work, essential medicines list (EML) participation and work on transversal tenders (RTs).

For specialist staff, it is recommended that:

25–30% of non-clinical time be provided for these activities in facilities that have academic responsibilities pertaining to teaching, training, and research.
Up to 20% of non-clinical time be allowed for specialists at facilities without academic responsibilities for undergraduate and postgraduate students.

Registrars

Unique to specialist trainees is that they must balance the competing goals of clinical service provision, academic performance, and personal needs whilst in the training programme. In tertiary level hospitals, registrars are the backbone of the anaesthesia service as they constitute most of the clinical staff establishment in any academic department. However, as postgraduate students, registrars also carry a huge responsibility for their studies, which must be completed successfully within the period allowed whilst also achieving the milestones set by the programme during training. If not managed carefully for registrars, clinical workloads can negatively impact clinical training and academic performance.

For registrars, it is recommended that:

Protected academic time is provided for registrars to ensure success in training.
20% non-clinical time be allowed for academic purposes per 60-hour week of contracted service.
Attendance of elective procedures should not exceed 10 hours at a time. Should elective lists extend beyond 10 pm and up to midnight, the provider must not be scheduled for clinical work the next morning but could be considered for scheduling in the afternoon.
Should an elective list extend beyond midnight, the provider should not be scheduled for work the next day.
The duration of after-hours calls should be capped at 16 hours where the main activity is the provision of anaesthesia (as per the employment contract with the State), but this may extend to 24 hours when service is being provided in ICU.
After-hours emergencies that extend beyond the 16-hour shift should be handed over to the day staff commencing duty after the call.

Medical officers

Similarly to registrars, medical officers provide front-line services under the supervision of specialists, depending on the hospital level or geographical location. In tertiary academic hospitals, they work alongside registrars and function to a large extent like registrars, but in non-teaching hospitals or some academic affiliated hospitals with little or no specialist presence, they undertake most of the anaesthesia services without the benefit of specialist cover. As the only clinician with some anaesthesia expertise in these environments, these providers often do not work to rule but tend to work for as long as there is service demand, with potentially detrimental effects to themselves and the safety of their patients.

For medical officers, it is recommended that:

Scheduling for medical officers be guided by the principles elucidated above, regardless of local conditions.
Scheduling for elective clinical work be for 40 hours per week (not more than 10 hours/day).
After-hours emergency shift duration should not exceed 16 hours at a time. Cases that extend beyond this time should be handed over to the day staff commencing duty after the call.
Providers should not be scheduled for a longer than 16-hour after-hours shift within 24 hours of completing a previous 16- hour after-hours emergency shift.

Medical interns

Interns represent the entry point into the professional ranks for graduates in medicine. Internship implies training, and the aim and purpose of internship are to equip these new medical graduates to function as safe and competent practitioners upon completion of their training. They are therefore not equipped to work independently and must be under constant supervision by an appropriate clinician during training. Internship training is regulated, and there are defined outcomes for the successful completion of training. For this to be realised, interns must at the very least be afforded the same protection accorded their senior colleagues in their domain of training.

For medical interns, it is recommended that:

Medical interns be subject to the same guidelines as medical officers.
The cumulative hours worked per week be capped at 60 hours. If work circumstances dictate otherwise, the total number of hours worked is not to exceed 80 hours per week in a rolling three-week period.
Overtime scheduled be capped at a maximum of 80 hours per month.
5–10% of time should be allocated to non-clinical time to allow for professional development.

Staff-to-workload ratios

The concerns with overwork and fatigue of anaesthetists in public hospitals are often due to a mismatch between staff and workload. This may be due to staff shortages in absolute terms or sometimes the result of poor planning by staff or managers. The mismatch between anaesthesia providers and workload not infrequently results from the organic growth of the surgical disciplines being serviced, without a commensurate increase in the number of providers from anaesthesia. This is particularly evident in the development of surgical subspecialties or speciality clinics.

For anaesthesia as a support service to keep pace with these developments, it is recommended that staffing models be used to properly align staffing needs with the basket of clinical services being offered on the platform. Such an approach would not only help to correct the current misalignment but can be used to predict what staff ratios would be required in future when new services are being contemplated. Staff planning must anticipate provider absences due to maternity or sick leave, and consideration must be given to the provision of alternative cover through job-sharing or locums.

Useful sites for further information

Australian Medical Association. National code of practice – hours of work, shiftwork and rostering for hospital doctors. Available from: https://ama.com.au/sites/default/files/docu ments/FINAL_NCP_Hours_of_work_2016.pdf
The Association of Anaesthetists of Great Britain and Ireland. Working arrangements for consultant anaesthetists in the United Kingdom. Available from: https://anaesthetists. org/Home/Resources-publications/Guidelines/Workingarrangements-for-consultant-anaesthetists-in-the-UK

Staff recommendations

Staff	Recommendation
Heads of Departments	- 30–50% of non-clinical time allowed for management function.
	- In clinical departments with academic programme responsibilities, up to 50% of total time dedicated to non-clinical activities.
	- Non-clinical time should be allowed for the training programmes’ administration, professional development, and academic management.
	- In service departments without teaching responsibilities at undergraduate and postgraduate levels, up to 30% of total time should be dedicated to non-clinical time. Non-clinical time should be allowed for administration, training, and professional development.
Specialist Staff	- 25–30% of non-clinical time be provided for these activities in facilities that have academic responsibilities pertaining to teaching, training, and research.
Specialist Staff	- Up to 20% of non-clinical time for specialists at facilities without academic responsibilities for undergraduate and postgraduate students.
Registrars	- Protected academic time is provided for registrars to ensure success in training.
	- 20% non-clinical time allowed for academic purposes per 60-hour week of contracted service.
	- Attendance of elective procedures should not exceed 10 hours at a time. Should elective lists extend beyond 10 pm and up to midnight, the provider must not be scheduled for clinical work the next morning but could be considered for scheduling in the afternoon.
	- Should an elective list extend beyond midnight, the provider should not be scheduled for work the next day.
	- The duration of after-hours calls should be capped at 16 hours where the main activity is the provision of anaesthesia (as per the employment contract with the State), but this may extend to 24 hours when service is being provided in ICU.
	- After-hours emergencies that extend beyond the 16-hour shift should be handed over to the day staff commencing duty after the call.
Medical Officers	- Scheduling for medical officers be guided by the principles elucidated above, regardless of local conditions.
	- Scheduling for elective clinical work be for 40 hours per week (not more than 10 hours/day).
	- After-hours emergency shift duration should not exceed 16 hours at a time. Cases that extend beyond this time should be handed over to the day staff commencing duty after the call.
	- Providers should not be scheduled for a longer than 16- hour after-hours shift within 24 hours of completing a previous 16-hour after-hours emergency shift.
Medical Interns	- Subject to same guidelines as medical officers.
	- The cumulative hours worked per week be capped at 60 hours. If work circumstances dictate otherwise, the total number of hours worked is not to exceed 80 hours per week in a rolling three-week period.
	- Overtime scheduled be capped at a maximum of 80 hours per month.
	- 5–10% of time should be allocated to non-clinical time to allow for professional development.
Anaesthesia Support	- Staffing models be used to properly align staffing needs with the basket of clinical services being offered on the platform.

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South African Society of Anaesthesiologists (SASA) Practice Guidelines_2022_Reviewed by: A Rantloane