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145]

Original Research Article

Residents’ and Attendings’ Perceptions of a Night

Float System in an Internal Medicine Program
in Canada
Anurag Saxena1,2, Loni Desanghere2, Robert P. Skomro3, Thomas W. Wilson3
Department of Pathology, 2Dean's Office, Postgraduate Medical Education, 3Department of Medicine, College of Medicine, University of
1

Saskatchewan, Saskatoon, SK, Canada

ABSTRACT
Background: The Night Float system (NFS) is often used in residency training programs to meet work hour regulations. The purpose of
this study was to examine resident and attendings’ perceptions of the NFS on issues of resident learning, well‑being, work, non‑educational
activities and the health care system (patient safety and quality of care, inter‑professional teams, workload on attendings and costs of
on‑call coverage). Methods: A survey questionnaire with closed and open‑ended questions (26 residents and eight attendings in an Internal
Medicine program), informal discussions with the program and moonlighting and financial data were collected. Results and Discussion:
The main findings included, (i) an overall congruency in opinions between resident and attendings across all mean comparisons, (ii)
perceptions of improvement for most aspects of resident well‑being (e.g. stress, fatigue) and work environment (e.g. supervision, support),
(iii) a neutral effect on the resident learning environment, except resident opinions on an increase in opportunities for learning, (iv)
perceptions of improved patient safety and quality of care despite worsened continuity of care, and (v) no increases in work‑load on
attendings or the health care system (cost‑neutral call coverage). Patient safety, handovers and increased utilization of moonlighting
opportunities need further exploration.

Keywords: Health care system, night float system, resident duty hours, resident education

Background In Canada, a uniform nationwide policy governing RDHs does

Resident duty hours (RDHs) include all time spent in
scheduled clinical and academic activities related to the
residency program including: Patient‑care, administrative
duties, in‑house call activities and scheduled learning
activities.[1] However, extended work hours and attendant
sleep deprivation pose risks to the health of residents and can
affect their cognitive and behavioral performance,[2‑6] which
can compromise patient safety. These safety concerns have
been the main impetus driving RDH reforms.[1]
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DOI:
10.4103/1357-6283.170125
not exist, with shift lengths ranging from 16 h in Quebec to up
to 24–26 h in other provinces.[7] As a way to address increased
concerns of RDHs, many institutions have implemented a Night
Float System (NFS),[8] which typically involves consecutive
shifts of 10–12 h or alternate nights of longer shifts. [1]
Although this system offers a potential solution in addressing
RDH restrictions, changes in educational experiences and
the effectiveness of the system have resulted in conflicting
results in terms of benefits for resident wellness, learning
and patient safety (for review see[7]). For example, research
has shown that residents during night float (NF) rotations felt
there was less emphasis placed on educational activities,[9‑12]
with studies demonstrating a decrease in resident involvement
in these activities during their NF rotations.[10] Some research
indicates overall negative attitudes from residents, nurses
and attendings about the NFS in general.[13] Indeed, some
institutions have abandoned the use of the NFS because
of perceptions of affected delivery of care in terms of

Address for correspondence:

Dr. Anurag Saxena, Room 402, St. Andrews College, PGME, College of Medicine, University of Saskatchewan, 1121 College Drive, Saskatoon, SK.,
Canada, S7N 0W3. E‑mail: anurag.saxena@usask.ca

118 Education for Health • Volume 28 • Issue 2 (August 2015)

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Saxena, et al.: Perceptions of the night float system
cohesiveness, team spirit and continuity.[14] Conversely, other
research[9] has shown the opposite to be true, with residents
favoring the NFS over traditional call and believing that it
results in fewer medical errors (for review see[15]).
Given the inconsistent results in the literature on the effects
of the NFS, the purpose of this study was to examine the
perceptions of residents and attendings on the impact of the
NFS in an Internal Medicine residency program. Since the
implementation of such systems necessarily changes many
ways in which medical education and health care are delivered,
the results from this study will help programs make informed
changes when working to effectively reduce RDHs.
Methods
The NFS
The NFS at this institution was implemented on July 1, 2012
and was structured in 12‑h shifts, five shifts per week, for
second and third year (senior) residents. During the previous
call system, senior residents were on‑call during the nights they
covered and typically stayed in hospital until 5 p.m., receiving
call throughout the night thereafter. Under the NFS, residents
are expected to remain in the hospital from 7:30 p.m. to 11:30
p.m., followed by home call for the remainder of their shift.
It was anticipated that the NFS would have a positive impact
on resident learning, work and well‑being. For example, the
NF structure required schedules to be arranged a year in
advance, enabling residents to book conferences, holidays,
rounds and clinics; these educational and personal priorities
were harder to commit to under the previous system where the
schedule was only organized 4–8 weeks in advance. As well,
residents were not scheduled for work the day after their NF
shift, a change that was anticipated to impact both resident
well‑being and participation in education‑related activities
(e.g., academic half days) by decreasing resident fatigue. The
NFS also enabled senior residents more opportunities for
bedside teaching and observation of patient assessments
performed by junior residents. Under the old system there
were no requirements to be in‑house and first year residents
were frequently unassisted and unobserved in their patient
assessments.
Participants
Twenty‑six residents (female = 13; 53% response rate) and
eight attendings (27% response rate) participated in this study.
All participants were from the Internal Medicine program
at the University of Saskatchewan, which has its primary
teaching and training sites at the Royal University Hospital
and St. Paul’s Hospital‑two tertiary care hospitals in Saskatoon,
Saskatchewan, Canada. All participants had experience with
the previous night call system and the newly implemented
Education for Health • Volume 28 • Issue 2 (August 2015) 119
NFS. Data was initially collected as part of a quality assurance
and improvement project and was exempt from Behavioral
Research Ethics review at the University of Saskatchewan.
Materials and procedure
An online survey was designed to assess perceptions of the
impact of the NFS on residents and the health care system (not
all questions were asked to both residents and attendings,
[Figure 1]). Responses to questions were evaluated on a 5‑point
Likert scale (1 = completely disagree; 5 = completely agree).
Figure 1 displays the overarching themes along with the
abbreviated questions within each theme. Three of these topics
(improved resident stress, improved opportunity for learning,
and improved patient safety,) were composed of several
specific questions [Table 1]. These scales had acceptable levels
of internal consistency for exploratory studies (recommended
minimum Cronbach’s alpha of 0.6),[16,17] as determined by
Cronbach alpha’s of 0.60, 0.77 and 0.89, respectively. An
open‑ended question inviting any comments regarding the
NFS was included at the end of the survey. All responses were
anonymous, and participation was completely voluntary. To
ensure residents and attendings did not feel obligated to
answer the survey because of pressures of authority, all survey
links were sent out through program administrators and
participants were ensured of the anonymity of their responses.
Information on moonlighting and financial aspects were
obtained from the data bases in the College of Medicine.
Descriptive statistics and Mann–Whitney U tests were used
to characterize and examine differences between resident and
attendings responses. Content analysis was used to extract
themes from the open‑ended responses.
Results
Open‑ended responses were provided by 27% of residents and
33% of attendings. Figure 1 displays the data from each survey
Table 1: Displays three overarching topics used in the survey and
lists the questions comprising those topics. Internal consistency
(Cronbachs alpha) is listed for each scaled item. Overall scores are
depicted in Figure 1
Cronbachs α
Improved resident stress
The NFS has: (a) reduced my stress when on call; (b) helped
reduce stress related to my workload 0.60
Improved opportunity for learning
The NFS has: (a) enabled me/residents to devote more time to
reading; (b) enabled me/residents to devote more time to learning
through simulation; (c) allowed me/residents to gain training/
learning opportunities; (d) a net positive effect on my/resident
learning; (e) a positive impact on my/resident learning while on call 0.77
Improved patient safety
The NFS has: (a) improved patient safety; (b) helped improve
the safety of care I offer 0.89
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Saxena, et al.: Perceptions of the night float system

Figure 1: Displays the mean responses, standard errors and 95% confidence intervals of residents and attendings across four themes related
to the impact of the NFS on residents and three themes related to the impact of the NFS on the health care system. Mean responses plotted
between the dashed lines represent a neutral response, indicating that aspect did not change with the implementation of the NFS. Any means
below or above those points represent disagreement or agreement with the improvement of that particular aspect

question; mean values falling above 2.5 and below 3.5 are
categorized as having a “neutral” effect, suggesting no changes
after the implementation of the NFS. For questions posed to
both residents and attendings, Mann–Whitney U tests showed
no significant differences in the mean responses (P > 0.05),
demonstrating an overall congruency in perceptions between
groups on the impact of the NFS across all themes.
Implementation of the NFS and its Impact
on Residents
Resident learning
Residents felt that the NFS improved opportunities for learning
(e.g., reading, simulation training, increased opportunities for
learning); perceptions for all other aspects of learning did not
change [Figure 1a]. Open‑ended comments suggested that the
NFS led to: (a) A better operation of the clinical teaching unit
(CTU) with more availability of senior residents to teach, better
management of the team, more time for interdisciplinary
rounds, and higher morale, and (b) a reduction in the number of
call shifts throughout the year that allowed for better learning
experiences while on subspecialty rotations.
Resident work
Residents felt that the NFS had a positive impact their work
through better support and supervision [Figure 1b]. Although
residents felt that the work associated with handovers and
their overall workload was reduced under the NFS, the
attendings did not have similar perceptions.
Resident well‑being
Both residents and attendings agreed that the NFS reduced
resident stress and fatigue. Although residents reported
increased alertness when woken and an improved social
life, attendings thought that these aspects had not changed.
Residents and attendings also differed in their opinions on the

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Saxena, et al.: Perceptions of the night float system
amount and quality of resident sleep; attendings believed that
there was an improvement, whereas residents did not believe
these to have changed [Figure 1c]. Open‑ended responses
from residents reflected an improved work‑life balance due to
reductions in postcall days taken off rotation as well as fewer
call shifts throughout most of the months. Attendings’ (n = 2)
impressions were that the NFS had a beneficial net effect on
well‑being due to a reduction in the overall call frequency
throughout the year.
Residents’ non‑educational activities
Neither residents nor attendings believed the NFS enabled
residents to start moonlighting or that there was an increase
in the moonlighting frequency [Figure 1d]. However, a review
of the actual moonlighting data for 18 months preceding (9
requests) and following (23 requests) the implementation of
NFS showed significant differences in moonlighting requests
[χ2 (1) =6.125, P = 0.013].
Implementation of the NFS and its Impact
on the Health Care System
Patient safety and quality of care
Participants agreed that the NFS helped improve patient safety
and quality of care despite the attendings’ perceptions that the
continuity of care worsened after the implementation of the
NFS [Figure 1e]. Open‑ended responses also reflected improved
quality of care and attributed this to higher diligence due to
NF permitting more rest.
Inter‑professional teams
Neither the residents nor the attendings believed that the
NFS increased provision of care by inter‑professional teams
[Figure 1f]. Residents were concerned that the increased
frequency of handovers and a lack of familiarity with patients
could result in less clinical information being available for
other team members and less flow of information among the
inter‑professional teams.
Work‑load
All participants agreed that the NFS did not increase workload
on either the health care system or on the attendings [Figure 1g].
Informal discussions within the program highlighted occasional
concerns including non‑committal attitudes of some residents
towards patients, admitting a higher number of patients while
on night call, and not gaining realistic exposure during residency
of night‑call due to the shorter length and frequency of shifts.
Examination of the on‑call schedule and associated costs for
the 10 months prior versus after the implementation of the NFS
did not reveal any increases in expenses for on‑call coverage.
In addition, there were no increases in the requirement for
ancillary staff to provide coverage during the NF operation.
Education for Health • Volume 28 • Issue 2 (August 2015) 121
Discussion
There is evidence for both the detrimental [10,11,18] and
positive[18‑22] effects of reducing RDHs through such methods
as a NFS. Given the controversy, we aimed to distinguish
perceptions of the impact of a NFS from both residents and
attendings in an Internal Medicine Program in Canada. Our
results showed two overarching findings. First, there was an
overall congruency in the opinions between residents and
attendings across the themes in how the NFS has affected
the residents and its impact on the health care system. The
congruency in these perceptions is important because it
provides more confidence in how changes in the call system
affect resident learning and patient care. Although the mean
responses across participants for improved quality and amount
of sleep were not statistically different, we still saw that most
attendings believed these aspects to have improved, whereas
only half of residents reported this as accurate. Incongruent
perceptions such as this on aspects of resident well‑being could
potentially have implications on attendings’ assessments and
opinions of the residents.
Second, the NFS implementation was perceived to not have
adversely affected any aspect of resident learning or the
health care system, except the continuity of care where
attendings believed this aspect to have worsened; and even
this, in their opinion did not affect patient safety or quality
of care. The effects of the NFS were perceived as either
an improvement (resident well being, resident working
environment, patient safety and quality of care, increased
quality and opportunity for learning) or no effect. The perceived
benefits on resident learning could result from several factors
including opportunities for more structured teaching for and
by residents, better consult processes since senior residents
are contacted first by the consulting physicians followed by
appropriate delegation by the senior residents to the junior
residents thereby creating opportunities for teaching/learning
of intrinsic CanMEDS roles such as communicator and manager
roles.
Extended duty hours have been associated with high levels of
fatigue, burnout and psychological distress.[23‑27] In our study,
the residents believed that their stress, fatigue, alertness and
social life had improved after the implementation of the NFS,
while attendings perceived improved amount and quality
of sleep in addition to improved stress and reduced fatigue.
Improved resident well‑being has been shown to be associated
with increased quality of care,[28‑32] a finding corroborated in
our study where residents and attendings believed that patient
safety and quality of care had improved.
Although residents did not believe that the NFS enabled or
increased the amount of moonlighting, official requests for this
opportunity were found to increase after the implementation
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Saxena, et al.: Perceptions of the night float system
of this system. This could simply be a reflection of rules around
moonlighting, which limit moonlighting to weekends only.
For example, the residents who get off at 0730 on Friday
could moonlight on Saturday (0800–2400) and go back to
work at 1930 on Sunday. These explanations are important
to ensure that increased moonlighting requests are perceived
appropriately preventing sweeping generalizations about how
residents use their time.
Our finding that the continuity of care was perceived to be
negatively affected is supported by other studies, which have
demonstrated that more interruptions to continuity of patient
care occur as a result of RDH restrictions in particular[18,33] and
after a NFS implementation in general.[10,11,34,35] While these
studies showed that patient satisfaction and safety were
actually negatively impacted due to disruptions of patient
care, our study did not directly assess these aspects; both
residents and attendings reported perceptions of improved
patient safety and quality of care, a finding that is consistent
with other studies, which showed lower morality rates,
decreases in surgical complications and missed radiological
diagnoses following the NF implementation (for review
see[15]). The positive or neutral responses in our study could
be the result of residents being committed to one service
only, allowing better handovers and time to focus on that
specific service.
The NFS did not affect provision of care by inter‑professional
teams, this is not surprising since most inter‑professional
interactions occur during daytime hours. There was no
perceived increase in work‑load on attendings or the health
care system in general, an important finding indicating that
modifications in RDH do not necessarily increase the need
for additional health care professionals. Finally, the NFS did
not increase on‑call costs and appears to have affected the
system positively.
Limitations
The limitations of our study include (a) low response rates
and thus a small sample size, (b) the questionnaire not being
validated prior to the study being performed and (c) the
changes in actual physician behavior and the effects on patient
care were not directly measured.
Conclusions
Overall, our study indicates that reductions to RDHs, via
the NFS, have mainly positive (resident well‑being, work
environment, increased opportunity for learning, improved
patient safety and quality of care – despite perceptions of
worsened continuity of care, increased quality and opportunity
for learning and cost‑neutral effects for on‑call work) or neutral
(all other aspects) effects. Patient safety, handover issues and
increased utilization of moonlighting opportunities need to
122 Education for Health • Volume 28 • Issue 2 (August 2015)
be further investigated. In Canada, many program directors
are faced with little and non‑directive evidence‑based results
regarding the impact of RDH reductions.[7] The perceptions of
residents and attendings on aspects of resident well‑being,
work, learning and non‑educational activities, as well as the
impact on the health care system, provide valuable information
on the consequences and impact to changes in RDHs, which
can be used to help inform future changes to programs.
Acknowledgements
The authors would like to thank Jennifer Dybvig for her assistance in
compiling the resident moonlighting and financial data.
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How to cite this article: Saxena A, Desanghere L, Skomro RP, Wilson TW.
Residents' and attendings' perceptions of a night float system in an internal
medicine program in Canada. Educ Health 2015;28:118-23.
Source of Support: This project was funded by the College of Medicine,
University of Saskatchewan. Conflict of Interest: None declared.