Keywords pediatric cardiac intensive care unit - pediatric intensive care unit (PICU) - working
conditions - motivation
Introduction
Based on fundamental improvements in diagnostics and therapy, the prognosis of critically
ill premature and newborn infants has improved greatly in recent decades. However,
this has also led to a considerable increase in the complexity of the children treated
and thus to increased demands on the expertise and skills of medical staff working
in the pediatric intensive care sector.[1 ]
[2 ] More recent guidelines of the Joint Federal Committee “Gemeinsamer Bundesausschuss”
take these additional requirements into account. In German centers which are authorized
to perform cardiac surgery in children with congenital heart disease, these guidelines
demand among other issues the continuous presence of a fully trained pediatrician
who has either started or completed a fellowship in pediatric cardiology.[3 ]
Perinatal centers, specialized in the treatment of high-risk pregnancies including
premature babies below 29 weeks of gestation and birth weight <1,250 g (so-called
level 1 perinatal centers), must provide a shift service with continuous medical presence
and a fully trained neonatologist on call.[4 ] The increasing need for highly qualified medical staff to be present in pediatric
intensive care units (PICUs) poses a great challenge to hospitals in recruiting staff,
as the number of applicants for this psychologically and physically demanding work
is very limited.[2 ]
[5 ]
[6 ]
[7 ] To counteract this staff shortage and to make jobs as attractive as possible for
applicants, it is necessary to understand the needs and expectations of colleagues
who are interested in training in this field. This study deals with the expectations
of residents in pediatrics, fellows in training for pediatric cardiology, pediatric
intensive care, and neonatology working on intensive care units (ICUs) regarding the
framework conditions of their workplace.
Methods
An online survey was created containing 27 questions (predominantly matrix questions
supplemented by nominal, cardinal, and open-ended questions) using web-based software
(Survey-Monkey, https://www.surveymonkey.de ). The original and translated version of the questionnaire is provided in the [Supplementary Material ] (online only). The focus of the ICU (pediatric/pediatric cardiology/neonatology)
as well as the current level of staff specialization and the working model (possibility
of part-time employment, weekend and night workload, shift work model) were queried
along with the participant's age and the location of the ICU.
The second part of the survey focused on the prioritization of the attractiveness
of working conditions in the ICU. Three subjects had to be rated according to their
importance ([Table 1 ]). 1: Good working atmosphere in the team including an appreciative working environment,
the opportunity to contribute to therapeutic decisions and mutual respect and understanding
in the communication with colleagues and principals. 2: Good guidance in the independent
performance of interventions. 3: Good working conditions.
Table 1
Assessment of the criteria according to their importance in priority; 1: most important,
2: important, 3: less important
1
2
3
Total
Good working atmosphere in the team
(being able to contribute and have a say)
57.3%
n = 79
29.0%
n = 40
13.8%
n = 19
n = 138
Good guidance in the independent performance of interventions
(intubation, central venous line insertion, etc.)
24.8%
n = 35
48.9%
n = 69
26.2%
n = 37
n = 141
Good working conditions
(tolerable shift work, etc.)
19.0%
n = 27
22.5%
n = 32
58.5%
n = 83
n = 142
Note: n : number of responses.
Furthermore, the survey asked for criteria that could improve shift work in an ICU.
The following four criteria should be rated according to their importance: (1) better
pay, (2) less weekend working time, (3) less night duty, and (4) more days off for
compensation following a night duty block ([Table 2 ]). The age (<40 years and ≥40 years) of the participants was taken into account for
this question and for preferred night and weekend working hours. This allowed us to
record possible differences due to the phase of their personal life.
Table 2
Rate shift patterns by importance of priority; 1: most important, 2: very important,
3: less important, 4: not important (subdivided by <40 years and ≥40 years)
<40 years
≥40 years
1
2
3
4
1
2
3
4
Better payment
10.1%
n = 12
27.7%
n = 33
23.5%
n = 28
38.7%
n = 46
n = 119
27.3%
n = 6
22.7%
n = 5
0.0%
n = 0
50.0%
n = 11
n = 22
Less weekend working time
40.0%
n = 48
30.8%
n = 37
25.0%
n = 30
4.17%
n = 5
n = 120
40.0%
n = 8
25.0%
n = 5
20.0%
n = 4
15.0%
n = 3
n = 20
Fewer night shifts
28.3%
n = 34
16.7%
n = 20
27.5%
n = 33
27.5%
n = 33
n = 120
23.8%
n = 5
33.3%
n = 7
28.6%
n = 6
14.3%
n = 3
n = 21
More days off for compensation following night shifts
21.7%
n = 26
25.0%
n = 30
24.2%
n = 29
29.2%
n = 35
n = 120
13.6%
n = 3
18.2%
n = 4
50.0%
n = 11
18.2%
n = 4
n = 22
Note: n : number of responses.
The survey was distributed to hospitals with PICUs with the help of contacts from
the Working Group on Pediatric Cardiac Intensive Care Medicine (AKKI) of the German
Society for Pediatric Cardiology (DGPK) and the Pediatric Intensive Care Medicine
Section of the German Interdisciplinary Association for Intensive Care and Emergency
Medicine (DIVI). It was posted online from August 10, 2018 to August 1, 2019. The
prerequisite for participation was a residency in intensive care and intensive care
experience of more than 6 months. Formal approval by the local ethics committee was
not required (project number: 933/2019BO2) because anonymized data were used in the
study.
Results
A total of 165 participants answered the survey (mean age: 35.2 years [standard deviation: ± 4.8]).
Two participants over 50 years were included with the 50-year-old participants. In
total, 138 participants were <40 years old and 24 participants ≥40 years old. The
responses came from 21 cities. It is not possible to determine the exact rate of responses,
as only one contact person at a clinic was contacted and the person forwarded the
link to the survey to colleagues in education. The ICUs of the participants in our
survey fell into the following categories: (1) PICU, (2) PICU + pediatric cardiointensive
care unit, (3) pediatric cardiointensive care unit, (4) PICU + neonatal ICU, (5) neonatal
ICU, (6) other ICU.
In summary, 87.2% of the participants (n = 143/164) worked in a PICU, of which 75.6% were associated with heart centers performing
surgery of congenital heart disease (n = 124/164). In addition, 12.8% (n = 21/164) of the participants worked in purely neonatal ICUs. About one-third of
the participants (32.7%, n = 54/165) were residents in specialist training in pediatrics and adolescent medicine.
The majority of participants were fully trained pediatricians in subspecialty training
for pediatric cardiology (32.7%, n = 54), pediatric intensive care (14.6%, n = 24) or neonatology (6.1%, n = 10), and fully trained pediatric cardiologists (5.5%, n = 9). A further 7.3% (n = 12) were pediatricians without a postgraduate training position or fully trained
anesthetists in subspecialty training for intensive care medicine 1.2% (n = 2).
Actual State/General Conditions
One-third of the participants (32.9%, n = 54/164) stated that a fully trained pediatrician (pediatric specialist frequently
performing subspecialist training/fellowship) was present permanently on site in the
ICU, while 14.0% (n = 23) answered that their institution at least tried to ensure continuous presence
of fully trained pediatricians among the assistant doctors. The other participants
declared that pediatric specialists were not always present on shift duty. A total
of 55.6% (n = 79/142) of the respondents stated that experienced doctors (including fully trained
pediatricians or colleagues in their last year of pediatric training) were predominantly
assigned to late and night duty. The possibility of part-time employment was affirmed
by the majority of respondents (83.3%, n = 120/144); among those aged ≥40, this was 95%. Weekend work time included an average
of 2 weekends/month for 78.5% (n = 113) of the participants, 3 weekends per month for 11.1% (n = 16), and 1 weekend per month for 6.3% (n = 9). During the week, 62.1% (n = 90/145) of the respondents worked in a three-shift system and on weekends in a
two-shift system. A total of 9.0% (n = 13) of the respondents worked in a continuous two-shift system and 27.6% (n = 40) worked in a continuous three-shift system. Twelve-hour shifts were perceived
as too stressful by 52.5% (n = 75/143) of respondents.
The frequency peak of the average number of night duties was 7 per month (34.0%, n = 48/141), with a variation between 4 and 10 night duties per month ([Fig. 1a ]; number of nights per night duty block, [Fig. 1b ]). Following a night duty block, half of the participants (50.4%) received 1 to 2
compensation days, whereby the day immediately following the night duty was not included
([Fig. 1c ]).
Fig. 1 (a ) Average number of night shifts worked per month. n = number of responses. (b ) Number of night duties performed on average per night duty block. n : number of responses. (c ) Average number of compensation days after a night duty block. The day directly following
the night shift was not counted as a compensation day. n : number of responses, additionally n = 15 free text answers.
Motivation/Perspective
A total of 92.3% (n = 132/143) of the participants stated that they enjoyed working in a PICU in principle.
Moreover, 65.0% (n = 93) could imagine undergoing further subspecialty training in pediatric intensive
care medicine, while 12.6% (n = 18) were already undergoing this training.
When answering the question of what priorities they would set when evaluating the
working conditions, the respondents considered an appreciative working environment
and a good working atmosphere in the team to be the most important issue. This was
selected as priority 1 by 57.3% (n = 79) of respondents. Good guidance during interventions followed at a considerable
distance in priority 1 (24.8%, n = 35), while good working conditions came third with 19.0% (n = 27). Priority 2 was dominated by good guidance in the performance of invasive procedures,
such as intubations or placement of central venous catheters, with 48.9% (n = 69) of respondents. In priority 3, a majority of 58.5% (n = 83) of the respondents mentioned good working conditions, such as tolerable shift
work ([Table 1 ]).
When answering the question which criterion should be prioritized to make shift work
in an ICU more attractive, priority 1 was most often given to less weekend working
time, regardless of the age of the respondents ([Table 2 ]). Among <40-year-olds, priority 1 was followed in second place by fewer night duties,
followed by more days off following a night duty block. Better pay was only mentioned
in the fourth place under priority 1. Also under priority 2, the largest group of
respondents opted for the desire for fewer weekend working hours; under priority 3
the largest number of respondents chose fewer night services; while under priority
4 the desire for better pay dominated ([Table 2 ]). Among those aged ≥40 years, the wish for better pay followed by fewer night services
and more days off following night services was mentioned in the second place under
priority 1. In this age group, priority 2 was dominated by the wish for less night
work, and priority 3 by the wish for more days off after night work. In this age group,
too, a clear peak for better pay only emerged under priority 4 ([Table 2 ]).
Among the <40-year-olds, 61.2% of the respondents said that in a case of a workload
exceeding 3 weekends per month, the job became less attractive to them. In contrast,
61.9% of those aged ≥40 answered that from 2 weekends per month onwards, the job became
less attractive to them ([Fig. 2a ]). Regarding the number of night services in a row that are still considered tolerable,
77.5% of the respondents <40 years named several three to five services. Among participants
≥40 years, 71.4% of participants named a range of two to four services ([Fig. 2b ]). It was remarkable in this group that 23.8% of the participants also rated a sequence
of seven night services as still tolerable ([Fig. 2b ]). Among the study participants <40 years of age, the majority (75.6%) named 2 to
3 days off work as adequate recovery time following a night duty block of 4 nights,
with a frequency peak at 3 days ([Fig. 2c ]). In the group of those aged ≥40 years, the respondents reported 2 to 4 days off
work with approximately the same distribution ([Fig. 2c ]). The day on which the night service ends was not counted as a compensation day.
There was no relevant difference in the responses of participants working in ICUs
with less than 11 full-time positions as compared with participants working in larger
units employing more than 11 full-time physicians.
Fig. 2 (a ) Number of weekends per month after the job becomes less attractive (subdivided into
<40 years and ≥40 years). n : number of responses. (b ) Number of night shifts per night service block that are perceived as well tolerated
(subdivided into <40 years and ≥40 years). n : number of responses. (c ) Number of compensation days to a service of 4 nights perceived as appropriate (subdivided
into <40 years and ≥40 years). n : number of responses.
Discussion
The growing complexity of pediatric intensive care medicine requires a high level
of competence from residents in this field, combined with a heavy workload due to
shift and weekend duty. Increased quality requirements[3 ]
[4 ] and declining numbers of applicants in line with general trends[6 ]
[7 ] pose great challenges to the clinic's management team. What is remarkable about
our survey is the fact that 92.3% of the respondents stated that they enjoyed working
in an ICU in principle and 65.0% of the respondents could in principle imagine completing
the training in special intensive care medicine. How can clinics attract these potential
applicants to work in the PICU?
A total of 87.2% of respondents reported working in a PICU, of which 75.6% had a pediatric
cardiology focus. The latter ICUs at pediatric cardiac surgery centers contain a critical
patient population requiring a high level of attention with rapid action, be it in
the context of cardiac arrhythmias, bleeding, or coagulation disorders after complex
interventions.
Working in a PICU is emotionally and physically demanding.[8 ]
[9 ]
[10 ]
[11 ]
[12 ]
[13 ] Shift work means that social contacts and family life, which mainly take place in
the evenings and at weekends, are considerably impaired by the professional activity.[14 ] Especially for the ≥40-year-olds, the attractiveness of the job decreases significantly
in case of a workload exceeding weekends two per month ([Fig. 2a ]). Night shifts are also physically demanding due to the changing day–night rhythm.[15 ] The vast majority of all respondents stated that they worked an average of seven
night shifts per month. The majority of respondents in the <40-year-old group found
up to four night shifts at a stretch well tolerable, and in the ≥40-year-old group
up to three night services at a stretch. In our survey, most respondents received
two free compensation days following a night duty block. However, 3 compensation days
following a night duty block of 4 nights to re-synchronize the day–night rhythm were
considered adequate in the majority of both age groups. This illustrates the eminent
importance of creating duty models that, while optimizing shift rotation patterns,
shift duration, and duration of time off between shifts, allow for adequate regeneration
of staff and thus ensure their efficiency.[16 ]
In our survey, an excellent working climate in the unit was clearly more important
than the general work conditions. The mutual respect, the support in the team as well
as the possibility being involved in the decision making about patient care were mentioned
by the respondents as the most important factors for choosing to work in a PICU. These
criteria are followed by good instructions on how to carry out invasive procedures
independently, while the framework conditions were rated as less important by the
majority.
Our survey clearly confirms the statements made in earlier work on the topic of “Generations
in the Hospital,”[17 ]
[18 ] that the inner-clinical working environment and the appreciative guidance for independent
activity are the main criteria for taking on a physically and psychologically stressful
activity.[19 ] According to our survey, the willingness to work weekends decreases with increasing
age. This speaks against a “generation conflict”[20 ]
[21 ] with increased attention to the so-called “work–life balance” by the younger generation,
but rather suggests that an orderly family life/social life with many weekend shifts
becomes less feasible with increasing age.[22 ] Social compensation in particular helps staff to deal with stressful borderline
situations, to cope with a heavy workload,[23 ] and it can improve patient care.[23 ]
[24 ]
[25 ]
Also, with increasing age, respondents indicated that they consider fewer night shifts
en bloc to be tolerable. The possibility of part-time employment can reduce the workload/number
of night shifts. Our survey shows that hospitals are already responding in this regard,
as part-time employment in the ICU was already possible in the vast majority of institutions.
While part-time employment appears helpful to increase motivation and reduce the workload,
there is probably a lower limit of employment required to maintain the necessary skills
for treatment of these complex patients. In addition, increasing employment of part-time
physicians will make it challenging to ascertain continuity in patient care. In the
future these questions will have major impact in the successful organization of PICUs.
The survey result shows that neither the so-called “work–life balance,” in the sense
of an increased weighting of time off work, nor pay is the main motivator for choosing
an interesting, but also exhausting and emotionally stressful job. Especially for
the strenuous work in a PICU, an appreciative working environment in the team is important.[26 ] Activities with family and friends mainly take place at weekends, matching the survey
result “more than two weekends per month lowers the attractiveness of the workplace.”
This issue was taken into account in the recent collective agreement negotiated with
the German Physicians' representation “Marburger Bund” on March 7, 2020 for university
hospitals and on May 22, 2019 for municipal hospitals, which limits the number of
average weekend shifts to two per month.[27 ]
Another approach to improve the framework conditions could be to limit night shift
blocks and to grant adequate free compensation days.[11 ]
[28 ]
Limitations
Limitations of the present survey include the limited number of participants. The
response rate could not be precisely determined, as individuals were not specifically
contacted, but the link to the survey was passed on within the clinics. The responses
came from 21 German cities. The DIVI reported in 2015 a total number of 77 PICUs in
Germany. Based on data of the AKKI, 20 of these units are either exclusively or partially
dedicated to pediatric cardiac intensive care following surgery of congenital heart
disease. Since only a relatively small proportion of the responses in our survey came
from neonatal ICUs while 75.6% of our respondents reported to work in PCICUs, the
results to a large extent reflect the motivations and conditions of physicians working
in the latter units. The data of the survey did not allow the night shifts and weekend
shifts to be calculated and evaluated as a percentage of possible part-time employment.
Conclusions
The working atmosphere, the mutual appreciation in the team, and the guidance in the
independent performance of invasive procedures form the greatest incentive to work
in a PICU on shift duty. The framework conditions for social contacts and family,
and here especially the number of free weekends, are particularly important and serve
to balance the often stressful activities. Positive impulses can be expected here
from the implementation of the current, new collective agreement for university hospitals
as of October 1, 2020.[27 ]
According to our survey, financial compensation under present conditions in Germany
appears to be of secondary importance when it comes to deciding on a postgraduate
training position in pediatric intensive care medicine. Thus, the conclusion of the
survey can be summarized as follows: the working environment in a team where people
feel respected and supported is more important than work–life balance.
