Participants

Medical residents and faculty members were recruited from Chonnam National University Hospital in April 2019. We targeted participants from major clinical departments including general surgery, internal medicine, obstetrics–gynecology, and paediatrics. They are in charge of critically ill patients and numerous inpatients, and therefore, they experienced the largest fluctuations in working hours before and after DHRs.

Since senior residents (who have experienced before and after DHRs) and junior residents (who are training after DHRs) may have different experiences and perspectives, we conducted interviews with residents from different training years in each clinical department. We sent emails containing an interview invitation to a total of 76 residents and encouraged participation through text messages. The resident interviews were conducted after confirmation of the participant’s willingness to participate.

After sending an official letter of cooperation to the aforementioned four clinical departments, the faculty interviews were conducted based on the recommendation of each department. The faculty members, recommended by respective departments, were in charge of the residency schedule and managing resident education in their clinical department. If additional explanation or clarification was needed, the next interview was conducted with a faculty member recommended by the previous interviewee. The total number of faculty members who were eligible for the interview was 89.

Informed written consent was obtained from all the interviewees. Finally, 15 residents (8 junior residents and 7 senior residents [in the third year or higher]) and 9 faculty members were included in the study.

Data collection

A semi-structured interview guide was devised by two authors (S1 Appendix). Qualitative research is grounded to understand the diversity of experiences and perspectives [21]. An interview guide was constructed on the basis of previous studies in countries with different contexts but with work regulations and our previous findings implemented in the same social context [3, 8, 9, 15–18]. In-depth interviews focused on the effects of DHRs on the quality of the resident’s life, the resident’s education, and patient care, and how residents and faculty members coped with the change.

One of the authors conducted face-to-face interviews with each participant between May and June 2019. One interviewer author completed the residency training at the same university hospital and currently manages the clinical clerkship for medical students in respective clinical departments. The second author, independent of a residency program, is an expert in medical education and helped balance data interpretations during analysis.

Interviews ranged from 30 to 50 minutes with an average time of 43.2 minutes per sessions. Each interview was audio-recorded and transcribed verbatim. After each transcription was completed, the transcript was sent to the participant by email to ensure the correct meaning. For omitted or ambiguous expressions, the participant was asked to add a more detailed description. Among the participants, 5 out of 15 residents and 4 out of 9 faculty members further described the background and reasons behind some of the utterances. Thereafter, the anonymized transcripts were repeatedly analyzed and the interview scripts were revised for subsequent interviews.

Interviews were conducted using open-ended questions and clarification was sought from the participant if the interviewer could not fully understand or had any follow-up questions related to the interviewee’s answers. During the interviews, we simultaneously analyzed the collected data and made decisions about how to conduct the next interview. When a new topic emerged that required further exploration, we recruited additional participants who could reframe the question for clarification and provide contrasting perspectives.

Data analysis

We analyzed the anonymized transcripts iteratively using a constant comparative method [21–23]. Each researcher read the interview transcript individually to identify key concepts in the texts and develop a code draft. We met to review the initial code set and reconcile any differences in coding. During the interviews, we read each new interview and compared the concepts conveyed in the new interviews with existing codes and categories. When there was no consensus or a new concept failed to meet an existing code or category, we returned to the original transcripts for review and reinterpretation. In the four data analyses where consensus could not be reached, we invited the relevant participants to a second session of member checks. We presented the analysis results via email and listened to their comments. Based on this exercise, the codebook and categories were iteratively revised and refined to include the themes. We continually sorted the collected data, analyzed and coded the information, and reinforced theory generation through theoretical sampling. We stopped collecting data when no new information could be obtained.

To minimise researcher bias, we used respondent validation, wherein participants checked their own interview transcripts. All researchers were constantly aware of their personal perspectives in research process and reflected on how these perspectives may have influenced the research strategies and results. Through open discussion, we reverified that the results align with the research aim to answer the research questions.

1. DHRs improved work schedule

The implementation of DHRs provided junior residents with regular off-duty time. Senior residents have experienced exhaustion due to critical patient care and unrelenting work when they were junior residents, but they expected that DHRs would provide junior residents with time for physical and emotional recuperation. Furthermore, the junior residents reported being able to organize their schedule after the end of day-work. Some junior residents reported being able to research on the patient’s condition and some others reported being able to better focus on preparing for a report or presentation on the next day.

The participants had the following responses about residents’ work schedule and lives after the DHRs.

“I have an allowed time, not to be blamed when I am out there.” (junior resident)

“Considering the situation in which I was never able to leave the hospital at the beginning of the first year, the current junior residents can put their cell phones down and rest for a while. Then, they could concentrate on their work the next day and afford to accept hospital calls.” (senior resident)

“The quality of life of residents now is much better than when I was a resident. Actually, it should have been like this.” (faculty member)

2. Residents have more time to learn on their own

As the allowed free time increased, the resident’s individual competencies depended more on self-directed learning. With the implementation of DHRs, the medical tasks concentrated on junior residents are evenly distributed among almost all residents, delaying the junior residents’ commitment to intensive care and tending to slow down the residency training process than before. DHRs seemed to allow residents to gradually adapt to their work. Faculty members opined that while basic core competencies can be acquired during the residency training course, a fellowship course will be required to acquire a higher level of knowledge and skills. Residents should improve their own knowledge and skills to avoid falling behind in the field after the residency training program. Some residents planned on undertaking a fellowship course to acquire advanced professional skills and gather more patient experience.

Regarding residency training because of reduced working hours, the participants had the following responses.

“Most patient care and treatment were done during the daytime, so I can discuss with my supervisor while I am awake and I can learn more.” (junior resident)

“Rather than seeing a lot of patients quantitatively, we should realize what we need to learn. In the end, I think it will depend on individual capabilities.” (senior resident)

“In comparison with a previous residency training course, the Korean Academy of Medical Sciences has developed the core competency of residents in detail and strengthened the evaluation, such as work-based assessment to determine their proficiency. I believe that active learning has become more possible and a requirement other than passive training because residents have more resources to acquire the medical knowledge they need, not just relying on patient experiences.” (faculty member).

3. Clinical departments have come to distribute work

The DHRs have facilitated changes in duty system and shift pattern. That is, by limiting the individual resident’s work hours to secure off-duty time and making patient care a team effort, work shifts progressed within a team including residents across course years. Few clinical departments are rapidly complying with the regulation. Within intensive care units or delivery rooms where physician presence is mandatory, the shift-based duty system has already been used. This duty system within a team was extended to other divisions within the same department after the DHRs implementation. To improve working conditions for residents and prevent dropout, this system was being applied to departments with a low annual resident recruitment rate, which had an insufficient number of residents. However, other departments in the transitional stage were of the view that coordination with the nursing department of the ward was necessary to communicate with the on-call resident after their work shift.

The participants expressed the following opinions regarding changes in work patterns caused by the reduction of individual resident working hours.

“Although the redistribution of work gave me more tasks than before, it was not difficult for me because of the faster decision-making and speed of processing.” (senior resident)

“I thought it was not unfair to work the night shift on behalf of the junior residents because of understanding the purpose of DHRs.” (senior resident)

“I would like the nursing department of the ward to check the next day’s prescription before the day shift resident leaves work in time for the takeover, and provide brief information about the patient when reporting to the night shift resident.” (junior resident)

“In order to prevent a gap in patient care, residents in charge and shift workers were assigned as a priority for the intensive care unit. So, there was no burden on a certain resident.” (faculty member)

4. Organization members have strived to improve patient safety

DHRs help eliminate immediate hazards to patient safety such as long working hours, although their long-term consequences on patient safety remain unclear. To redistribute the workload, junior residents were placed in charge of the general ward or the emergency room, and the senior residents were given charge of the intensive care unit. The night duty was rotated, with an even distribution of residents by training year (from the first to the fourth year). Patients in emergency were attended to by residents across all training years working at night rather than only by the junior resident in charge. Faculty members in the training hospital still made the final decisions on patient care and were more directly involved in patient care than before. Therefore, the quality of patient care during the training period remained unchanged.

As members of the organization, they presented the following opinions about the effect of DHRs on patient safety.

“It’s better now that a resident can sleep for a day and focus on his patient care the next day (senior resident)

“I am not alone in the ward late at night, so I can discuss the patient’s problems with my seniors.” (junior resident)

“The resident in charge was able to stay alert without getting tired because of the redistribution of workload. Although the residents’ work shift resulted in discontinuity of patient care, the negative impact caused by it was outweighed by the workload and intensity of their non-stop work on patient care.” (faculty member)

“I feel more reassured because senior residents are in charge of the intensive care units and they reside instead of on-call duty.” (faculty member)

“Considering the continuity of patient care, the working hours of faculty members should also be guaranteed by recruiting experts rather than distributing tasks within a limited workforce.” (faculty member)