Research team and reflexivity

The head physician of both study sites gave the impetus to investigate aspects of work-life balance in physicians working in EDs. After joint consultation, the conception, implementation and analysis of the study was allocated to cooperating researchers from the Institute of Medical Sociology and Rehabilitation Science. Two female employees were appointed for the realization of this focus group study, i.e., one doctorate public health researcher and a medical student in her 7^th semester who worked as an undergraduate assistant in the ED. In preparation of the study, both were trained and advised by an experienced senior researcher with a background in sociology. Both moderators demonstrated prior experience with research projects in the emergency medical setting, which induced that some of the study participants were familiar with their names and occupational roles before focus groups. However, moderators refrained from sharing their personal goals and reasons for conducting research on work-life balance in the ED so that it seems unlikely that participants held preconceptions about their roles or opinions concerning this topic.

Study design

The target population consisted of physicians who worked at one of two ED sites of a major university hospital in a capital city during the time of data collection. We applied purposive sampling with regard to the professional position of potential participants (stratified into residents/ specialists vs. senior physicians) and with regard to parenthood (stratified into parent vs. no parent) to enable the collection of relevant and rich data with regard to our research question. We excluded physicians from other hospital wards who underwent a six- to twelve-month mandatory rotation in the ED as part of their residency. This exclusion criterion was applied to ensure sufficient knowledge of and familiarity with ED work conditions among participants. A study information sheet and informed consent were sent via email to all eligible ED physicians with the request to participate in the study. The contact information of one of the moderators was provided in the email for potential inquiries. Out of 18 physicians who were invited to take part in the study, 14 agreed to participate. Reasons for non-participation were not sampled. After physicians’ consenting feedback, participants were divided into four groups, consisting of three to four physicians each. Participants’ gender was collected but not used for assignment to groups.

Focus groups were carried out between May 2019 and March 2020 at both ED sites located on two different campuses of the university hospital. Focus groups were held in seminar rooms spatially in or close to the respective EDs in order to increase the accessibility for participation during or after the physicians’ work shifts. Upon arrival at the seminar room, participants chose a seating position at an arranged rectangular table facing each other. The moderators were seated next to each other. Participants had the opportunity to ask questions regarding the study content and data protection measures at the beginning of each focus group. Pastries and beverages were offered. No further compensation was provided for study participation. No other persons besides the participants and the two moderators were present during focus groups. The study was approved by the ethics committee of the Charité–Universitätsmedizin Berlin (EA2/135/19) and was presented to the general works council of the hospital. Written informed consent was obtained from all participants.

The fourteen final participants were diverse regarding their professional position (n = 5 residents, n = 2 specialists, n = 7 senior physicians), their gender (n = 7 females, n = 7 males) and with regard to their characteristic of being a parent (n = 8 yes, n = 6 no). The time frame of one hour was set at the beginning of each focus group. The average duration of a focus group was 52 minutes. The total duration of all focus groups was 209 minutes. One of the following stimuli on the topic of work-life balance was presented at the start of each focus group to initiate discussion between participants:

Stimulus 1: “(…) but for example Denmark (…) there is no way that a physician cannot go home on time to pick up his children from daycare (…)”, “(…) we can talk about the compatibility [of family and work] but in everyday clinical routine it can often not be implemented, except when you would ditch the patient but, thankfully, that does not happen.” What do you associate with this quote?

Stimulus 2: "As a childless young assistant, I was always suspicious of these colleagues who were parents. They never had time, always had to go home when I was still working on my 27th medical report, were always already finished with their stuff, had concepts in the twinkling of an eye, and never came along to the pub. I had no understanding of kids and even less of parents." What thoughts and own experiences do you associate with this quote?

Stimuli depicted an interview quote from a previous research project and a blog quote. In the first focus group, the stimuli and guideline were tested and deemed suitable for application. Stimulus 1 was chosen for focus groups with specialized and senior physicians. For the focus group with residents only, stimulus 2 was applied since moderators considered it the better fit. Moderators did not interrupt participants during their conversation and kept their participation during focus groups to a minimum. If the discussion held off for multiple seconds, moderators asked questions that followed a prepared guideline (see S1 Table). The guideline focused on the following topics: (1) current experiences of participants regarding work-life balance, (2) comparison between their situation now and in prior professional positions, (3) comparison of their current with other workplaces and (4) ideas and improvement measures concerning work-life balance in emergency medicine.

Data analysis

All focus groups were recorded with a solid-state digital tape recorder. Additionally, moderators took anonymized field notes to describe the spatial setup and the interaction between participants during focus groups. Transcription of audio tapes was performed loosely based on the rules of Dresing and Pehl [28]. All person-related data was pseudonymized in the transcription process to impede inferences about individual participants. We did not provide participants with transcripts for comment or correction after focus groups to minimize workload for participants. A word-processing program was applied for data management. The methodological orientation of this study was based in content analysis. Hence, final transcripts were analyzed using the qualitative content analysis approach described by Kuckartz [29]. To derive categories from the material, transcripted speech was separated into paragraphs with similar content. In the next step, the paragraphs were reduced to specific key lines that reflected the main statement of this section. In the following, categories were assigned to the paragraphs based on their key lines. In the beginning, the transcript of one focus group was used to create a category tree that was applied to the remaining transcripts and continuously improved during this process. Another author analyzed the transcripts of ten-minute sequences of each focus group to cross-control the coding strategy. Subsequently, discrepancies and similarities were discussed to optimize the derived codes and themes. Preliminary and final findings were repeatedly discussed between co-authors in different constellations in order to integrate multi-professional perspectives from emergency medicine, sociology, public health and health services research. Superordinate topics used for the following presentation of results were structured based on the focus group guideline. However, we derived all themes from data only. Due to the small study group and data protection measures, results are presented across focus groups and not for individual groups. Furthermore, the topic of data saturation was discussed before study start but the small target group of ED physicians prevented researchers from conducting more than the four realized focus groups. Nevertheless, current methodological research suggests that four focus groups and an inclusion of participants from all relevant strata regarding the research question is sufficient for achieving code saturation, i.e., to capture the breadth of a topic [30], which corresponded with our exploratory aim to identify relevant topics regarding work-life-balance in ED physicians.

Past work-life balance of emergency physicians

Participants discussed the topic of work-life balance by drawing comparisons between their respective past and current experiences in different clinical environments. The discussion particularly evolved around their past and current work in the field of emergency medicine as well as in the more general university medical context. Generally, participants described a predominantly positive temporal development of the state of work-life balance in emergency and university medicine. Physicians reported beneficial factors for a better work-life balance in the past. However, they further described numerous past work conditions and work structures, which hampered work-life balance in comparison to current ED work.

Past work conditions and aspects of the work environment

According to participants, the past work environment was characterized by a strong, inner-clinical hierarchical structure which restricted physicians’ work-life balance decisively. Relevant decisions concerning the scheduling of shifts were predominantly made by the department head and some senior physicians. Thus, participants reported a lack of possibilities to express wishes in the scheduling of their shifts in the past, which they contrasted with current practice in the ED. Participants described the past resulting lack of flexibility as a reason for diminished work-life balance, mostly for young and female physicians. Furthermore, the planned and actual duration of shifts was longer compared to today’s shifts. The number of physicians scheduled per shift as well as in the core team was lower. In the past, overtime was common and taken for granted by most junior and senior physicians. Further, the stigmatization of male physicians who expressed claims for parental leave was illustrated as a problem. However, contrary to these statements, participants highlighted that a stronger solidarity and social bond among physicians facilitated work-life balance in the past. High personnel turnover in university hospitals was designated as a reason for weaker and transient social bonds between young physicians working in the ED.

Past physician’s mentality and behavior regarding work-life balance

Participants reported that physicians showed a stronger tendency to prioritize their work instead of their family or private life in the past. Individual motives as well as external expectations of the department head and senior physicians were discussed as possible reasons. In this context, a shift in priority from work towards family and private life among present young physicians was identified. Further, in the past, younger physicians pursued less claims regarding adequate work times, workload, flexible work time models or participation in work scheduling. In addition, participants underlined that a variety of employment laws were already in effect in the past. However, physicians often did not make use of them due to worries about possible negative consequences for their training or career. Consequently, participants emphasized that part-time work and longer periods of parental leave were rarely claimed. Especially during residency, a reduction of work hours with the aim to focus on childcare was unusual. Today, however, reductions and sick days in case of acute health problems of the child, are common practice and more self-evident for both female and male young physicians.

Past context factors of emergency medicine and university medicine

Participants reported that a high patient turnover, along with staff shortages, caused a high workload for physicians in the past. This indirectly restricted work-life balance. However, some participants claimed lower ED patient numbers in the past. Organizational support structures for physicians with children were described as minimal in the past. In contrast to today, physicians could not resort to support from so-called “hospital father’s representatives” when considering parental leave or work time reduction or when addressing topics of work-life balance with their superiors. According to participants, these now available structures are of great relevance for physicians.

Present work-life balance of emergency physicians

When discussing current conditions that influence work-life balance, participants shared positive and negative experiences from their everyday work. The maintenance of work-life balance was seen as highly dependent on available private support by partners as well as the age and stage of career of the individual physician, respectively. Work-life balance was described as being achievable for physicians with leadership roles rather than for young physicians during residency.

Present work conditions and aspects of the work environment

Several work conditions were described to be directly linked to the compatibility of a career and family or private life. Physicians positively highlighted the current ED practice to be involved in work scheduling which allowed physicians with children to better plan ahead work and family time. Further positive factors mentioned in this context were (a) the scheduling of two days off in between the switch from night to the late or early shift, (b) the restriction of night shifts to four, or maximum five in number, and (c) the availability of an on-call service to coordinate the work schedule in case of staff shortages due to illness. According to participants, the latter practice allowed for a more balanced distribution of shifts among staff by avoiding that the same physicians fill in too often. The total increase in the department’s staffing of the last few years was also positively emphasized.

On the other hand, the common occurrence of overtime hours was presented as highly incompatible with family and private life. Reasons for overtime included deficits in the handover of patients between shifts, which were described as unstructured and frequently interrupted. Reduced physician staffing of the night compared to the late shift was also reported as a common cause for overtime work in the late shift. Participants discussed that overtime not only reduced family time, but also increased the risk for negative physical and psychological health effects, e.g., insomnia and exhaustion. By hampering everyday planning, overtime resulted in challenges of organizing childcare and leisure activities. Furthermore, the aspect of missing regular work breaks was described as problematic, which was associated with a nonexistent “culture of taking breaks” among ED physicians. This observation deviated from participants’ narratives of other clinical specialties with shift work systems where work breaks were coordinated and staff adhered to them more strictly. The shift work system itself was another relevant factor influencing work-life balance in participants’ point of view. Reported advantages of shift work included the possibility to hand over patients to the next shift. This practice would theoretically result in fixed work hours and a good planning capability for physicians. However, shift work-pertinent holiday and weekend work reduced work-life balance. Also, participants described that adhering to appointments regarding childcare, e.g., visits to the pediatrician or school events, was often complicated since shifts cannot be individually shortened. Generally, the remuneration of shift work was described to be inadequate when considering the high work burden and the accompanying physical and mental health impairments in affected physicians. The only possibility to get past the shift work system, and to profit from more flexibility and family-friendly work hours, was seen in the professional advancement to the position of a senior physician. Finally, another significant work demand was seen in the lacking overall hospital patient transfer system. This process obliged ED physicians to make numerous phone calls to transfer ED patients to internal and external hospital wards. Participants associated this practice with a delay in patient treatment and with unnecessary frustration, stress and conflicts in ED physicians.

Participants underlined that trusting interpersonal work relationships indirectly accounted for a family-friendly workplace. These opened up the possibility to ask colleagues for support if needed, e.g., to switch shifts or to ensure leaving work on time. The current ED work atmosphere was described as naturally tolerant towards physicians with children. However, some participants apprehended that physicians without children would fill in more often and work more often on holidays. The relationship between physicians with and without children was also described to differ with regard to the individual competitiveness and solidarity of physicians. However, for both groups, participants mentioned that perceived high expectations regarding their availability and work effort would cause pressure, which negatively affected private life. Furthermore, work-life balance was related to restrictions in the planning of clinical rotations for residents working part-time. Participants pointed out that these disadvantages caused delays in their residency progress and negatively affected future career chances.

Present physician’s mentality and behavior regarding work-life balance

Participants reflected that specific personality features were more common among physicians than other professional groups. These characteristics included a high degree of dedication, the will to sacrifice for patients and a high sense of responsibility towards colleagues. The wish of younger physicians to represent high-performing individuals in the workplace was seen as a means to leave a good impression on colleagues and to increase the prospect of an extension of a fixed-term employment contract. Causes for overtime work were thus also seen in physicians’ feeling of responsibility and solidarity as well as the tendency to feel guilty when leaving work on time. Participants summarized that more experienced physicians, in contrast to their younger colleagues, knew about the operating principles of the hospital system. This knowledge would make it easier to evaluate task priority and to effectively manage work time. Both factors were considered to reduce the risk of overtime hours. Differences in the mentality of younger and older physicians were also discussed. In this context, older physicians showed the tendency of practicing and expecting more overtime hours from colleagues. This practice was believed to still set an example to the younger generation of physicians.

Present context factors of emergency medicine and university medicine

Participants described ED-specific characteristics such as high patient turnover, unpredictable patient volumes and frequent work interruptions. These work requirements hampered time slots for organizational tasks (e.g., documentation, student teaching, and research) during regular work hours and thus resulted in overtime work. With regard to work-life balance, participants recognized that their employer offers family-friendly structures. These included childcare with long opening hours and flexible pick-up times, parent’s representatives or the possibility to claim flexible worktime models. However, some participants criticized that the actual chance to receive a place in the hospital-owned daycare center was very low. Furthermore, fixed-term employment contracts were described to be family-unfriendly as they would come along with worries and fears about the future career.

To evaluate ED structures in a greater context, participants drew comparisons with (a) other EDs, (b) with other clinical workplaces and disciplines, and (c) with jobs outside the healthcare sector. Some participants discussed similarities and differences between the two ED sites of the study hospital from their own experience. Based on that comparison, participants concluded that one ED site was characterized by less overtime hours and workload, which was attributed to the availability of a patient manager responsible for patient transfers and better handover practices. Furthermore, one ED employed more balanced shift work times, which, according to participants, caused less potential for overtime work. Based on their work experience at other wards, participants stated that structures increasing family-friendliness in other wards with shift work systems were clear work assignments, strict regulations concerning work times and breaks, and higher staffing in every shift. Participants also explained that, compared to the ED, patient numbers were foreseeable and staff fluctuations less common. Both improved work-life balance in the long run. However, contrary experiences of chaotic and unfair work scheduling at other wards were also shared. Regarding international comparisons, participants stated that inner-clinical patient transfer structures were partly better regulated in EDs of other countries. They speculated that this circumstance was based on the consensus of ED patients’ high priority and their immediate entitlement to inpatient admission. Other statements concerning clinical work abroad dealt with the lower rates of overtime work in countries like Denmark, the lower prioritization of work and, generally, the higher relevance of work-life balance for employees. Accordingly, physicians with children would be granted more days off in other countries. Furthermore, participants emphasized that other countries provisioned a bigger pool of substitute physicians in case of sick leave. With regard to other professions, participants reflected that jobs outside of the healthcare sector are characterized by longer employment contracts, more structured work breaks and less workload. This was regarded as being more compatible with family and private life than in health professions.

Improvement suggestions for work-life balance in emergency physicians

When reflecting on possible ways to address the above-mentioned challenging work conditions with the aim to increase work-life balance, participants underlined the importance of an open and honest exchange between junior and senior ED physicians. Furthermore, the strengthening of the importance of the ED in the context of university hospital structures was considered as an important step to allow for better work conditions for ED physicians.

Suggestions for the improvement of work conditions and aspects of the work environment

To simplify work scheduling in cases of high illness rates and, simultaneously, in order to increase the attractiveness of ED work, suggestions to increase the pool of part-time workers were made. This measure was also seen as a way to reduce the workload of each individual physician. According to participants, the promoting of punctual shift ends should be emphasized, irrespective of the family, partner or child status of each physician. Overtime work should therefore become an exception rather than the rule. Means to achieve fixed work times are undisturbed, fast and punctual patient handovers between shifts, e.g., by reinforcing the intermediate shift overseeing patient care during handovers. Furthermore, an increase of staffing in the night shift was discussed as a strategy to avoid overtime hours in the late shift. Participants further described that a higher variability in everyday tasks may decrease the risk of monotonous work. The implementation of a stricter “culture of taking breaks” by setting up break times for each shift, as far as patient volumes allow, was seen as a possibility to create recreational opportunities during high workload.

Certain privileges for physicians in the first two years after the birth of a child were discussed, including an additional day off in each annual quarter or one shorter shift per month. Acceptance and tolerance towards physicians with children were considered crucial to increase family-friendliness at the ED workplace. Especially for young physicians, demands for equal chances during residency were phrased, which would not depend on their child status or their work model. These included fair conditions regarding clinical rotations. Finally, participants expressed their wish for more appraisal interviews with the department head to foster a trusting relationship and to offer regular opportunities to discuss current problems concerning one’s own work-life balance.

Suggestions for the improvement of context factors in university medicine

Providing more places in hospital-owned daycare centers was described as an important support structure for physicians with children working in the shift system. Furthermore, general claims for more vacation days and a reduction of total monthly work time for shift workers were expressed. Likewise, an increase in remuneration and more long-lasting employment contracts were voiced. Participants also strongly advocated for the setup of a coordinated hospital-wide patient transfer structure.

Results of qualitative content analysis regarding discussed aspects of ED physicians’ work-life balance in sub-categories and themes are summarized in (Fig 1).

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Fig 1. Pertinent aspects of ED physicians’ past and present work-life balance and avenues for future improvement.

https://doi.org/10.1371/journal.pone.0277523.g001