Including a method of organising hospital shift work that is more than 20 years old in a collective agreement should not be the first priority for solving any of the problems that the specialist health services are facing. The doctors should rather have gone on strike to come under the protection of the Working Environment Act.
With the strike that has recently ended, the Norwegian Medical Association wanted a more than 20 year old practice for the organisation of shift work to be enshrined in a collective agreement. The objective was to make it harder for employers to adapt the shift rosters to the work of the departments. I have more than 40 years of experience from the specialist health services, as an employee and as a manager. In addition, I have been elected as a department representative in two university hospitals. I have thus seen the organisational challenges in hospitals from both sides. Against this background I find it very difficult to understand the justification for this strike on the part of the Norwegian Medical Association.
Impractical work schedules
There are many indications that resources of medical personnel in the hospitals are not properly organised, and that this is one of the main obstacles to optimal use of personnel and equipment. Despite the fact that running a hospital is a 24-hour activity, 83 % of the hospital doctors’ working hours are scheduled in the daytime from Monday to Friday, a period that accounts for no more than 24 % of the total weekly working hours (1). Since the patient load is distributed a lot more evenly, this gives rise to such large differences in workloads during the evenings, nights and weekends compared to weekdays that many hospital departments are presumably overstaffed in the daytime from Monday to Friday, as has been indicated previously (2).
The doctor as a daytime worker
The uneven distribution of doctors’ working hours is a consequence of labour agreements specifying that planned work with patients shall only take place in the daytime on weekdays. This is clearly disadvantageous for the utilisation of medical resources. In its study of operating theatres, the Office of the Auditor General found that 80 % of operations took place between 08.00 and 16.00. In half of the operating theatres the last operation was finished at 14.30. The report concluded that many planned operations were not started because of uncertainty as to whether they could be finished before the end of the doctors’ regular working hours (3).
National statistics also testify to a development whereby the amount of medical resources is greatly increasing without an equivalent increase in admissions, operations or outpatient treatments (4). There is thus all the more reason to do something about the organisation of doctors’ work in hospitals. The British journalist and labour market researcher Charlotte Santry has consequently characterised doctors as the last major professional group that has failed to adapt to developments in the enterprise they are working for (5).
The doctors and the Working Environment Act
Since the hospitals represent a 24-hour activity, the doctors have committed through their work contracts to cover the need for emergency assistance outside the specified working hours by using shift rosters. This was the bone of contention in the doctors’ strike. With limited daytime hours, 24-hour coverage by doctors gives rise to long shifts lasting from the end of the working day in the afternoon until the next morning, meaning that shifts often last for 19 hours with no scheduled breaks to eat or rest. To enable this, the doctors have been exempted from the provisions on working hours in the Working Environment Act, and as recently pointed out by medical editor Liv-Ellen Vangsnes, it seems odd that we as doctors, who are responsible for human life, should be exempted from the protection granted by the Working Environment Act (6). She believes that this has worked nevertheless, because there has been sufficient time for resting between shift periods. This is a truth with a number of modifications. As she points out, doctors are like most other people, and they are prone to make errors after working too many hours deprived of sleep. Many doctors also feel pressured by their colleagues to accept such strenuous shifts, even when they are ill (7).
Academic studies from a number of countries also show that treatment complications and deaths occur more frequently in patients who are admitted on evenings, nights and weekends, when compared to the daytime working hours on weekdays (8 – 10). This is because overworked and tired doctors more frequently make mistakes, for example by deviating from established procedures. During the shift periods, there are also significantly fewer doctors in attendance than on weekdays in the daytime, and this means that there is less competence available around the patient. In a population survey, nearly 70 % of the respondents stated that they were concerned that the workload on doctors might be a cause of malpractice (6).
An incomprehensible doctors’ strike
It is thus incomprehensible that doctors would go on strike to have such shift arrangements enshrined in the collective agreement. For the vast majority of other employees, the Working Environment Act provides protection against abuse and exploitation on the part of their employers. The same ought to apply to doctors.
The provisions in the Health Personnel Act that obligate hospitals to facilitate responsible conduct are under threat from several quarters, including the doctors themselves. Instead of going on strike to incorporate irresponsible shift rosters in the collective agreement, the doctors should rather have gone on strike to be encompassed by the Working Environment Act. In a completely different manner, such a strike would also have been in the patients’ best interests.