BACKGROUND AND OBJECTIVE: Changes to the structure and nature of resident duty hour assignments can create compensatory workforce needs in hospital or outpatient settings to ensure appropriate patient care. The objective of this study was to understand what, if any, adjustments children’s hospitals have made in staffing and assignments of specific duties during the past 2 years as a result of residency duty hour changes, and what changes are anticipated in the upcoming 2 years.
METHODS: Mail survey to chief executive officers and chief operating officers of 114 freestanding children’s hospitals or children’s hospitals within a larger hospital.
RESULTS: Response rate was 65.4%. Respondents from more than half of hospitals (57%, N = 36) reported increasing the overall full-time equivalent (FTE) of hospitalists in response to the 2011 resident work hour changes. Forty-eight percent (N = 30) increased the overall FTE of pediatric nurse practitioners (PNPs), and 42% (N = 27) increased the FTE of neonatal nurse practitioners (NNPs). Most hospitals plan to increase the number of hospitalists (69%, N = 44), PNPs (59%, N = 37), or pediatric attending physicians (56%, N = 35) over the next 2 years. Forty-three percent (N = 27) of hospitals plan to increase the number of NNPs over the next 2 years, and a quarter plan to increase physician assistants (25%, N = 16) or pediatric house staff (24%, N = 15).
CONCLUSIONS: Changes in work hours for pediatric residents appear to have an impact on workforce planning within pediatric hospitals. Decreases in available resident work hours will create an increasing demand, primarily for nonresident physicians, PNPs, and NNPs.
- FTE —
- full-time equivalent
- NNP —
- neonatal nurse practitioner
- PA —
- physician assistant
- PNP —
- pediatric nurse practitioner
What’s Known on This Subject:
Changes in resident work hours are believed to have an impact on resident education and patient safety.
What This Study Adds:
This study provides an understanding of the impact of changes in resident work hours on the staffing strategies of children’s hospitals.
Requirements for the components and structure of residency training are the purview of the Accreditation Council of Graduate Medical Education and the residency review committees for each specialty.1 Alterations to these requirements can take several different forms. Some may be related to content, and some are related to the overall amount of time required or allowed in any specific component of training. Recently much attention has been drawn to changes in the overall amount of duty hours permitted for a trainee in a given week1–4; however, other changes may have no impact on the overall number of duty hours allowed per week but may affect the structure of how those hours are assigned.5 For example, such changes may involve the total number of consecutive hours allowed in a duty setting or the amount of rest time required between hospital shifts.
Modifications to resident duty hour requirements can have a significant impact not only on the trainees but also on the institutions in which they work. Changes to the structure and nature of duty hour assignments can create compensatory workforce needs in hospital or outpatient settings to ensure appropriate patient care and attention to patient safety concerns. Because of the complexity in staffing health care institutions, hospitals may need to act in anticipatory fashions to ensure that patient care needs are met in the face of frequent changes to the regulatory training environment for residents.
Recently, several real and proposed changes to the limits placed on pediatric residency duty hours and the structure of how those hours are assigned have been the subject of considerable discussion and debate.4–6 As these changes are made in the context of a limited available supply of physicians, nurse practitioners, and physician assistants (PAs), they can impact the market to influence hiring of potentially increasingly scarce components of the health care workforce. Although there are many factors that may influence staffing patterns of hospitals, including a secular trend in the formation of hospitalist programs nationwide, for teaching hospitals resident availability is potentially an important consideration. We sought to understand what, if any, adjustments children’s hospitals have made in their staffing patterns and their assignments of specific duties over the past 2 years as a result of residency duty hour changes, and what changes they plan to make during the upcoming 2 years. Such information may help to provide information on the current and future workforce demands in children’s hospitals.
The National Association of Children’s Hospitals and Related Institutions, Inc, is a membership association of 221 children’s hospitals and related institutions across the world. All National Association of Children’s Hospitals and Related Institutions member hospitals identified as freestanding acute care children’s hospitals or children’s hospitals within other hospitals in the United States were included in the sample (N = 114).
In collaboration with the American Board of Pediatrics Research Advisory Committee, we developed a structured questionnaire to be administered by mail. The survey was composed of a mix of fixed-choice and open-ended questions and was designed to be completed in ≤10 minutes. The survey focused on hospital staffing response to the 2011 resident work hour restrictions and future staffing plans.
The first mailing of questionnaires was sent via priority mail to the 114 hospitals in the sample in August of 2011. The survey packet was addressed to the hospital’s chief executive or chief operating officer and contained a personalized cover letter signed by the principal investigator (G.L.F.), the instrument, a business reply mail envelope, and a $5 bill as an incentive to complete the questionnaire. Two additional mailings were sent to nonrespondents in September and October 2011.
Frequency distributions were calculated for all survey items. Next, residency training program size for each hospital was dichotomized to small and large programs as defined by those with ≤16 residents per level of training being classified as small and those with >16 residents per level classified as large. χ2 Analysis was conducted to assess association of program size with responses to our questions. The study was approved by the University of Michigan Medical School institutional review board.
Of the 114 survey packets mailed, staff from 68 hospitals returned the survey, 10 surveys were undeliverable, and staff from 1 hospital declined to complete the survey, yielding a response rate of 65.4%. Three hospitals with staff who returned the survey were ineligible because their hospital does not employ pediatric residents, leaving a total of 65 surveys for analysis.
Demography of Respondents
Most respondents who completed the survey on behalf of their hospital were chief executive officers or chief operating officers (62%, N = 69). Nearly one-third of respondents held leadership positions related to pediatric residency or training (30%, N = 19). On average, the hospitals employed 18 to 19 pediatric residents in each training level (Table 1).
Hospital Response to Change in Resident Work Hours
Respondents from more than half of hospitals (57%, N = 36) reported that they increased the overall full-time equivalent (FTE) of hospitalists in response to the 2011 resident work hour changes. Forty-eight percent (N = 30) of hospitals increased the overall FTE of pediatric nurse practitioners (PNPs), and 42% (N = 27) reported that they increased the FTE of neonatal nurse practitioners (NNPs) (Table 2).
Two-thirds of hospital respondents in the study (67%, N = 43) reported that they transferred new or additional work assignments from pediatric house staff to hospitalists in response to the 2011 work hour changes, and more than half (60%, N = 38) reported that they transferred work to NNPs. Approximately half of hospital respondents reported that they shifted work to PNPs (49%, N = 31) or pediatric attending physicians (48%, N = 29), and 25% (N = 16) transferred work to PAs (Table 3).
Future Plans for Pediatric Care Staff
Respondents from most hospitals reported that they plan to increase the number of hospitalists (69%, N = 44), PNPs (59%, N = 37), or pediatric attending physicians (56%, N = 35) over the next 2 years. Forty-three percent (N = 27) of hospitals plan to increase the number of NNPs over the next 2 years, and a quarter of respondents plan to increase PAs (25%, N = 16) or pediatric house staff (24%, N = 15). Few hospital respondents reported that they plan to increase nonpediatric house staff (8%, N = 5) or family nurse practitioners (FNPs) (2%, N = 1) (Table 4).
Similarly, respondents from most hospitals reported that they plan to transfer additional pediatric patient care responsibilities to hospitalists (70%, N = 45), PNPs (63%, N = 40), or pediatric attending physicians (52%, N = 32) over the next 2 years. Respondents from 48% (N = 30) of hospitals in the study reported that they plan to transfer pediatric care to NNPs, and 34% plan to transfer pediatric care to PAs (34%, N = 21) (Table 5).
Variation by Program Size
There were differences seen when examining the variation between hospitals with large and small pediatric residency training programs. Hospitals with larger residency programs were more likely to report that they had increased the overall FTE of NNPs in response to resident work hour changes (57% vs 30%; P = .04). They were also more likely to have transferred work from pediatric house staff to hospitalists (80% vs 57%; P = .5).
With regard to future planning, similar differences were found. Hospitals with larger residency programs were more likely to report that they plan to transfer pediatric patient care to hospitalists in the next 2 years (87% vs 57%; P = .01). They are also more likely to report that they plan to transfer pediatric patient care to task-tailored substitutes (eg, laboratory technicians, registered nurses, and nursing aides) over the next 2 years (46% vs 13%; P = .01).
The most important finding from our study is that the nonresident workforce needs of children’s hospitals are increasing, and there is an intention across most of these institutions to hire additional medical professional staff in the next 2 years. Based on the response to our questions, it appears that at least some of this intent is due to changes in the total work hours and the work hour distribution for pediatric house staff.
Of significant importance are the plans by many hospitals to hire additional PNPs and NNPs to address changes in pediatric residency training. Recent studies have documented the intention of both pediatric primary care physicians and pediatric subspecialty physicians in hiring additional PNPs and NNPs as well.7 Although there may be some overlap in these intentions, there is also considerable independence among the hiring practices of pediatric hospitals, departments of pediatrics, and physicians in private practice. Taken together, these intentions raise the question as to whether the supply of PNPs and NNPs is poised to meet this increasing demand.
Although there has been significant publicity surrounding an increase in the overall pipeline of nurse practitioners nationwide, recent studies have demonstrated that there has been no appreciable increase in the new graduates of PNP and NNP programs over the past 15 years.8 Although the number of new family nurse practitioners and other adult nurse practitioners completing training each year has doubled, the same has not occurred in pediatrics. Because PNPs and NNPs make up only ∼10% of the total nurse practitioner workforce, trends for these professionals are subsumed when looking at the field of nurse practitioners overall.8 As such, when examining pediatric workforce projections, it is imperative to look at the pediatric-specific component of each aspect of the medical workforce.
The other major finding of our study is the intention of hospital executives to hire more pediatric hospitalists to offset the decreases in available resident duty hours and that this varied by residency training program size. Recent studies have demonstrated that there is likely a ready pool of potential pediatric hospitalists leaving residency training each year and that number, although small, is growing.9 Approximately 3% to 5% of residency graduates intend to pursue positions as hospitalists after completion of their training. Among those who have taken such positions in recent years, a significant proportion did not remain in these roles for >5 years,10 creating a need to regularly replenish the positions of those who leave. Current efforts to develop a consistent and more professional career path for those choosing to pursue pediatric hospital medicine may have an impact on the turnover of these positions.11
Pediatric residency positions are funded almost exclusively by hospitals and usually through Graduate Medical Education funding from the Center for Medicare & Medicaid Services; however, some hospitals may fund additional positions through their own resources. The finding that 25% of hospitals intend to increase the number of pediatric resident positions is of interest for several reasons. First, currently >97% of available pediatric residency positions were filled in the latest residency match process.12 Expanding the number of available positions would require either an increase in the number of graduating medical students who choose pediatric training or an increase in the number of international medical graduates filling pediatric residency positions to address hospital workforce needs. Second, increasing the number of training positions also will have an impact on the resources of departments of pediatrics to provide the infrastructure to support such training.
Our study found that many fewer hospitals intend to increase the number of PAs compared with those intending to increase the number of PNPs, which may be a function of the current market for PAs or a preference for 1 type of professional over another in a children’s hospital setting. Nationally, only a small number of PAs work currently in pediatric settings; <3% of all PAs spend most of their clinical time providing care to children.13
It is important to consider that there may be other factors, unrelated to changes in resident work hours that also may affect or prompt changes in hospital staffing patterns. For example, many hospitals already have increased their hospitalist workforce and may continue to do so totally unrelated to resident factors. Also, this study did not specifically focus on changes in outpatient staffing as a result of resident work hour changes.
Changes in the allowable number and structure of work hours for pediatric residents appear to have an impact on workforce planning within a pediatric hospital. Decreases in available resident work hours will create an increasing demand, primarily for nonresident physicians, PNPs, and NNPs. A lack of increase in the pipeline of new PNPs and NNPs and increased competition for their services will likely lead to significant competition among employers in both inpatient and outpatient settings.
The members of The Research Advisory Committee of the American Board of Pediatrics are William F. Balistreri, Dimitri A. Christakis, Lewis R. First, George Lister, Julia A. McMillan, Joseph W. St. Geme, III, Linda A. Althouse, Marshall L. Land, Jr., Gail A. McGuinness, and James A. Stockman, III.
- Accepted June 4, 2012.
- Address correspondence to Gary L. Freed, MD, MPH, Child Health Evaluation and Research (CHEAR) Unit, University of Michigan, 300 North Ingalls Building, Room 6E08, Ann Arbor, MI 48109-0456. E-mail:
Dr Freed conceptualized and designed the study, drafted the initial article, and approved the final article as submitted; Ms Dunham designed the data collection instruments, coordinated and supervised data collection, critically reviewed the article, and approved the final article as submitted; Ms Moran conducted data collection and tracking, coded the responses, reviewed and revised the article, and approved the final article as submitted; and Ms Spera conducted the analyses, reviewed and revised the article, and approved the final article as submitted.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: This project was funded by the American Board of Pediatrics Foundation.
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- Copyright © 2012 by the American Academy of Pediatrics