|Year : 2020 | Volume
| Issue : 2 | Page : 306-311
The influence of time-management on medical resident's perceived stress scale and overtime: A tertiary care hospital experience from Switzerland
Lorenz Bärlocher1, Meghan McConnell2
1 Department of Internal Medicine, Hospital of St. Gallen, Gallen, Switzerland
2 Department of Innovation in Medical Education, University of Ottawa; Department of Anesthesiology and Pain Medicine, University of Ottawa, ON, Canada
|Date of Submission||24-Nov-2020|
|Date of Decision||12-Dec-2020|
|Date of Acceptance||12-Dec-2020|
|Date of Web Publication||23-Dec-2020|
Dr. Lorenz Bärlocher
Department of Internal Medicine, Hospital of St. Gallen, Rorschacherstrasse 95, 9007 St. Gallen
Source of Support: None, Conflict of Interest: None
Background and Aim: Many physicians express challenges in managing time demands during clinical practice. Effective time-management skills may counter the negative effects of high workload and time pressures, and subsequently improve productivity as well as professional and personal wellness. The objective is to determine the impact of time-management training on medical residents' overtime hours and self-reported stress scores. Materials and Methods: The present study employed a within-subjects, single group pretest-posttest design. Convenience sampling was used to recruit 27 medical residents from a tertiary care hospital in Saint Gall, Switzerland. Each resident participated in a single, 2-h interactive time-management workshop. Each resident completed the Perceived Stress Scale-10 (PSS-10) 1-week before and 8-week after the time-management intervention. Overtime of every resident was documented during the same time intervals using a hospital-based computer system. Finally, we recorded whether residents experienced any stressful life events during this 8-week study. Results: Residents worked significantly fewer overtime hours after the time-management intervention than before the intervention (P = 0.01). There was also a significant reduction in mean PSS scores following the intervention, but only for residents who reported experiencing stressful life events during the study (P = 0.028). The intervention had no effect on mean PSS scores for residents who did not report a stressful life event (P = 0.36). Conclusion: The present study reported an effect of time-management training on overtime and perceived stress in residents. We argue that time-management can help residents cope with external stressors, and that individuals who experience stressful life events may especially benefit from time-management training.
Keywords: Overtime, perceived stress, residents, time-management training, time-wasters
|How to cite this article:|
Bärlocher L, McConnell M. The influence of time-management on medical resident's perceived stress scale and overtime: A tertiary care hospital experience from Switzerland. Arch Med Health Sci 2020;8:306-11
|How to cite this URL:|
Bärlocher L, McConnell M. The influence of time-management on medical resident's perceived stress scale and overtime: A tertiary care hospital experience from Switzerland. Arch Med Health Sci [serial online] 2020 [cited 2021 Jan 17];8:306-11. Available from: https://www.amhsjournal.org/text.asp?2020/8/2/306/304724
| Introduction|| |
Time-management is a critical skill for healthcare professionals. Time is a critical component of high quality patient care, and many physicians express concern that they have inadequate time for clinical practice. Physicians are increasingly expected to manage a growing number of patients in less time and complete larger volumes of administrative responsibilities.,,,, Furthermore, advances in medical and communication technologies have affected how physicians manage their professional and personal time.,,, For these reasons, it should come as no surprise that many physicians report difficulties in managing high workloads and increasing time demands.,,
High workloads and time pressures not only influence the ability to provide appropriate patient care; such demands also have substantial impact on physician wellbeing. [1,3-5,11-14] Indeed, many physicians “frequently sacrifice time with family and friends, and the time they need to look after their own health and pursue personal interests, in an effort to meet seemingly endless work commitments” (p. 1). Research has shown that time pressures and adverse workflow are strongly associated with physician dissatisfaction, stress, burnout, and intent turnover rates. Similarly, long working hours and overtime have been associated with increased levels of burnout, perceived stress, and depressive symptoms. [7,16-19] These findings are concerning, given that poor job satisfaction and burnout are associated with increased medical errors, lower patient satisfaction, longer postdischarge recovery times, and decreased professional work effort.,,,,,,, For these reasons, it is critical that physicians learn to manage their time effectively and efficiently. Indeed, time-management behaviors have been described as core competencies in several competency-based medicine initiatives.28],, The integration of time-management skills into competency-based education programs emphasizes the importance of teaching these skills early on in training to help learners deal with the demands of busy work schedules, stressful situations, and unanticipated emergencies in clinical settings.
Outside medicine, research within education and occupation contexts has shown effective time-management increases productivity and promotes various measures of wellbeing. Several randomized controlled studies have found that time-management interventions reduce perceived stress and increase perceived control of time among undergraduate students leading the authors to conclude that time-management training have positive impact on students' well-being., Similarly, research in occupational settings has found that time-management training can be helpful in reducing worry, stress, and procrastination at work., Together, these findings suggest that time-management interventions can positively affect various measures of well-being. That being said, the effectiveness of time-management interventions depend on a variety of factors, such as individual differences in motivation and the presence of external stressors.,,
While research outside medical education has reported positive effects of time-management training on various outcomes, there is a lack of empirical research examining the impact of time-management intervention within healthcare professionals. A few studies in the nursing literature have found that poor time-management is significantly correlated with high levels of stress among undergraduate nursing students., While such correlational studies highlight the benefits of fostering time-management skills among health professionals, we have found no study that has examined the effects of time-management training on stress among medical trainees. The purpose of the present study was therefore to examine whether an educational program in time-management can improve medical residents self-reported stress scores and reduce the number of overtime hours worked. Furthermore, given that external stressors can influence the effectiveness of time management programs, we examined whether the impact of our intervention on perceived stress and overtime hours was mediated by the presence of self-reported stressful life events.
| Materials and Methods|| |
Context and participants
The present study took place in the department of internal medicine within a tertiary care hospital in the Swiss German speaking canton of Saint Gall, Switzerland. Within Switzerland, Internal Medicine specialty consists of 5 years of postgraduate training, with training taking place in both tertiary care hospital wards and outpatient settings.
The present study took place from September 2019 to January 2020. During this time, the department of internal medicine consisted of 65 trainees, with 55 working a hospital ward and 10 working in an outpatient setting. To control for the potential confound of workplace environment on our outcome measures, we chose to only include residents who were working in a tertiary care hospital ward.
Residents were invited to take part in the study through E-mail newsletters. Residents were told that participation would involve partaking in a training program designed to improve their time-management skills. Participation was voluntary and the confidentiality of responses was assured. The study protocol was reviewed and approved by the Swiss Association of Research Ethics Committee (Req-2019-00485).
The intervention was based on the framework provided by Gordon and Borkan, who used psychological theory and research to identify four specific time-management strategies for physicians: (1) Setting short and long-term goals, (2) Setting priorities among competing responsibilities, (3) Planning and organizing activities, and (4) Minimizing time wasters. Of these four strategies, the present study focused specifically on time-management strategies related to minimizing time wasters. Time wasters refer to interruptions, distractions, and other activities that reduce productivity and result in “lost time.”
The time-management intervention consisted of a single, 2-h interactive workshop. Each workshop consisted of no more than six residents, which resulted in a total of five workshops. All workshops were conducted by the same trainer (LB).
The workshop started with a brief, 15-min didactic lecture. This lecture oriented residents to the importance of time-management on both patient outcomes and physician wellbeing, and described of Gordon and Borkan's four time-management strategies.
Next residents were divided in small groups of 2–3 people, where they worked together to identify time wasters that influence their professional and personal productivity. Time wasters were documented on a flip chart and after 15 min, each small group presented their findings to the entire group. Next, residents returned to their small groups, where they discussed possible strategies to overcome each identified time waster. These strategies were again recorded on a flip chart, and each group presented their strategies to the whole group. Finally, the instructor described ten common time wasters and potential solutions identified by Gordon and Borkan, and the entire group discussed how these related to their own local circumstances. The workshop ended by having residents identify two specific time wasters they wanted to avoid in the future, describe how they plan to overcome these time wasters, think about possible obstacles they might encounter and how they plan to overcome them. Four weeks after the workshop, the residents received an E-mail reminding them of Gordon and Borkan's ten common time wasters and potential solutions.
Perceived stress was measured using the German version of the Perceived Stress Scale-10 (PSS-10). The PSS-10 is one of the most widely used psychological instruments for assessing the extent to which individuals appraise situations in their lives as stressful and has been used to assess the effectiveness of various stress-reducing interventions.,,,,, The PSS-10 consists of 10 items that use a 5-point response scale (1 = “never,” 2 = “almost never,” 3 = “sometimes,” 4 = “fairly often,” 5 = “very often”). Higher scores indicate higher levels of perceived stress. Previous research on the psychometric characteristics of the German PSS-10 has reported high internal consistency (Cronbach's alpha = 0.84) and positive correlations with measures of depression, anxiety, fatigue, and life satisfaction.
The current labor law in St. Gallen, Switzerland designates a working time of 48 h/week for residents. Accordingly, during a 5-day work week, the average working day contains 9.6 h. Any hours >9.6 h on a given day count as overtime. The number of hours worked by resident is documented using a hospital-based computer system (”Polypoint PEP”), which records the time the start and end time of each resident.
Stressful life events
Finally, we documented whether residents experienced any stressful life events throughout the study. Residents were given a single open-ended question that asked, “Have you experienced any stressful life events during the past 8 weeks?” Residents' qualitative responses were coded afterward.
This study used a within-subjects, single group pretest-posttest design. One week before the intervention, residents completed a demographic questionnaire that documented their gender, family status, children, employment level (working part or full time), age, years of working experience in our department). In addition to collecting demographic data, residents also completed the PSS and we documented the number of overtime hours (beyond 9.6 h per day) accumulated during the past 8 weeks. Residents then participated in the time-management workshop. Eight weeks after the workshop, residents once again completed the PSS and documented whether they experienced any stressful life events during the past 8 weeks. The number of overtime hours was also calculated for this 8-week period.
Statistics were analyzed using Statistical Package for the Social Sciences (SPSS), version 26.0 (SPSS Inc., Chicago, IL, USA). Our primary outcome measures included the average total PSS score and mean number of overtime hours worked. For each outcome measure, we conducted a 2 × 2 mixed measures analysis of variance, with Pre-Post (2 levels: preintervention vs. postintervention) as the within-subjects variable and stressful events (2 levels: Stressful events vs. No stressful events) as the between-subjects variable. Bonferroni corrections were applied to all multiple pairwise comparisons. Effect sizes were calculated using partial eta-squared (χ2) and the magnitude of these effect sizes was interpreted using classifications proposed by Cohen: small effect sizes ˜ χ2 < 0.02; medium effect sizes ˜ 0.02< χ2 < 0.13; and large effect sizes ˜ χ2 > 0.14 and d > 0.8.
| Results|| |
Of the 55 eligible residents, 30 (55%) volunteered to participate in the present study. Three residents were assigned to outpatient clinic after agreeing to participate in the study and were therefore excluded from the study. The remaining 27 residents were predominantly female (70%; n = 19), with a mean age of 30.3 years (standard deviation [SD] = 1.7). Majority of the residents reported being in a committed partnership (52%; n = 14), while 26% (n = 7) were single, 19% (n = 5) were married, and 4% (n = 1) were divorced. In addition, majority of the residents did not have any children (96%, n = 26). Nearly all of the residents (98%; n = 26) worked full time, with an average of 3.05 years (SD = 1.1) working in the department of internal medicine.
Stressful life events
Of the 27 residents who participated in the study, 13 (48%) reported experiencing a stressful life event during the 8 weeks following the time-management intervention. Four reported writing the Swiss licensure examinations, which is a requirement for being a specialists in Internal medicine, three reported a difficult family situation without any further specification, two residents reported relocation (change of residence), two reported the extreme working load at a specific ward, one reported completing a PhD dissertation, and finally, one reported a personal drop out at his ward.
Effects of intervention
There was an effect of pre/post on mean overtime OT scores (F [1, 25] = 7.158, P = 0.0.13, χ2 = 0.223). As shown in [Figure 1], mean OT scores were higher before the intervention (mean [SD] = 1.26 [0.68]) than after the intervention (0.916 [0.80]). There was no effect of stressful event on mean OT scores (F [1, 25] = 0.089, P = 0.768, χ2 = 0.004), nor was there a significant interaction (F [1, 25] = 0.35, P = 0.559, χ2 = 0.014).
|Figure 1: Effect of time-management intervention on mean overtime scores as a function of stressful life events. Error bars represent standard error of the mean|
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Perceived stress scale
There was no effect of Pre/Post on mean PSS scores (F [1, 25] = 1.61, P = 0.216, χ2 = 0.060). Surprisingly, there was no effect of Stressful event on mean PSS scores (F [1, 25] = 0.02, P = 0.892, χ2 = 0.001). There was, however, a significant interaction (F [1, 25] = 6.195, P = 0.02, χ2 = 0.199). As illustrated in [Figure 2], there was no difference in mean PSS scores for individuals who did not report stressful life events (Pre mean [SD] = 13.92 [5.58] vs. Post = 15.38 [5.38], t = 0.96, P = 0.356, Cohen's d = 0.266). However, for those individuals who reported stressful life events, pre-PSS scores were significantly higher than post-PSS scores (Pre = 17.14 [5.86] vs. Post = 12.33 [5.06], t = 2.467, P = 0.028, Cohen's d = 0.659).
|Figure 2: Effect of time-management intervention on mean perceived stress scores as a function of stressful life events. Error bars represent standard error of the mean|
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| Discussion|| |
The goal of the current study was to examine whether a time-management intervention focused on minimizing time wasters would influence the number of overtime hours worked and perceived stress in a group of internal medicine residents. The results of our study revealed several notable findings.
First, residents reported a significant reduction in the number of overtime hours worked in the 8 weeks following time-management intervention. Arguably, by teaching residents how to reduce potential time wasters, they were better able to manage the time spent on other important tasks. Indeed, prior research has demonstrated that time-management training can improve relevant skills such as planning and prioritizing behavior and reduce procrastination. A more recent study examined the effects of time-management training in nurse managers and reported significant improvements in self-reported time-management and task delegation skills.
Second, residents reported a reduction in self-reported stress scores following the intervention, but only if they experienced a stressful life events during the 8-week study period. This finding is somewhat consistent with prior research, which has found that time-management training can have positive effects on different indicators of stress.,,,, Building on this research, our study suggests that the positive effect of time-management training on perceived stress is moderated by the presence of stressful life events. More specifically, time-management training reduced perceived stress scores only for residents who reported experiencing stressful life events throughout the study duration; the intervention had no effect on perceived stress of residents who did not report the occurrence of a stressful life event.
One potential explanation for this finding is that time-management strategies lessen the impact of external stressors, and as a result, residents who reported experiencing stressful life events would particularly benefit from time-management training. In a recent study, Häfner et al. argued that time-management behaviors serve as a coping strategy to enable individuals to adjust to external stressors. According to these authors, time-management interventions help individuals develop better strategies for dealing with external stressors, thereby reducing levels of perceived stress. That is, “…through the use of the described time-management strategies, potentially stressful events can be anticipated and emotionally controlled resulting in positive effects on perceived stress” (p. 411). In this way, time-management interventions may be particularly helpful in reducing perceived stress measures in individuals who report experiencing multiple external stressors.
That being said, we cannot rule out that the reduction in perceived stress in residents reporting external stressors did not occur naturally. For example, some residents reported examinations as stressful life event and given that the examinations were completed a week prior to the second questionnaire, the reduction in PSS score could easily be attributed to the removal of the stressful life event (e.g., completion of examination) as opposed to the time-management training. Because we did not measure perceived stress at different time points throughout the intervention, we cannot rule out that the reduction in PSS scores may have occurred naturally.
There are several limitations to the study that need to be acknowledged. First, we had a small number of participants and did not include a control group. Therefore, our findings need to be examined in more depth with a larger sample of residents with an appropriate control group. Second, as previously mentioned, we cannot rule out the possibility that perceived stress decreased naturally in the external stressor group. Third, assuming the reduction in perceived stress was due to our time-management intervention, we are unable to speak to the mechanisms underlying the effect. That is, while we hypothesize that time-management strategies provide individuals with strategies to cope with external stressors, more research is needed to determine how time-management mediates perceived stress. For example, several studies have reported a relationship between time-management and perceived control of time, which relates to individuals' feelings of control over their workload.,,, According to these studies, the use of time-management strategies help individuals experience structure and gain feelings of control, thereby reducing stress. Other researchers have argued that time-management mediates perceived stress by promoting feelings of self-efficacy., Self-efficacy refers to the extent to which people believe they have the competence to successfully perform a given task. In this way, it is possible that time-management may foster feelings of self-efficacy and subsequently reduce perceived stress. The goal of the present study was to examine whether time-management training would reduce perceived levels of stress in residents, rather than identify potential mediators linking time-management to perceived stress. The identification of mechanisms underlying the influence of time-management strategies on perceived stress is an important direction for future research.
| Conclusion|| |
Our results add to the limited findings on the effectiveness of time-management training on overtime and perceived stress in physician trainees. That our intervention had significantly reduced overtime hours provides preliminary evidence on the benefits of time-management training in internal medicine residents. More research is needed to determine whether the impact of time-management on perceived stress is mediated by the presence of external stressors.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]