Background: Nocturnist turnover is high at many institutions, leaving vacant positions, with potential impact on patient care and satisfaction, as well as substantial recruitment expenses. The reasons that nocturnists choose to leave their positions, and night work in general, have not been formally studied. We sought to gain deeper understanding about the reasons for nocturnist attrition at our institution.
Methods: A mixed methods study of former nocturnists from a large nocturnist program (27 FTE) at an academic cancer center was conducted. This included a survey, structured interviews, and analysis of staffing data for nocturnists who voluntarily left their night positions between 2013 and 2022. In March 2023, all former nocturnists were sent an anonymous email survey in REDCap about their reasons for leaving the position. This included 28 Likert-style items (5-point scale from “not important at all” to “extremely important”) about hypothesized reasons for leaving night work in categories including: workload, career development, health/well-being, and compensation. In 2019 the staffing numbers and salary were increased for nocturnists, and responses from those employed before and after the change were compared. A selection of participants was interviewed in more detail about their reasons for leaving. Annualized turnover rates were also calculated from staffing data. This study was approved by the Institutional Review Board.
Results: All 59 former nocturnists with available contacts were sent the survey. The survey was completed by 41 participants- a response rate of 69%. 85% of former nocturnists started the position immediately after residency. The factors that former nocturnists reported to be “very” or “extremely” important to their decision to leave the position were: plans to pursue fellowship training (62%), the physiologic hardship of night shifts (59%), and mental health hardships of night shifts (48%). They did not find the following factors to be “very” or “extremely” important: workload (12%), number of admissions (12%), number of cross-cover patients (17%), illness severity (10%), the emotional burden of caring for cancer patients (5%), inadequate compensation (12%), or lack of appreciation (13%), respect (20%), research opportunities (3%), mentorship (8%). There were no statistical differences in responses between those who were employed before or after 2019 in the importance of workload (p=0.2) or compensation (p=0.2) in their decision to leave. Interviews conducted with a selection of volunteers confirmed that the physical hardship (i.e., “always felt jet-lagged”) and impact on social life were major influences. Turnover has trended downward over time with a high of 70% in 2015 to a low of 20% in 2022.
Conclusions: At the study institution, the physiologic, mental, and social hardship of night shift work were the main contributors to nocturnist attrition, in addition to plans to pursue fellowship training. While compensation and workload were not perceived to be major influences on the decision to quit nocturnist work, turnover has decreased as these factors have been improved. Since the physical act of working overnight is seen as a significant driver of turnover, future interventions should target the total number of night shifts worked, or number of hours per shift, to reduce the burdens of night shift work.
