Over 70% of all hospitalist programs have nocturnists, according to the 2016 State of Hospital Medicine Report. For adult-only practices, this has increased to 72.3% from 46.1% in the 2012 State of Hospital Medicine Report.
While one can assert that most hospital medicine practices have nocturnists, not all nights are covered by nocturnists. Thirty-nine percent (39%) of adult practices report that nocturnists cover 100% of nights, and 9.2% report that less than 25% of nights are covered by nocturnists. So, there remains a great deal of variability in the widespread use of nocturnists for nighttime coverage.
Amanda Trask
Why is nocturnist presence continuing to increase?
Categorically, nocturnists are hospitalists who work primarily at night, providing in-house coverage for hospitalist admissions and coverage for patients cared for by the hospitalist group.
Other clinicians, such as nurses, patient care technicians, medical technologists, and radiology technologists, have worked night shifts for many, many years. The phenomenon of hospital-based physicians and advanced practice clinicians working only at night is reflective of the needs in an acute care environment.
There are many lifestyle benefits to being a nocturnist – raising a family during the day while working at night, working fewer hours for more pay, and being in high demand.
Nocturnists can also allow a hospitalist group to offer more flexible scheduling options and create career longevity within the group. Having a nocturnist can allow a group to offer other hospitalists a “day shift only” option and other flexible scheduling options that many seasoned hospitalists are looking for.
Demand
Because of the increasing demand, it’s becoming more difficult to find long-term nocturnists, and therefore permanent nocturnists are expensive to hire. As reported in the 2016 State of Hospital Medicine Report, groups with nocturnists may offer either a differential in the hours or shifts worked, or compensation, or a combination of both.
About half of nocturnists work fewer shifts, compared with non-nocturnists. Equally stated, about half of nocturnists work the same number of shifts as their day-only counterparts. Of those groups whose nocturnists work fewer shifts than their daytime counterparts, about 60% work 1%-20% fewer shifts.
Nearly 70% of groups with nocturnists pay nocturnists differently. The median pay differential is 15%. While this compensation differential is an increase since the 2014 report, it is on par with the 2012 report.
It should not be construed that every practice with hospitalists offers both fewer shifts and more compensation. In fact, there are many who may offer neither and develop other, more creative ways of recognizing the nocturnist differently, such as evaluating scheduled hours per shift (e.g., 8 vs. 10 vs. 12).
Responsibility
With more adaptation and remuneration for nocturnists comes more responsibility.
Working as a nocturnist can be grueling work. Many times nocturnists may be working alone, and with less support from consultants and fewer hospital resources at night. On the other hand, it’s quieter at night and there can be a strong camaraderie from the smaller team at the hospital at night.
Nocturnists, many times, must be comfortable working alone; they must have strong clinical skills, and may need to seek extra training. In fact, in some hospitals the nocturnists may be the primary, or only, physician covering in-house codes.
Nocturnists must also take responsibility to remain abreast of the quality initiatives of the hospitalist group and hospital, since many of the quality committee meetings and hospitalist group meetings typically occur during daytime hours. Nocturnists may need to make an extra effort to feel a part of the group by voluntarily participating in daytime group activities, so that they don’t feel like an outsider.
Nocturnists should take the lead in receiving hand-off each evening, and handing off each morning to the day shift. This will likely mean handing off valuable patient care information with more than a few of their hospitalist colleagues. This is so immensely important that national patient safety-focused organizations have emphasized it for many years.
Since four out of five hospitalist programs have a hospitalist on site at night, and the majority of those programs have at least some nocturnist coverage, designing hospitalist programs and staffing models that meet the patient care need of 24/7 in-house coverage is a necessity. Also, given the strong demand for nocturnists, more and more program leaders are being challenged to evaluate creative alternatives to provide sustainable hospitalist services.
Some examples of creative solutions for in-house night coverage are implementing telemedicine for admissions, cross cover, or both; expanding coverage by advanced practice clinicians; and staggering shifts to cover late evenings and early mornings.
Perhaps we’ll see more questions about how hospitalist groups are addressing this need in future surveys?
Amanda Trask, MBA, MHA, FACHE, CMPE, SFHM, is national vice president, Hospital Medicine Service Line, at Catholic Health Initiatives, Englewood, Colo.