Impact of a Pediatric Night Float on Medical Students’ Education: Clerkship Student Perspectives

We conducted a qualitative study using semistructured interviews of third-year medical students who completed a night float experience at an academic children’s hospital. We chose qualitative methodology because it is well suited to answer questions about informal learning in complex environments.¹³  We used grounded theory methodology, which is appropriate for research questions involving social interactions and in which data collection and analysis employ an iterative approach.¹⁴  Three investigators (K.S., M.E., and R.L.) were postgraduate year-3 pediatric residents and 1 (B.S.) was a pediatric hospitalist with experience conducting qualitative research. Participants provided verbal consent and the institutional review board approved the study protocol.

Medical students complete their inpatient pediatric clerkship (2–4 weeks) at a 434 bed, quaternary care, university-affiliated, freestanding children’s hospital. To better align with pediatric resident schedules, in 2015, the pediatric clerkship transitioned from intermittent night call to a night float model, in which students work up to 1 week of consecutive nights. In 2018, a hospital medicine nocturnist program that provides nightly coverage throughout the year was implemented. During the night float, students worked with either residents or a nocturnist.

Students who completed a night float from June 2019 to April 2021 were eligible for study inclusion. Eligible students were invited to participate in the study toward the end of each rotation. We sampled students throughout the academic year to allow for varying degrees of clinical experiences. As a result of cancelled inpatient clerkships because of coronavirus disease 2019, sampling was paused for several months during 2020. After clerkships resumed, sampling continued until analyses indicated that saturation was reached (the point at which analysis of new data does not produce further insight).¹⁴ 

Derived from situated learning theory, we developed a semistructured interview guide with probes (eg, how did that impact your learning?) to explore students’ perspectives on their role at night and how the night float impacted their learning and quality of life. The interview guide was iteratively modified to explore concepts that emerged from data analysis. The interviews were conducted by 3 investigators (K.S., M.E., R.L.) who were trained by the department’s vice chair of education. Nineteen clerkship students participated in interviews, each lasting ∼20 minutes in an institutional conference room. Investigators who performed interviews did not clinically supervise participating students. We collected student demographic data, and each participant received a $5 gift card as a token of appreciation. Data were audio-recorded and transcribed by an online transcription service (Rev.com) at https://www.rev.com.

In accordance with qualitative methodology, data collection and analysis were performed concurrently. We analyzed data with the constant comparative method.^14,15  Coding of transcripts began after the first 2 interviews. Investigators coded data in pairs (K.S./B.S., M.E./B.S., and R.L./B.S.), with 1 investigator (B.S.) maintaining coding consistency between the pairs. Each investigator coded the data and discrepancies were resolved by consensus. Through an iterative approach, initial codes were modified, and new codes were added to best reflect data content. After finalizing the coding list, investigators individually organized data into categories describing themes. All 4 investigators then, together, compared categories and resolved additional discrepancies. HyperRESEARCH (Boston, MA) was used to organize the data to facilitate construction of thematic summaries. Trustworthiness of findings was established by involvement of multiple researchers in data collection/analysis,¹³  debriefing student comments after interviews,¹³  and modified member-checking,¹⁶  in which we discussed the themes that emerged from our data with a similar group of 6 third-year medical students from the following academic year. To manage reflexivity, we collected data over time, which enabled investigators who periodically worked night shifts to analyze data through the lens of shared experiences while others maintained an outsider position.¹⁷  We also managed reflexivity by establishing trustworthiness of findings.¹⁸ 

We completed 19 student interviews; 13 students worked with residents and 6 worked with nocturnists (Table 1). Comments from students who worked on resident teams were similar to those who worked with nocturnists. Data analysis yielded 4 themes: professional identity formation (PIF), learning activities, clinical experiences, and work–life balance. Representative quotations are shown in text and in Table 2.

The night float provided clinical opportunities that contributed to student PIF. Many students described having a greater role with patient care tasks during the night float, compared with day shifts, which made them feel like a physician.

“In internal medicine, I struggled with taking on the role of primary provider. On nights [in pediatrics], I was able to step into that role because I thought my resident and intern were more appreciative of me, more grateful of me offering to do something” (student 11).

Having a role in patient care enabled students to practice their clinical reasoning skills and formulate plans of care. Skill development in these areas increased student confidence, which students felt was an important characteristic of physicians.

“One of the hardest things about becoming a physician is becoming confident in your ability to make decisions. On nights, I got to do that. You get to justify your decisions, which is not something I’ve gotten in a lot of other places in third year” (student 12).

Students described how being up in the middle of the night facilitated bonding with team members and helped further develop their sense of community.

“I enjoyed the camaraderie and the silliness, and making it feel like a home while you're in the work room, 'cause it's the night time and you're in it together” (student 2).

However, not all students felt the night float contributed to their PIF or learning, especially if they did not have a clear role.

“[At night], you feel like you’re not involved and not part of the team and you’re a burden. It makes you not want to learn. You’re like, I’m kind of miserable, just sitting in the corner. I can’t concentrate on actually learning” (student 16).

Still, students considered the night float as important exposure of resident life.

“It’s helpful to have the experience [night float] that everyone in residency will have. Getting to see what that looks like. I have a better idea of what’s expected, things to work on, so I don’t come into residency and have no idea what I’m doing” (student 15).

Students described the nighttime learning climate as less formal than during the day. Being the only student on a night team meant more patient care opportunities, which were diluted among multiple learners on day teams. Experiential learning that focused on admitting patients and developing differential diagnosis was a key driver of student education.

“On days, I have the history of present illness and I’m following the thought process. [At night], I liked being the first person to get a history. To exercise my brain and go through building a differential. It was good for my learning” (student 8).

Students received teaching from their supervisors and valued its individualized nature as they were the only learner on the team. Teaching by nocturnists may have had additional value.

“[Hearing how nocturnists] think about problems clinically, it feels like it carries more weight because they have more experience” (student 14).

However, some nights, minimal, if any, teaching occurred.

“They kept saying we should do teaching but teaching never happened. Maybe they don’t really want to, or they keep getting messages from nurses” (student 19)

Some students described receiving higher quality and more timely feedback on patient presentations, physical examination assessments, and written notes at night compared with day shifts.

“[During days], 2 hours later [after family-centered rounds], someone asks, ‘Can you give me some detailed feedback on my presentation?’ The feedback gets generic when it’s delayed. [On nights], I would present an admission, talk directly with the resident, and we could talk for 5 to 10 minutes, giving me formative feedback” (student 12)

Students who worked with the same night float team often developed meaningful relationships, which led to helpful feedback. However, students who worked with nocturnists, compared with resident teams, sometimes had less continuity.

“I had 3 different attendings within 5 days. I didn’t really get a relationship with any of them” (student 18).

Although some nights were slow, students described admitting more new patients during the night float compared with day shifts and were exposed to a greater number and diversity of patients.

“Three nights were really busy, and I did a lot of admits on my own, which was really helpful. Two of the nights, there were no admits and I didn’t do anything” (student 18).

Students learned the importance of good patient handoffs from the lens of the night team. When students had continuity with the same night team, they were able to demonstrate clinical skills and earn more patient care responsibilities.

“It helps if you can be there a couple nights and work with a team. To have that continuity, they can see what you’re capable of and they’ll let you do more, and they trust your exams more because they’ve worked with you” (student 10).

Adjusting one’s sleep–wake cycle, especially at the beginning of the night float, was challenging for students. Fatigue was common during the night float, with little time for anything but work and sleep.

“I would get home and automatically go to sleep and then sleep all day, and then get up and come straight here. I wouldn’t have time to hang out with anyone or study. I’d just be sleeping, or I’d be here” (student 11).

Students were occasionally sent home early in similar fashion by both supervising residents and nocturnists; this extra time at home helped some students maintain a good quality of life.

“Getting to go home early, I would go to bed, be awake by 10 am and not have to come in until 5 pm. I had time to spend at home, cook, shop, hang out with my girlfriend and our dog, and go to the gym” (student 15).

However, being excused early hampered students’ ability to transition to a nighttime schedule and develop a sense of community.

“The latest I was there was 2 am 1 night. It made me feel less necessary. I feel like they didn’t see me as someone to help. I’m not really part of a team” (student 19).

In this qualitative study, clerkship students described a night float that both positively and negatively impacted their education. Feeling like an integral member of the night team significantly influenced student experiences. Those who had a clear role admitted new patients, cross-covered hospitalized children from a large and diverse patient pool, and evaluated clinically deteriorating patients. This experiential learning enabled students to practice their clinical reasoning skills, which heightened their confidence levels. In contrast, students who did not feel included found the night float less educational. Teaching and feedback were inconsistent and depended more on supervisor workload than on feeling like a member of the team.

In situated learning, knowledge is obtained during the process of developing an identity through legitimate access to a community of practice,¹²  which has been defined “as a persistent social network of individuals who share and develop an overlapping knowledge base, set of beliefs, values, history, and experiences focused on a common practice.”¹⁹  However, our study highlights how students needed to join the community of practice from the outset to optimize their learning. This finding aligns with a proposal for communities of practice to serve as a foundational theory for medical education within which other learning theories (eg, situated learning) can provide the theoretical basis for integrated educational activities.²⁰ Figure 1 depicts a conceptual model illustrating the potential impact of a night float on student PIF and work–life balance.

Focusing on student PIF, defined as “thinking, acting, and feeling like a physician,”²¹  has been recommended by the Carnegie Foundation for the Advancement of Teaching.²²  In alignment with existing literature, students in our study described how admitting and cross-covering patients, and developing meaningful relationships with team members, contributed to their PIF.^4,23  Our study adds to these findings by describing how the night float can enhance self-confidence, felt to be an important physician characteristic, for students who had a clear role.

Students in our study also felt it was important to experience night shifts, knowing that will be expected of them during residency. Similar findings were reported from a survey of students on an internal medicine clerkship.⁸  In a study of surgical residents, feeling unprepared for residency was associated with inadequate exposure to night call during medical school.²⁴ 

Thus, experiencing a night float influences students’ perception of residency preparation. Yet, how to best incorporate night call during medical school remains unclear. Internal medicine clerkship directors felt overnight work was important for students to experience their future roles as interns; however, they placed greater importance of night call during subinternships than clerkships.²⁵  In summary, these findings suggest participating in night call is important for residency preparation, but further work is needed to determine the optimal night call schedule.

Our study begins to provide insight on student experiences working with nocturnists. Student experiences working with nocturnists were overall similar to those with residents. Students valued the individualized interaction and clinical expertise of the nocturnist. However, some students had limited continuity with the same nocturnist over the course of their night float. A paucity of literature exists on students working on attending physician-only teams. One previous study reported that medical students appreciated getting to work closely with the attending physician on a nonresident, internal medicine hospitalist rotation, similar to findings from our study.²⁶  Students may have greater opportunities to work directly with nocturnists because hospitalist overnight coverage has become increasingly used due to resident workhour restrictions, trainee supervision requirements, and a trend toward on-site coverage of inpatient wards.²⁷ 

This study has implications for medical education. Clerkship directors and clinical supervisors should recognize the importance for students’ education of needing to integrate into a community of practice, for which evidence-based guidelines are needed. Educators should be aware that shortening shifts for students, in an attempt to support work–life balance, may hamper student integration into the team. If students can successfully integrate into a team, a night float model may positively contribute to learning. Future research could explore the optimal amount of night call for students that supports their PIF and feelings of residency preparation. In addition, further research could compare the impact on student education from working with residents versus nocturnists.

This study had several limitations. This was a single-center study at a large quaternary care hospital, which may limit the transferability of our findings. Selection bias resulting from students who agreed to participate may have limited breadth of comments. Students had variable shift duration during their night float, which may have affected their experience. However, these varying shift lengths provided additional insight on education and work–life balance. Students’ perceptions of feeling like part of the team may have been impacted by factors such as team members’ personality characteristics; thus, student comments may have differed if they had worked with other supervisors. It is possible that differences in patient demographics and census during the coronavirus disease 2019 pandemic influenced student experiences after their return to inpatient rotations; however, comments were similar to those collected prepandemic. Finally, students did not work with both residents and nocturnists, which limited our ability to fully compare experiences working with these different types of supervisors.

Clerkship medical students described varied impact of a night float on their education. The night float was felt to be important experience to prepare for residency. Students’ integration into the night team was necessary for the night float to support their professional identity formation.

We thank J. Lindsey Lane, BM, BCh, and Mary Rocha, MD, MPH, for their assistance in preparing the original manuscript. We also thank Dr Kimberly O’Hara and Dr Jillian Cotter for their reviews of the manuscript.