Theme 1: The rewards and demands of being on-call.

In more than half of the studies across all occupations, there tended to be conflicting results with regards to participants’ evaluations of their on-call experiences (Cuddy et al., 2001; Imbernon et al., 1993; Smithers, 1995). To put differently, while being on- call was described as demanding, it was also rewarding and considered a “reasonable and important” part of the participants’ jobs (Bamberg et al., 2012, p. 310). The majority of studies which had as its main objective the exploration of participants’ perceptions of being on-call were conducted in the medical profession (e.g. Callaghan et al., 2005; Corriere et al., 2013; McDonald et al., 2005). Among these, the opportunity to provide comfort for the ill and continuity of care were identified as rewards of being on-call (Cuddy et al., 2001).

Team or ward relationships (including relationships with seniors) also seemed to influence the perception of participants’ on-call experiences. Three studies (Callaghan et al., 2005; Corriere et al., 2013; McDonald et al., 2005) addressed the value of team relationships within the context of the medical profession. With the exception of one (Callaghan et al., 2005), results revealed that being on-call provided the opportunity to improve team relationships (including relationships with senior doctors) which was believed to enhance learning and act as a buffer against the detrimental impacts of being on-call. In one study (McDonald et al., 2005), the majority of residents felt comfortable contacting their seniors at home for assistance. The authors concluded that when junior

doctors know that they can solicit the help of their seniors, their perceptions of their ability to handle on-call work improves and their stress lowers (McDonald et al., 2005).

Despite, the consensus that better team relationships were developed on-call, there was a disconfirming case. The senior house officers in Callaghan et al. (2005) felt that they did not feel as part of a team when on-call neither did they avail themselves of opportunities to liaise with medical and nursing colleagues. As a result, they described their on-call experience as “isolating” (Callaghan et al., 2005, p. 61). The difference in results may have been due to the context in which on-call work was provided in the studies. Unlike the homogeneous sample of participants in the other studies who remained at the hospital with their colleagues during the on-call period, and thus, might have had better opportunities to work together, some of the participants in Callaghan et al. (2005) were on distal call. Hence, they may not have had the same opportunities to work together with colleagues as those on proximal call.

Another reported benefit of being on-call was its educational value or the opportunities it afforded particularly junior doctors on proximal call to obtain practical clinical experience which they believed prepared them for their future careers as senior doctors (Callaghan et al., 2005; Corriere et al., 2013). While the fatigue associated with the demands of frequent on-call duties hindered private study time (Tucker et al., 2010), being on-call was thought to provide junior doctors on proximal call with valuable training experiences such as informal sessions with seniors and opportunities to manage unstable patients (Corriere et al., 2013). Being on-call, in the context previously described, was found to improve doctors’ confidence to make decisions and gave them

insight into what being a senior doctor would be like (Callaghan et al., 2005; Corriere et al., 2013).

Despite the opportunity to provide continuous care and comfort to the ill, foster excellent team relationships and gain clinical experience, medical participants described being on-call as tiring and stressful. Tiredness was particularly common among junior doctors and students who were on proximal call at night and seemed to be related to the frequency of these shifts (Corriere et al., 2013; Tucker et al., 2010). For example, the junior doctors in Tucker et al. (2010), on proximal on-call rotas structured in blocks of seven consecutive nights, reported more fatigue than those working three or four nights consecutively. The authors suggested that this was due to the lack of recovery between duties since fatigue was also associated with the number of rest days following consecutive nights on-call and with the length of the interval between shifts. Other studies revealed that increasing hours of active on-call duty had adverse impacts on the health and well-being of physicians including surgeons (Balch et al., 2010; Heponiemi et al., 2014).

However, in studies conducted on distal medical and non-medical participants, while fatigue was mentioned as a negative consequence of being on-call, it was not merely due to exposure to active on-call duty. In a study on on-call professionals from various occupations (Ziebertz et al., 2015), exposure to active on-call duty was not related to fatigue. The authors reasoned that the difference between their study’s findings and previous findings may have been due to the time at which their participants were on- call. Previous studies on the impact of exposure to active on-call duty have been mostly

carried out on participants who were on-call at nights. Night shifts have been shown to be negatively related to employees’ health and well-being (Ziebertz et al., 2015).

However, another explanation might have been due to the type of on-call provided (i.e. distal versus proximal). Proximal employees (especially doctors) are the first to respond and as such are essentially always faced with an emergency. Therefore, their exposure to active on-call duty would be relatively higher than those on distal call who are usually only called out in the event that proximal workers are unable to manage the emergency. The participants in Ziebertz et al. (2015) were on distal call and thus, their exposure to active on-call duty might have been too insignificant to have had a substantial impact on fatigue.

Electricity and gas supply on-call workers on distal call in Imbernon et al. (1993) reported that their tiredness was related to the “frequency of on-call shifts” (p. 1135). Frequency in this instance, did not merely describe exposure to active on-call duty but represented how often participants had to be on-call. This finding suggests that for distal workers it may be that the sheer expectation or preoccupation with being called out and not only active on-call duty is tiring. The reports of the transplant coordinators in Smithers (1995), some of whom were on distal call and the distal network administrators in Bamberg et al. (2012), support this explanation.

Several studies across the literature (e.g. French, McKinley, & Hastings, 2001; Lindfors, Heponiemi, Meretoja, Leino, & Elovainio., 2009; Lindfors et al., 2006) and in this review (e.g. Bamberg et al., 2012; Heponiemi et al., 2014; Ziebertz et al., 2015) have either reported on the effect of on-call work on stress or have characterised

participants’ evaluations of being on-call as stressful based on scores on various scales or measures. This has been mainly due to the quantitative research objectives and methods used in these studies. Thus, on-call stress was usually a tested variable and did not necessarily emerge as a theme in the participants’ responses. As such, the underlying meanings participants attached to their evaluation of being on-call as stressful were not always visible.

Nevertheless, in three of the studies included in this review (Cuddy et al., 2001; Rout, 1996; Smithers, 1995), participants (the majority of whom were on distal call) described their evaluations of being on-call as stressful. This was due to the disruptive impact it had on their family and social lives and its unpredictable nature. In one of these studies, which was based on qualitative traditions, a GP commented that “often what becomes stressful is not what you have to do but what you have to be available to do” (Cuddy et al., 2001, p. 287). These results were consistent with the reports of GPs who were men in another qualitative study by Rout (1996) as described in the quote below:

The uncertainty about the content of an on-call day makes me really unhappy. Any moment the telephone might ring. (p. 158)

Women GPs, on the other hand, found the role conflict and overload they experienced in attempting to meet their professional and personal commitments, stressful (Rout, 1996). These findings suggest that (based on their role expectations) there may be differences in the underlying meanings of on-call stress for men and women and perhaps in how they perceive their on-call experiences generally. However, as previously mentioned, differences in gender were either not identified as a research objective or

definitive conclusions within studies could not have been made due to the imbalanced nature of some samples.

As mentioned earlier, spouses’ perceptions of their experiences when their partners are on-call were only explored in three studies (Cuddy et al., 2001; Emmett et al., 2013; Rout, 1996). In these studies, the participants were spouses of doctors on distal call. Furthermore, with the exception of one (Rout, 1996), the spouses were predominantly women. As with their medical partners, spouses generally perceived their experience as tiring and stressful (Emmett et al., 2013). They also felt depressed, frustrated and angry (Emmett et al., 2013). This was primarily due to the impact of their partners’ call on their personal lives (including their careers) but also due to the lack of intimacy and communication with their partners, their partners’ detachment from the family during the on-call period, their workload, short-tempered moods and patients who intruded their homes (Cuddy et al., 2001; Emmett et al., 2013; Rout, 1996).

Yet, despite these negative perceptions, spouses believed that being on-call was beneficial to their partners because it provided them with opportunities to enhance their skills, gain “financial stability, [offer] community service and [provided] a sense of career satisfaction” (Emmett et al., 2013, p. 248). They also felt that there was an added advantage of having their partners at home during inactive on-call periods (Emmett et al., 2013). Spouses in Emmett et al. (2013) compared their experience now with a time earlier in their partners’ careers when their partners were on-call more frequently and were on proximal call. They concluded that in those times, there were more “destructive effects” (Emmett et al., 2013, p. 248). Yet, being on distal call meant that for these

workers, various aspects of their family and social lives were disrupted as is discussed in the following sections.