Pediatric hospital medicine (PHM) programs with nocturnists have more than doubled in recent years.¹ Consequently, more hospitalists face the hazards of overnight work, including sleep-related health risks, burnout, and attrition.2-11 Sleep impairment is closely linked to burnout, lower fulfillment, and increased self-reported errors, threatening workforce sustainability.⁵ In 2024, an American Academy of Pediatrics section on hospital medicine survey identified overnight coverage as the second most common concern in PHM.¹
Our PHM division at the University of Colorado School of Medicine in Aurora, now with more than 170 faculty, has doubled in size due to increasing patient complexity, economic pressures, regionalization, residency changes, and workforce shortages.12-16 Since implementing a nocturnist model in 2018, our institution has relied on nocturnists to admit and cross-cover multiple teams, manage escalations, teach learners, and triage transfers—essential to sustaining overnight care. Although occupational risks are well described, mitigation strategies and data on pediatric nocturnist burnout, retention, and sustainability remain limited.3,17,18
Solution Overview
To understand the experiences of faculty working overnight, we developed a mixed-methods evaluation with four objectives: (1) assess morale and mediators of job satisfaction and professional fulfillment; (2) measure cognitive load; (3) identify factors influencing sustainability; and (4) understand the lived experience of nocturnists.
Nocturnists were the primary participants, providing direct input that shaped both the process and outcomes of this project. Hospitalists and hospital leadership were key partners, supporting implementation and aligning findings with institutional goals. Hospital administrators and departmental leaders had vested interests given the financial and operational impact of staffing and turnover.19 Any changes made as a result of the information we obtained might also have implications for workload equity for other faculty, supervision of trainees, and overall patient care for nursing staff and patients.
Key Strategies
- Developed a mixed-methods needs assessment, combining validated survey instruments (Professional Fulfillment Index,20 Physician Task Load (adapted from the NASA Task Load Index22 as a measure of cognitive load),21 and Hospitalist Morale Index23) with demographic data.
- Conducted semi-structured interviews guided by SHM’s pillars of career satisfaction24 and triangulated findings with survey data to generate actionable insights.
- Convened a multidisciplinary staffing workgroup that used results to identify threats and opportunities in the staffing model, prioritize interventions, and specifically address nocturnist cognitive load.
- Partnered with divisional and financial leadership to share results and advocate successfully for additional full-time equivalents (FTEs).
This approach ultimately provided a robust, data-driven needs assessment that directly informed divisional planning and laid the foundation for interventions aimed at improving nocturnist sustainability and well-being.
Implementation Process
Planning for this initiative began in early 2024, with support from PHM leadership to ensure alignment with divisional priorities and institutional goals. From May through July, we administered an electronic survey to all nocturnists at our quaternary care children’s hospital using REDCap software. Survey items were adapted from validated instruments, including the Professional Fulfillment Index, Physician Task Load, and Hospitalist Morale Index, and were created and analyzed by our divisional survey methodologist.20,21,23 To enrich these findings, we conducted five semi-structured interviews. Interviews were recorded, transcribed, and analyzed using rapid qualitative methods, allowing triangulation with survey results and identification of themes not captured quantitatively.25,26
The project was led by the nocturnist lead and included hospitalists, PHM leadership, and a survey methodologist. The nocturnist lead coordinated the project, synthesized preliminary findings, and managed communications, while other participants contributed to survey design, dissemination, and methodological oversight. The group examined the cognitive load of nocturnists to inform actionable strategies to support well-being and workforce sustainability. Based on survey and interview data, we convened a multidisciplinary staffing workgroup to review findings, identify potential threats and opportunities in the staffing model, and prioritize interventions.
Obstacles and Solutions
Four major obstacles emerged during implementation. First, survey response fatigue was a challenge, as faculty receive multiple institutional surveys annually. We addressed this by framing the survey as a targeted needs assessment tied to programmatic change and leadership action.
Second, concerns about morale arose, with some fearing that discussions of workload and burnout could worsen well-being. We maintained a solutions-focused approach, validated experiences, and communicated transparently about next steps to build trust and encourage participation.
Third, advocating for additional FTE in a constrained financial environment was difficult. We combined survey and interview data with operational metrics, national benchmarks, and literature to demonstrate a clear link between nocturnist workload, sustainability, and institutional priorities.
Lastly, discussions about workload and support for nocturnists, who represent a small fraction of our large section, expanded into broader conversations about workforce equity across diverse roles and scopes of practice. A key challenge was that interventions aimed at improving the experience of nocturnists were sometimes met with resistance, particularly when they implied an added burden for daytime staff. While many daytime faculty expressed genuine appreciation for nocturnists, they also defended a status quo in which the personal and professional benefits of daytime schedules are more favorable. This dynamic underscored the importance of “shift equity,” the principle that fairness in staffing requires acknowledging and balancing the relative burden of work, including timing, duration, workload, and personal disruption, across providers. The literature reflects this imbalance: day shift employees report better well-being, career satisfaction, and work-life balance compared to their night shift counterparts.27,28 Daytime schedules may also allow greater participation in leadership, teaching, and committees, offering professional visibility and advancement less accessible to nocturnists.2,29,30 While many of these issues extend beyond the scope of this project, maintaining transparency and open dialogue has been essential to progress.
Outcomes and Impact
Survey findings highlighted substantial vulnerabilities in nocturnist well-being. Seventy percent of nocturnists reported being “pretty likely” or “very likely” to reduce their night work if given the opportunity, placing overnight coverage in a precarious position. Cognitive load was high, with a mean Physician Task Load (PTL) Index score of 339 out of 400; for context, a national study of over 4,000 physicians reported a mean PTL of 260, with pediatricians averaging approximately 253.21 Most nocturnists (75%) rated their shifts as mentally demanding, yet only 30% felt successful, and just 10% felt accomplished at the end of a typical shift. Burnout was prevalent, with 70% reporting persistent or definite symptoms. Satisfaction was mixed—40% reported being satisfied with their role, yet 90% indicated they would decrease nocturnist effort if given the opportunity. Nearly all nocturnists (89%) reported adequate career mentorship.
The Hospitalist Morale Index revealed the lowest satisfaction in institutional climate, family time, and workload (see Figure 1).23 Semi-structured interviews reinforced these findings, emphasizing the importance of shift equity, connection with colleagues, and transparency in decision-making. Participants identified opportunities to reduce cognitive load, including clarifying team member expectations, minimizing interruptions, and pacing admissions more evenly throughout the night. To support interpretation and guide planning, we created a figure modeling nocturnist sustainability, which has since informed division-wide well-being initiatives (see Figure 2).
Previously, nocturnists managed both admissions and cross-coverage, with only one swing shift provider available. Survey and interview data, combined with staffing workgroup discussions, supported adding a second swing shift provider to absorb evening admissions (see Figure 3). Hospital leadership approved this change and allocated additional FTEs, representing a tangible financial investment to support nocturnist well-being and workforce sustainability. Informally, nocturnists reported that winter months with extra swing coverage were well-received. Early operational data also suggest better alignment of staffing to peak patient volumes.
Beyond staffing, this initiative strengthened communication between nocturnists and the leadership of the section, department, and hospital. It also fostered a culture of transparency and created a framework for ongoing monitoring and improvement. By quantifying cognitive load, burnout, and morale while integrating faculty experiences, the project provides a robust evidence base to guide sustainable overnight coverage and prioritize physician well-being in PHM.
Lessons Learned
Several lessons emerged that may inform other hospitalist programs considering similar efforts. Early leadership engagement was critical for building trust with faculty and securing institutional support to translate findings into actionable change, including funding for additional FTEs. Involving division and departmental leaders from the outset facilitated alignment with operational priorities and strengthened advocacy.
Using a mixed-methods approach—combining validated survey instruments with qualitative interviews—proved highly effective. Quantitative data provided rigor and credibility, while qualitative insights added nuance, highlighting experiences and concerns that numbers alone could not capture. Framing the project as a needs assessment rather than an evaluation of individual performance encouraged participation, candid feedback, and transparency.
The initiative also highlighted the importance of regular conversations about shift equity and role expectations, particularly in a rapidly growing division. Adjustments to the nocturnist workload cannot occur in isolation—reducing responsibilities for one group affects others. Engaging faculty early, validating these impacts, and collaboratively reaching consensus about what is most equitable is essential for morale, fairness, and long-term sustainability.
Finally, sustainable improvements require structural solutions rather than relying solely on individual resilience. Adjustments such as redistributing admissions to a swing shift and clarifying expectations can reduce cognitive load and support retention. Pairing faculty experience data with operational metrics also strengthens the case for resource allocation, helping programs address workload, well-being, and workforce sustainability.
Overall, this project highlights the value of integrating faculty perspectives, data-driven analysis, and leadership engagement to create pragmatic, actionable, and sustainable interventions in PHM.
Future Directions
The immediate next step was to evaluate how the additional swing shift affects the nocturnist’s well-being. The results of this needs assessment informed a grant application to study the impact of the additional shift on physician task load, burnout, and job satisfaction in our nocturnists. Using repeated surveys, we will determine whether adding FTE for admission support meaningfully reduces overnight burden and improves well-being, guiding decisions about maintaining or expanding the intervention.
In parallel, we plan to track longitudinal trends in nocturnist experience—monitoring changes in fulfillment, morale, and workload demands to ensure interventions have a lasting effect.
Future work will also focus on clarifying expectations, streamlining overnight workflows, tracking interruptions, and enhancing professional development to support clinicians in their roles. Understanding how workload and well-being interact may provide insights that inform future planning.
Ultimately, this initiative will continue to inform divisional planning, guide resource allocation, and serve as a model for similar efforts in PHM divisions seeking to optimize overnight coverage while supporting faculty well-being.
Dr. Kilinsky
Dr. Pronko
Dr. Reese
Dr. Sedler
Dr. Lockwood
Dr. Anderson
Dr. Ziniel
Dr. Kilinsky is a nocturnist lead and assistant professor of pediatrics in the section of pediatric hospital medicine at the University of Colorado School of Medicine in Aurora, Colo. Dr. Anderson is associate medical director-resident teams, and assistant professor of pediatrics in the section of pediatric hospital medicine at the University of Colorado School of Medicine in Aurora, Colo. Dr. Lockwood is medical director for pediatric hospital medicine and associate professor of pediatrics in the section of pediatric hospital medicine at the University of Colorado School of Medicine in Aurora, Colo. Dr. Pronko is an assistant professor of pediatrics at the University of Colorado School of Medicine’s section of pediatric hospital medicine in Aurora, Colo. Dr. Sedler is an assistant professor of pediatrics and associate director of education in the section of pediatric hospital medicine at the University of Colorado School of Medicine in Aurora, Colo. Dr. Reese is professor of pediatric hospital medicine and vice chair for faculty well-being in the department of pediatrics at the University of Colorado School of Medicine in Aurora, Colo. Dr. Ziniel is an associate professor in the department of pediatrics at the University of Colorado School of Medicine and Children’s Hospital Colorado, both in Aurora, Colo.
Key Takeaways
- Nocturnists are an essential but vulnerable subset of the PHM workforce, facing high cognitive load and burnout.
- A mixed-methods needs assessment revealed significant risks to sustainability, with most nocturnists likely to reduce night work if given the option.
- Transparent, ongoing conversations about shift equity and role expectations are critical, as workload adjustments affect the broader team.
- Combining validated survey tools with interviews created a robust picture of nocturnist challenges and built leadership engagement.
- Findings led to the creation of an additional swing shift, aimed at reducing cognitive load by separating admissions from cross-coverage.
- Ongoing evaluation of this intervention will guide long-term workforce planning and support sustainable nocturnist models.
References
1. Barrett Fromme H, et al. Insights into the pediatric hospital medicine workforce: 2024 data and recent trends for programs. Hosp Pediatr. 2025;15(8):623-629. doi: 10.1542/hpeds.2025-008335.
2. Haber LA, et al. Acute medical care by nocturnists: a narrative review. J Gen Intern Med. 2025;40(7):1584-1589. doi: 10.1007/ s11606-025-09403-y.
3. Brown JP, et al. Mental health consequences of shift work: an updated review. Curr Psychiatry Rep. 2020;22(2):7. doi: 10.1007/s11920-020-1131-z.
4. Kancherla BS, et al. Sleep, fatigue and burnout among physicians: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2020;16(5):803- 805. doi:10.5664/jcsm.8408.
5. Trockel MT, et al. Assessment of physician sleep and wellness, burnout, and clinically significant medical errors. JAMA Netw Open. 2020;3(12):e2028111. doi: 10.1001/ jamanetworkopen.2020.28111.
6. Machi MS, et al. The relationship between shift work, sleep, and cognition in career emergency physicians. Acad Emerg Med. 2012;19(1):85-91. doi: 10.1111/j.1553- 2712.2011.01254.x.
7. Tomasko JM, et al. Sleep deprivation increases cognitive workload during simulated surgical tasks. Am J Surg. 2012;203(1):37-43. doi: 10.1016/j.amj-surg.2011.08.009.
8. Lund S, et al. NASA-TLX assessment of workload in resident physicians and faculty surgeons covering trauma, surgical intensive care unit, and emergency general surgery services. Am J Surg. 2021;222(6):1158- 1162. doi: 10.1016/j.amjsurg.2021.10.020.
9. Ki J, Choi-Kwon S. Health problems, turnover intention, and actual turnover among shift work female nurses: analyzing data from a prospective longitudinal study. PLoS One. 2022;17(7):e0270958. doi: 10.1371/journal.pone.0270958.
10. Smith-Coggins R, et al. Night shifts in emergency medicine: the American Board of Emergency Medicine longitudinal study of emergency physicians. J Emerg Med. 2014;47(3):372-378. doi:10.1016/j. jemermed.2014.04.020.
11. Atlas KR, et al. Why do nocturnists quit?: a mixed-methods assessment of nocturnist attrition. Journal of Hospital Medicine website. https://shmabstracts.org/abstract/why-do-nocturnists-quit-a-mixed-methods-assessment-of-nocturnist-attrition/. Abstract presented at SHM Converge 2024. Accessed March 6, 2026.
12. Roberts KB, et al. The history of pediatric hospital medicine in the United States, 1996-2019. J Hosp Med. 2020;15(7):424- 427. doi:10.12788/jhm.3381.
13. Hickman RJ. New ACGME peds program requirements present challenges and opportunities. The Hospitalist website. https://www.the-hospitalist.org/hospitalist/article/37015/pediatrics/new-acgme-peds-program-requirements-present-challenges-and-opportunities/. Published May 1, 2024. Accessed March 6, 2026.
14. Harrison WN, et al. Child health needs and the pediatric hospital medicine workforce: 2020-2040. Pediatrics. 2024;153(Suppl 2):e2023063678M. doi: 10.1542/peds.2023-063678M.
15. Kulkarni SA, Wachter RM. The hospitalist movement 25 years later. Annu Rev Med. 2024;75:381-390. doi: 10.1146/annurev-med-051022-043301.
16. Freed GL, et al. Resident work hour changes in children’s hospitals: impact on staffing patterns and workforce needs. Pediatrics. 2012;130(4):700-704. doi:10.1542/peds.2012-1131.
17. Li X, et al. Chronobiological disruptions: unravelling the interplay of shift work, circadian rhythms, and vascular health in the context of stroke risk. Clin Exp Med. 2024;25(1):6. doi:10.1007/s10238-024- 01514-w.
18. Hansen J, Lassen CF. Nested case–control study of night shift work and breast cancer risk among women in the Danish military. Occup Environ Med. 2012;69(8):551-556. doi:10.1136/ oemed-2011-100240.
19. Pappas MA, et al. Estimating the costs of physician turnover in hospital medicine. J Hosp Med. 2022;17(10):803-808. doi:10.1002/jhm.12942.
20. Trockel M, et al. A brief instrument to assess both burnout and professional fulfillment in physicians: reliability and validity, including correlation with self-reported medical errors, in a sample of resident and practicing physicians. Acad Psychiatry. 2018;42(1):11-24. doi:10.1007/s40596-017- 0849-3.
21. Harry E, et al. Physician task load and the risk of burnout among US physicians in a national survey. Jt Comm J Qual Patient Saf. 2021;47(2):76-85. doi:10.1016/j. jcjq.2020.09.011.
22. Hart SG, Staveland LE. Development of NASA-TLX (task load index): results of empirical and theoretical research. Advances in Psychology. 1988;(52):139-183. doi:10.1016/S0166-4115(08)62386-9.
23. Chandra S, et al. Introducing the Hospitalist Morale Index: A new tool that may be relevant for improving provider retention. J Hosp Med. 2016;11(6):425-431. doi:10.1002/jhm.2543.
24. Hinami K, et al. Worklife and satisfaction of hospitalists: toward flourishing careers. J Gen Intern Med. 2012;27(1):28- 36. doi:10.1007/s11606-011-1780-z.
25. Taylor B, et al. Can rapid approaches to qualitative analysis deliver timely, valid findings to clinical leaders? A mixed methods study comparing rapid and thematic analysis. BMJ Open. 2018;8(10):e019993. doi:10.1136/bmjopen-2017-019993.
26. Vindrola-Padros C, Johnson GA. Rapid techniques in qualitative research: a critical review of the literature. Qual Health Res. 2020;30(10):1596-1604. doi:10.1177/1049732320921835.
27. McElroy SF, et al. Shift work and hospital employees: A descriptive multi-site study. Int J Nurs Stud. 2020;112:103746. doi:10.1016/j.ijnurstu.2020.103746.
28. Ugwu LE, et al. Decoding the impact of night/day shiftwork on well-being among healthcare workers. Sci Rep. 2024;14(1):10246. doi:10.1038/s41598-024- 60882-1.
29. Reid MB, et al. Mentorship, productivtity, and promotion among academic hospitalists. J Gen Intern Med. 2012;27(1):23-27. doi:10.1007/s11606-011-1892-5.
30. Hanson JT, et al. The new education frontier: clinical teaching at night. Acad Med. 2014;89(2):215-218. doi:10.1097/ACM.0000000000000096.