To stay or not to stay? A grounded theory study of residents' postcall behaviors and their rationalizations for those behaviors.

PURPOSE Although policies to restrict residents' duty hours are pervasive, resident adherence to restricted duty hours has proved challenging. The authors sought to describe residents' postcall behaviors and understand the dominant rationalizations underpinning their decisions to stay or not to stay after a 24-hour shift. METHOD Using constructivist grounded theory methodology, the authors conducted semistructured interviews with 24 residents across six surgical and nonsurgical specialty programs at one Canadian institution during 2012. They analyzed transcripts iteratively using a constant comparative method of identifying and refining key themes as the data set accrued, and theoretically sampling until theme saturation. RESULTS Abiding by cultural norms was the dominant rationalization for both choosing to continue to work postcall or to go home. Cutting across this dominant theme were three subcategories (infrastructure, invoking values, and negotiating tension) with a pattern of residents invoking similar values of patient safety and education regardless of the cultural norms of their program, the infrastructure within which they worked, or the tensions they were navigating. CONCLUSIONS Although central to residents' rationalizations, values appear to be versatile, amenable to multiple, even conflicting, applications. Residents perceived that they were upholding the values of patient safety and education regardless of which postcall behavior they chose-staying or going. Based on this, for duty hours reform initiatives to be successful, a shift to emphasizing organizational changes will be required to reduce the circumstances in which postcall behavior is an individual, values-based decision.