1.1. Overview of the Patient Safety Practice

Fatigue is a safety risk in the workplace across industries,⁶ and consequently general principles and practices for fatigue risk management systems have been developed^7,8 and evaluated in different settings.⁹ This PSP topic was addressed in the MHS I report, which provided a broad review of workplace fatigue including studies across industries, as very little research had been conducted within healthcare settings at the time.¹⁰ The MHS I review covered interventions focused on hours of service (i.e., regulations limiting the maximum shift length or total hours worked, and comparisons of 8- versus 12-hour shift lengths), the direction and speed of rotation through shift work (i.e., shift rotation directions moving “forward” [day to evening to night] or “backward” [day to night to evening]; slow versus fast shift rotations), sleep hygiene education, work lighting, napping, and medical therapies (e.g., melatonin, sedatives, and stimulants). That report concluded that there was an insufficient evidence base within healthcare settings, but fatigue management interventions from other work domains had high face-validity, low likelihood of harm, and high ease of implementation. The hours of service and fatigue topic received a brief update in MHS II, focusing on evaluations of regulatory limitations on resident work hours.¹¹ Based on several systematic reviews of that literature, the MHS II review concluded that work hour limitations did not reduce mortality or improve safety; but there were fewer objective and self-reported medical errors with 16-hour shift lengths than with traditional 30-hour shifts. Patient safety risks due to fatigue and sleepiness of healthcare workers were not addressed in MHS III.

In the decade since the MHS II report, the high levels of burnout among clinicians have come into focus.^12,13 While burnout is complex, sleep deprivation has been implicated in the development and sustainment of high levels of burnout.¹⁴ The coronavirus disease of 2019 (COVID-19) pandemic may have amplified these issues in part due to atypical work schedules.¹⁵

In the prioritization process, the MHS IV TEP did not suggest alterations to past definitions of this patient safety risk or associated PSPs. However, due to the limited time and funding allocated for this rapid response, the report focuses on PSPs targeting clinicians rather than other healthcare workers because patient outcomes are more directly related to the performance of clinicians than to the performance of nonclinical healthcare workers. Clinicians are defined as any person providing healthcare to patients (e.g., physician, nurse, physician assistant, respiratory therapist, or pharmacist). The report also focuses on clinicians in acute care hospital settings because that is where interventions on shift schedules and fatigue risk management practices are most likely to have been conducted.

1.2. Purpose of the Rapid Response

The purpose of this rapid response is to summarize the most relevant and recent literature on PSPs focused on fatigue and sleepiness of clinicians related to hours of service and how these PSPs can be implemented. The report should be of interest to healthcare system and hospital leaders who are wrestling with concerns about clinician burnout.

1.3. Review Questions

1. What are the frequency and severity of harms associated with fatigue and sleepiness of clinicians due to hours of service?
2. What patient safety measures or indicators have been used to examine the harm associated with fatigue and sleepiness of clinicians?
3. What PSPs have been used to prevent or mitigate the harms associated with fatigue and sleepiness of clinicians due to hours of service and in what settings have they been used?
4. What is the rationale for the PSPs used to prevent or mitigate the harms associated with fatigue and sleepiness of clinicians due to hours of service?
5. What studies have assessed the effectiveness and unintended effects of the PSPs and what new evidence has been published since the search was done for the MHS II report in 2013?
6. What are common barriers and facilitators to implementing the PSPs?
7. What resources (e.g., cost, staff, time) are required for implementation?
8. What toolkits are available to support implementation of the PSPs?

2.1. Eligibility Criteria for Studies of Effectiveness

We searched for original studies and systematic reviews on Review Question 5 according to the inclusion and exclusion criteria presented in Table 1. As this review focuses on patient safety, we searched for studies and systematic reviews that report on clinical and patient safety outcomes. Work hours and fatigue risk management interventions also have intermediate outcomes for workers (e.g., well-being) and organizations (e.g., turnover and absenteeism), but these are out of scope for the current rapid response.

Table 1

Inclusion and exclusion criteria.

2.2. Literature Searches for Studies of Effectiveness

We searched PubMed and the Cochrane Library for systematic reviews and original studies published since the MHS II report in 2013 that address the review questions (Appendix Table A-1).

2.3. Selection of Studies

We used the AI Classifier Manager as a semi-automated screening tool to conduct this review efficiently at the title and abstract screening stage. The title and abstract of each citation were screened by a team member based on predefined eligibility criteria (Table 1), and then the AI Classifier Manager served as a second reviewer of each citation. The AI Classifier Manager generated a ranking score for each citation, based upon a training set of titles and abstracts screened first by team members. The threshold for the AI Classifier Manager to include citations was set at a ranking score of 0.5 or above (scale 0 to 1.0). The full text of each remaining potentially eligible article was reviewed by two team members to confirm eligibility. The data from eligible articles were extracted by a single team member who prepared a summary of the study, including author, year, study design, number of study participants, and main findings relevant to each of the review questions.

2.4. Risk of Bias (Quality) Assessment

For studies that addressed Review Question 5 about the effectiveness of PSPs, we used the Cochrane Collaboration’s tool for assessing the risk of bias of randomized controlled trials (RCTs) or the ROBINS-I tool for assessing the Risk Of Bias In Non-randomized Studies – of Interventions.^20–23

For RCTs, we used the items in the Cochrane Collaboration’s tool that cover the domains of selection bias, performance bias, detection bias, attrition bias, reporting bias, and other bias.^20,22 For nonrandomized studies, we used specific items in the ROBINS-I tool that assess bias due to confounding, bias in selection of participants into the study, bias in classification of interventions, bias due to deviations from intended interventions, bias due to missing data, bias in measurement of outcomes, and bias in selection of the reported results.^21,23 The risk of bias assessments focused on the main outcome of interest in each study.

For recent eligible systematic reviews, the primary reviewer used the criteria developed by the United States Preventive Services Task Force Methods Workgroup for assessing the quality of systematic reviews.²⁴

• Good – Recent relevant review with comprehensive sources and search strategies; explicit and relevant selection criteria; standard appraisal of included studies; and valid conclusions.
• Fair – Recent relevant review that is not clearly biased but lacks comprehensive sources and search strategies.
• Poor – Outdated, irrelevant, or biased review without systematic search for studies, explicit selection criteria, or standard appraisal of studies.

3.1. Number of Studies

Our search retrieved 3,319 unique titles and abstracts from which we reviewed 400 full-text articles for eligibility. We found 12 systematic reviews and 20 primary studies (reported in 21 articles) that met the inclusion criteria (Figure 1).

Figure 1

Results of the search and screening. *Total exceeds the number of citations in the exclusion box because citations could be excluded for more than one reason (i.e., both reviewers did not need to agree on reason for exclusion).

Figure 2

Number of included primary studies by year of publication and design. RCT = randomized controlled trial

3.2. Findings for Review Questions

3.2.5. Question 5. What Studies Have Assessed the Effectiveness and Unintended Effects of the PSPs and What New Evidence Has Been Published Since the Search Was Done for the MHS II Report in 2013?

A total of 12 systematic reviews met the criteria for inclusion. Of those 12 reviews, 11 reported the effects of work shift modifications or interventions on specific patient safety outcomes (incidence of medical errors or adverse events)^34–44 and 6 reported the effects on other clinical outcomes.^{38,40–42,44,45} Article types in reviews included, but were not limited to, randomized control trials (RCTs), non-randomized controlled trials, survey studies, observational studies, and meta-analyses. The clinician population in these SRs consisted of nurses, military and nonmilitary surgical teams, physicians, and residents. Of the 12 reviews, 5 reported findings for risk management practices and all 12 reviews investigated some type of work schedule modification. Reviews reported on outcomes including clinical and patient safety outcomes such as mortality, readmission, complications, or adverse events. Acute care settings included surgery, radiology, pediatrics, intensive care unit (ICU), and neonatal ICU, among others.

We also identified 20 primary studies in 21 articles. Eight of these studies (reported in 9 articles) prospectively assessed the impact of shift structure modifications on outcomes of interest, and a further 12 were cross-sectional studies evaluating differences in total hours or shift structure on outcomes of interest.

An overview of the included systematic reviews and primary studies is presented in Tables 2a and 2b.

Table 2a

Overview of the systematic reviews.

Table 2b

Overview of the included primary studies.

3.2.5.1. Clinical Outcomes (Mortality, Complications, and Readmissions)

Evidence for the association between work schedule modifications and clinical outcomes is mixed. One review found that limiting all resident physicians to 80-hour work weeks and 28-hour shifts was associated with an 11 percent reduction in mortality (p< 0.001).⁴⁴ Similarly, another review focusing on nurses found evidence that working more than 40 hours a week had an adverse effect on patient outcomes (medication error odds ratio [OR] 1.28 [95% CI: 1.10 to 1.49]; infection OR 1.14 [95% CI: 1.02 to 1.28]), as did increased overtime (urinary tract infection OR 2.53 [95% CI: 1.66 to 3.86]; decubitus ulcer OR 1.91 [95% CI: 1.17 to 3.11]), or having insufficient time away between shifts (pneumonia mortality OR 1.24 [95% CI: 1.03 to 1.50]; abdominal aortic aneurysm mortality OR 1.39 [95% CI: 1.11 to 1.73]).⁴² Supporting this, a meta-analysis revealed a significant weak association between extended duration shifts and increased patient mortality (OR 1.52 [95% CI: 0.75 to 3.07]).³⁸ Mixed results have been found between overtime and adverse patient outcomes,⁴² as well as reduced resident duty-hours and patient outcomes (e.g., mortality, morbidity, adverse events).⁴⁵ Finally, several systematic reviews failed to find any association between shift modifications and patient outcomes. One review found no difference between sleep deprived versus non-sleep deprived surgeons, due to overnight work or extended shifts, in patient mortality or postoperative complications, and findings on intraoperative complications and length of stay were mixed.⁴⁰ In another, no significant association was identified between reduced shift length and length of stay.⁴³ Additionally, another systematic review found no differences in length of stay, readmission rates, mortality, or codes associated with night floats.⁴¹

Eight primary studies (three trials, and five observational studies) reported mortality, complications or readmissions outcomes, including three RCTs. One RCT randomized medical residents to one of three teams, one compliant with the 2003 Accreditation Council for Graduate Medical Education (AGCME) duty hour regulations, and one of two different models compliant with the 2011 requirements, one with an overnight call shift every fifth day (Q5) and one with a night float schedule.⁵⁹ There were no differences in 30-day readmission rates between shift conditions.⁵⁹ The cluster-randomized non-inferiority iCOMPARE (Individualized Comparative Effectiveness of Models Optimizing Patient Safety and Resident Education) trial, including 63 internal medicine residency programs, found no differences in patient mortality between standard and flexible scheduling. Flexible scheduling did not impose maximum shift durations or minimum time off between shifts.⁶⁷

Additionally, the Flexibility In Duty Hour Requirements for Surgical Trainees (FIRST) trial, a large cluster randomized trial including 117 general surgery residency programs found that ‘flexible’ work hour systems were noninferior to the standard work hour systems compliant with ACGME policies in patient mortality or postoperative complications.⁶⁶ The flexible work hours intervention was required to maintain compliance with limitations of 80 total hours per week, 1 day off in 7, and on-call duty no more than every third night, but were not restricted on maximum shift length or minimum time off between shifts.

Five observational studies assessed the impact of work hours on patient outcomes. One study reported data from an intervention site in the FIRST trial described above, and, consistent with the overall study findings, found no differences in patient mortality for residents at their institution working under the flexible scheduling systems when compared to a representative national sample.⁶⁵ Another study found that patients in a general medicine service who were cared for by residents working more than 80 hours per week had increased length of stay and risk of ICU transfer, but not increased rates of mortality or 30-day readmission.⁵⁵

Using data from the American College of Surgeons National Quality Improvement Program, one study used a difference in difference approach to compare changes in a composite of death or serious morbidity, and secondary outcomes of postoperative complications and resident examination performance in the two years prior and following the 2011 ACGME duty hour restrictions.⁶¹ Across 23 teaching hospitals and 31 nonteaching hospitals, the duty hour reform was not associated with differences in general surgery patient outcomes.

One retrospective study of adult medical patients compared a handoff group (i.e., patients discharged within 7 days after a change in resident physician team) and a control group (i.e., patients discharged the third week of a four-week resident rotation) both before and after the ACGME 2011 duty hour regulation was implemented.⁶⁰ Prior to the 2011 policy, mortality in the handoff group was significantly higher than in the control group; however, after the 2011 policy implementation, this difference lost significance.

Another study evaluated the impact of the 2017 ACGME policy relaxing extended shift restrictions on patient, intern, and resident perceptions as well as clinical outcomes (i.e., ICU transfers, length of stay, readmissions, mortality and complications).³⁷ There were no differences in patient satisfaction or clinical outcomes, however, interns reported being less satisfied and more fatigued and residents reported more incorrect intern orders in the extended work hours system.

One study found no difference in mortality for patients undergoing percutaneous coronary interventions performed by sleep deprived operators (defined as operators performing a case between 7 am and 11:59 pm as well as a case the preceding night, between 12 am and 6:59 am).⁴⁸

3.2.5.2. Specific Patient Safety Measures (Incidence of Medical Errors or Adverse Events)

Evidence connecting work shift modifications (e.g., limiting total hours, changes to on-call schedule, limiting consecutive nights worked) and patient safety (e.g., medical errors, near-misses) is mixed. Several systematic reviews found evidence that increased medical errors are associated with night shifts,^{34, 40} and extended work shifts.^36,37 Specifically, medical errors were found to occur 12.1% more frequently during night or rotating shifts,³⁴ and risk of self-reported errors related to fatigue increased with more nights of work-related sleep disturbance (relative risk (RR) 1.25 [95% CI: 1.06 to 1.49]).⁴⁰ However, another systematic review found contradictory results, with one included primary study actually showing decreased diagnostic errors during night float.⁴¹ Additionally, a meta-analysis found that extended-duration shifts were weakly associated with serious medical errors (OR 1.65 [95% CI: 1.06 to 2.58]).³⁸

Limited shift durations and shorter work weeks were also found to be associated with improved patient safety in RCTs and observational studies.⁴⁴ However, other reviews found that duty hour restrictions had no association with serious medical errors⁴³ or on patient care.⁴¹ Another review found mixed findings between overnight work and extended shifts with medical errors.⁴⁰ Furthermore, a review on extended-duty shifts suggested that they may cause both cognitive (e.g., attention lapses, visual tracking errors, worsened recall) and physical (e.g., decreased motor skills, increased time to react to changes) errors by clinicians.³⁹ Another review examining the impact of surgical team sleep deprivation on cognitive performance found that sleep deprivation after 24 hour on-call periods is associated with an increase in errors and omissions.³⁵

We identified 12 primary studies that evaluated work schedules and patient safety outcomes, including two RCTs reported in three articles. In the RCT of residents described above,⁵⁹ nurse and resident perceptions of care quality were lower in the Q5 and night float conditions, to such an extent that the study was terminated early due to safety concerns. In a pediatric ICU setting, Landrigan⁶³ found that a shift structure intervention (eliminating extended shifts and cycling resident physicians through day and night shifts of 16 hours or less) was associated with significantly more serious medical errors made by physicians (RR 1.53) and unit-wide medical errors made (RR 1.56) than the control condition (night shifts followed by approximately 24 hours off duty, and then two or three consecutive day shifts). This finding was contrary to expectations. However, there was wide variability in the effect across the six study sites, and a secondary analysis controlling for patient loads per resident found no difference in safety outcomes across shift conditions. Resident sleepiness and attentional failures for this study were reported in a second article⁶⁴, which showed the control extended-duration work roster was associated with a significantly higher number of attentional failures (6.8 failures per 10 minute neurobehavioral assessment compared to 2.9 in the rapid cycling roster), reaction time (18% higher in extended-duration roster), and subjective sleepiness (9% higher in extended-duration roster) than the rapidly cycling work roster.

Three studies of resident physicians evaluated shift structure on patient safety outcomes. One study⁶² evaluated the impact of the 2011 ACGME policy change with a large national survey of resident physicians’ perceptions of safety. They found this policy, which was rescinded in 2017, was associated with a 32% reduction in resident reported medical errors, 34% reduction in resident-reported preventable adverse events, and a 63% reduction in resident reported medical errors resulting in patient death. All differences were statistically significant.

Using the Agency for Healthcare Research Quality (AHRQ) National Inpatient Sample, one observational study⁵⁸ evaluated the impact of the 2003 ACGME duty hour restriction policy limiting residents to no more than 80-hour work weeks on hospital-acquired conditions. They found that patients in the two years following the year of the policy change were 10% more likely to experience a hospital-acquired condition than in the two years prior to the policy implementation. This effect was predominantly in teaching hospitals.

A large prospective cross-sectional survey of 4,826 post-graduate year 2 or greater resident physicians found that, when compared to working 40 hours a week or less, working greater than 48 hours per week was significantly associated with increased risk for self-reported medical errors, and preventable adverse events and fatal preventable adverse events (ORs 1.61, 1.54, and 0.66). In addition, working between 60 and 70 hours a week more than doubled the risk of preventable adverse events (OR 2.93), and fatal preventable adverse events (OR 2.75), compared to working 48 hours or less. Working one or more extended shifts a month while averaging no more than 80 hours per week was associated with increased risk of these outcomes as well when compared to working 48 hours or less in a week (OR for medical errors of 4.01, preventable adverse events 3.84, and fatal preventable adverse events 3.67).⁵⁶

Three observational studies evaluated work hours for nurses and patient safety outcomes. One large cross-sectional survey of 3,710 pediatric nurses across 342 acute care hospitals⁵³ found that nurses working shifts greater than 13 hours reported significantly worse job outcomes (i.e., burnout, job satisfaction), and lower safety and quality of care for patients (i.e., nurse reported central line blood stream infections, urinary tract infections, patient complaints) than nurses who reported working shifts of 8 hours or less.

A retrospective study of 5,372 nurses triggering 420,706 near-miss medication alerts over the course of two years found that nurses working greater than 60 hours per week were more likely to trigger a near miss alert (4% weekly near-miss alert rate) compared to nurses working less than 60 hours (3% weekly near miss alert).⁵⁴

Another study evaluated the impact of mandatory nursing overtime protection regulations and hours worked on adverse patient events, surveying nurses from a state which had protections in place (West Virginia) and one that did not (North Carolina).⁵² Findings were mixed for the effect of mandatory overtime protection regulations, but when compared to nurses working 40 hours per week or less, nurses working more than 40 hours per week had increased risk of reporting involvement in adverse events (OR 14.36).⁵²

Four studies evaluated clinician sleep and safety outcomes. One prospective observational study of 30 emergency department nurses found that lower quality of sleep measured through actigraphy immediately before a 12-hour shift was associated with more minor self-reported errors during the shift.⁴⁷ The amount of sleep was not associated with errors.

One observational study evaluated differences between surgeons who were sleep deprived (defined as more than 2 hours of nighttime clinical duties the night prior to a procedure) and those who were not; no differences in errors between groups were found, though errors were uncommon in both groups.⁵⁰

Another observational study surveyed practicing neurointerventionalists and found that less than four hours of sleep was significantly related to more self-reported medical errors (OR 2.60).⁴⁹

A survey of 1,215 first year residents found that sleep durations less than six hours and work hours exceeding 70 hours per week were both associated with increased likelihood of self-reported medical errors.⁵¹ There was a significantly higher RR of self-reported medical errors for interns reporting short sleep duration (< 6 hours) at 3 months (1.3, p = 0.03) but a nonsignificant difference at 6 months. There was a significantly higher RR of self-reported medical errors for interns working 70 hours per week or more at both 3 and 6 months (RR 1.5, p < 0.01 and RR 1.4, p = 0.01, respectively).

3.2.5.3. Risk Management Practices

Less than half of the included systematic reviews investigated risk management practices. Results on the impact of risk management practices on patient safety and outcomes are mixed. One review focusing on the ergonomic design of workstations found that increasing ambient lighting was associated with decreased detection and identification errors for radiologists.³⁷ Another found no direct effect between breaks and patient safety, but found that increased breaks are associated with less missed care (e.g., hand washing, turning a patient). This could be meaningful as they also found that missed care had a significant negative effect on patient safety (i.e., falls with injury and medication error).⁴² However, another review found that protected time for brief sleep breaks (i.e., approximately 2 to 4 hours in duration) had no impact on patient care in a Veterans Affairs center or hospital settings.⁴¹

We identified no primary studies evaluating the impact of a fatigue risk management practice on outcomes of interest.

4.1. Interpretation of Findings

This rapid response identified 12 systematic reviews and 20 primary studies (reported in 21 articles) evaluating a patient safety practice (PSP) targeting patient harms associated with clinician fatigue and sleepiness due to long work hours. Consistent with the previous Making Healthcare Safer (MHS) II brief review on this topic, research on PSPs related to reducing the risks associated with clinician fatigue and sleepiness due to work hours continues to focus primarily on shift scheduling in physician trainee populations. All identified randomized controlled trials (RCTs) involved evaluating the impact of shift schedules compliant with different versions of the Accreditation Council for Graduate Medical Education (ACGME) duty hour regulations, and 7 of the observational studies also evaluated the impact of these policy changes. Studies involving practicing nurses or physicians were all observational.

Also consistent with MHS II, the evidence surrounding PSPs for mitigating the risks of fatigue and sleepiness due to duty hours remains mixed. The three RCTs on resident duty hour limitations included in this review generated conflicting findings. While the RCT for internal medicine residents found no difference in 30-day patient readmissions, self-reported patient safety was sufficiently lower in the two duty hour restricted conditions that they were terminated early (i.e., the study was halted due to safety concerns).⁵⁹

Two large cluster-randomized trials, one in internal medicine and one in general surgery residency programs, found a flexible scheduling system (which did not impose maximum shift durations or time off between shifts) to be non-inferior to scheduling systems compliant with the ACGME 2011 regulations.⁷² However, a trial in general surgery programs has been criticized on both ethical and methodological grounds.⁷³ Specifically, one interpretation of the meaning of the non-inferiority findings is that the ACGME should loosen regulations and give programs more discretion in flexibility, while others take the noninferiority to be evidence that the suspected risks of reduced continuity of care from reduced shift lengths is not meaningful.⁷³

Findings from the RCT in pediatric residents^63,64 first found that duty hour restricted scheduling systems had worse safety outcomes. However, follow-on analyses clearly demonstrated that the effects of fatigue on patient safety were not solely due to the amount of hours worked but to the intensity of workload experienced during those work hours.

Given the heterogeneity of findings, the ACGME duty hour policies remain contentious. Two prominent criticisms of the duty hour restrictions have been that they reduce educational opportunities for trainee physicians, and that they reduce continuity of care by increasing the number of patient handoffs as shorter shifts require more handoffs between clinicians.¹⁰ One included study showed decreased educational opportunities in duty hour restricted systems.⁵⁹ However, research has directly examined differences for physicians who trained under duty hour restricted systems and those who did not. No differences in patient complications⁷⁴ or mortality⁷⁵ were found for surgeons, though patients with surgeons who trained under duty hour restrictions did have longer length of stay, anesthesia time and increased cost.⁷⁵ No differences in mortality, readmissions, length of stay or cost was found for internists who trained under duty hour restrictions and those who did not.^75–77,45 One included primary study evaluated handoffs during resident team rotations prior to and after implementation of work hour restrictions and found that resident team transitions elevated risk of patient mortality, but this risk was significantly lower after the restrictions were in place.⁶⁰

The literature remains sparse on fatigue risk management practices beyond modifying work schedules. No primary studies were identified, and only three interventions (i.e., lighting, breaks, and naps) were mentioned in systematic reviews, each with a focus in only one study. Lighting and breaks showed beneficial effects, but brief protected time for sleep was not related to patient care outcomes. Given the complexity of shift scheduling, the mixed findings to date, and the paucity of research linking risk mitigation PSPs to safety outcomes, more research is needed in this area.

4.2. Limitations

We discuss limitations of the rapid response methods employed here as well as the literature on PSPs targeting clinician fatigue and sleepiness. First, rapid responses use streamlined processes to complete the effort in a short timeline. We only included primary studies and systematic reviews published between January 2013 and September 2023 that reported data on the impact of an intervention or strategy related to work hours on patient outcomes. Additionally, this rapid response report only focuses on acute care settings and studies based in the United States, which limits the generalizability to other settings and countries.

Findings from this rapid response revealed that there are several limitations to the literature on this topic, including a lack of evaluation of the impact of risk management practices on patient outcomes, inconsistent terminology, heterogeneity in both interventions and outcomes across studies, as well as the reliance on observational research making it difficult to draw strong conclusions from the literature. Information regarding the facilitators and barriers for the interventions and strategies identified is limited. Additionally, no primary study or review provided resources or toolkits for implementing these interventions.

This rapid response did not cover healthcare worker outcomes such as burnout or wellness or organizational outcomes like employee retention. This is important given overall concerns about the wellness of the healthcare workforce. Recent research from the World Health Organization and the International Labor Organization identified an increased risk of ischemic heart disease and stroke associated with working more than 55 hours a week.^78,79

4.3. Implications and Conclusions

The inconsistent findings from this body of research make it difficult to determine the most appropriate evidence-based policies for mitigating the risk of patient harm from clinician fatigue and sleepiness due to long work hours. Research remains inconsistent on the ability of PSPs to mitigate the risks of patient harm from clinician fatigue and sleepiness due to long work hours. Most studies focused on the resident physician population and work hour interventions. Higher quality studies are needed, particularly for practicing clinicians. Increased healthcare consolidation and shifts in employment models (i.e., more hospital employed physicians) may enable larger prospective studies of scheduling and fatigue risk mitigation strategies. Additionally, research is needed to develop fatigue risk management interventions beyond work hour restrictions or changes in shift structure. A recent Delphi study prioritized research needs for reducing risks of fatigue due to long work hours in the healthcare setting and identified developing better designs for work schedules and improving culture and leadership approaches to shift work and long work hours as the highest priority.⁸⁰

Appendix A. Methods

Appendix B. List of Excluded Studies Upon Full-Text Review

1.

Abera H, Hunt M, Levin JH. Sleep Deprivation, Burnout, and Acute Care Surgery. Curr Trauma Rep. 2023;9(2):40–6. doi: 10.1007/s40719-023-00253-9. PMID: 36721843. - Narrative or scoping review [PMC free article: PMC9880369] [PubMed: 36721843] [CrossRef]

2.

Actrn. Sleep health management for healthcare workers. http://www​.who.int/trialsearch/Trial2​.aspx?TrialID​=ACTRN12616000369426. 2016 PMID: CN-02440080. - No original data

3.

Alexander R, Waite S, Bruno MA, et al. Mandating Limits on Workload, Duty, and Speed in Radiology. Radiology. 2022 Aug;304(2):274–82. doi: 10.1148/radiol.212631. PMID: 35699581. - Narrative or scoping review [PMC free article: PMC9340237] [PubMed: 35699581] [CrossRef]

4.

Alfonsi V, Scarpelli S, Gorgoni M, et al. Healthcare Workers after Two Years of COVID-19: The Consequences of the Pandemic on Psychological Health and Sleep among Nurses and Physicians. Int J Environ Res Public Health. 2023 Jan 12;20(2)doi: 10.3390/ijerph20021410. PMID: 36674167. - Does not address fatigue and sleepiness of clinicians related to hours of service [PMC free article: PMC9859438] [PubMed: 36674167] [CrossRef]

5.

Alfonsi V, Scarpelli S, Gorgoni M, et al. Sleep-Related Problems in Night Shift Nurses: Towards an Individualized Interventional Practice. Front Hum Neurosci. 2021;15:644570. doi: 10.3389/fnhum.2021.644570. PMID: 33796014. - Narrative or scoping review [PMC free article: PMC8007770] [PubMed: 33796014] [CrossRef]

6.

Al-Hammouri MM, Rababah JA. Work family conflict, family work conflicts and work-related quality of life: The effect of rotating versus fixed shifts. J Clin Nurs. 2023 Aug;32(15–16):4887–93. doi: 10.1111/jocn.16581. PMID: 36369607. - Non-US study [PubMed: 36369607] [CrossRef]

7.

Al-Kofahi M, Mohyuddin GR, Taylor ME, et al. Reducing Resident Physician Workload to Improve Well Being. Cureus. 2019 Jun 29;11(6):e5039. doi: 10.7759/cureus.5039. PMID: 31501731. - No outcome of interest [PMC free article: PMC6721886] [PubMed: 31501731] [CrossRef]

8.

Amirian I, Andersen LT, Rosenberg J, et al. Working night shifts affects surgeons’ biological rhythm. Am J Surg. 2015 Aug;210(2):389–95. doi: 10.1016/j.amjsurg.2014.09.035. PMID: 25678472. - Non-US study [PubMed: 25678472] [CrossRef]

9.

An R, Li C, Ai S, et al. Effect of shift work on fatigue, reaction time and accuracy of nurses in the Department of Neurology: A cross-sectional observational study. J Nurs Manag. 2022 Sep;30(6):2074–83. doi: 10.1111/jonm.13665. PMID: 35510385. - Non-US study [PubMed: 35510385] [CrossRef]

10.

Anagnostopoulos F, Demerouti E, Sykioti P, et al. Factors associated with mental health status of medical residents: a model-guided study. J Clin Psychol Med Settings. 2015 Mar;22(1):90–109. doi: 10.1007/s10880-014-9415-2. PMID: 25554496. - No concurrent or historical comparison groups [PubMed: 25554496] [CrossRef]

11.

Anderson C, Ftouni S, Ronda JM, et al. Self-reported Drowsiness and Safety Outcomes While Driving After an Extended Duration Work Shift in Trainee Physicians. Sleep. 2018 Feb 1;41(2)doi: 10.1093/sleep/zsx195. PMID: 29281091. - No outcome of interest [PubMed: 29281091] [CrossRef]

12.

Angerer P, Schmook R, Elfantel I, et al. Night Work and the Risk of Depression. Dtsch Arztebl Int. 2017 Jul 16;114(24):404–11. doi: 10.3238/arztebl.2017.0404. PMID: 28669378. - No outcome of interest [PMC free article: PMC5499504] [PubMed: 28669378] [CrossRef]

13.

Arbour MW, Gordon IK, Saftner M, et al. The experience of sleep deprivation for midwives practicing in the united states. Midwifery. 2020 Oct;89:102782. doi: 10.1016/j.midw.2020.102782. PMID: 32554134. - Qualitative study with no quantitative data [PubMed: 32554134] [CrossRef]

14.

Arzalier-Daret S, Buléon C, Bocca ML, et al. Effect of sleep deprivation after a night shift duty on simulated crisis management by residents in anaesthesia. A randomised crossover study. Anaesth Crit Care Pain Med. 2018 Apr;37(2):161–6. doi: 10.1016/j.accpm.2017.05.010. PMID: 28882740. - Non-US study [PubMed: 28882740] [CrossRef]

15.

Asaoka S, Aritake S, Komada Y, et al. Factors associated with shift work disorder in nurses working with rapid-rotation schedules in Japan: the nurses’ sleep health project. Chronobiol Int. 2013 May;30(4):628–36. doi: 10.3109/07420528.2012.762010. PMID: 23445510. - Non-US study [PubMed: 23445510] [CrossRef]

16.

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Appendix C. Data Tables

Evidence Table C-1. Characteristics of included primary studies addressing fatigue and sleepiness of clinicians related to hours of service (MS Word, 442K)

Evidence Table C-2. Findings of included primary studies addressing fatigue and sleepiness of clinicians related to hours of service (MS Word, 441K)

Evidence Table C-3. Barriers and facilitators identified in primary studies addressing fatigue and sleepiness of clinicians related to hours of service (MS Word, 390K)

Evidence Table C-4. Risk of bias assessment for randomized controlled trials from included primary studies addressing fatigue and sleepiness of clinicians related to hours of service (MS Word, 397K)

Evidence Table C-5. Risk of bias assessment for non-randomized studies from included primary studies addressing fatigue and sleepiness of clinicians related to hours of service (MS Word, 423K)