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com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Received: 22 October 2022 Revised: 13 December 2022 Accepted: 25 January 2023
DOI: 10.1111/vsu.13943

REVIEW

A narrative review of the impact of work hours

and insufficient rest on job performance

Michele A. Steffey DVM, DACVS-SA 1 |

Marije Risselada DVM, PhD, DECVS, DACVS-SA 2 |
3
Valery F. Scharf DVM, DACVS-SA | Nicole J. Buote DVM, DACVS-SA 4 |
5
Helia Zamprogno DVM, MS, PhD, DACVS-SA, DECVS |
Alexandra L. Winter BVSc, DACVS 6 |
Dominique Griffon DVM, MS, PhD, DECVS, DACVS 7

1
Department of Surgical and Radiological
Sciences, School of Veterinary Medicine, Abstract
University of California-Davis, Davis, Objective: This review discusses the scientific evidence regarding effects of insuffi-
California, USA
cient rest on clinical performance and house officer training programs, the associa-
2
Department of Veterinary Clinical
tions of clinical duty scheduling with insufficient rest, and the implications for risk
Sciences, College of Veterinary Medicine,
Purdue University, West Lafayette, management.
Indiana, USA Study design: Narrative review.
3
Department of Clinical Sciences, North Methods: Several literature searches using broad terms such as “sleep depriva-
Carolina State University College of
Veterinary Medicine, Raleigh, North tion,” “veterinary,” “physician,” and “surgeon” were performed using PubMed
Carolina, USA and Google scholar.
4
Department of Clinical Science, Cornell Results: Sleep deprivation and insufficient rest have clear and deleterious
University College of Veterinary
effects on job performance, which in healthcare occupations impacts patient
Medicine, Ithaca, New York, USA
5
Evidensia Oslo Dyresykehus,
safety and practice function. The unique requirements of a career in veterinary
Oslo, Norway surgery, which may include on-call shifts and overnight work, can lead to dis-
6
Merck & Co., Inc, Rahway, New tinct sleep challenges and chronic insufficient rest with resultant serious but
Jersey, USA
often poorly recognized impacts. These effects negatively impact practices,
7
Western University of Health Sciences,
teams, surgeons, and patients. The self-assessment of fatigue and performance
College of Veterinary Medicine, Pomona,
California, USA effect is demonstrably untrustworthy, reinforcing the need for institution-level
protections. While the issues are complex and there is no one-size-fits-all
Correspondence
Michele A. Steffey, Department of
approach, duty hour or workload restrictions may be an important first step in
Surgical and Radiological Sciences, School addressing these issues within veterinary surgery, as it has been in human
of Veterinary Medicine, University of medicine.
California-Davis, 1 Shields Ave, Davis,
CA 95616, USA. Conclusion: Systematic re-examination of cultural expectations and practice
Email: [email protected] logistics are needed if improvement in working hours, clinician well-being,
productivity, and patient safety are to occur.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2023 The Authors. Veterinary Surgery published by Wiley Periodicals LLC on behalf of American College of Veterinary Surgeons.

Veterinary Surgery. 2023;1–14. wileyonlinelibrary.com/journal/vsu 1

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2 STEFFEY ET AL.

Clinical significance (or Impact): A more comprehensive understanding of

the magnitude and consequence of sleep-related impairment better enables
surgeons and hospital management to address systemic challenges in veteri-
nary practice and training programs.

1 | INTRODUCTION causes of sleep insufficiency and their professional

impacts on veterinarians and physicians. Manuscripts
Insufficient rest has well-understood effects on human that focused on nonoccupational stressors that might
functioning,1 which in healthcare professions such as vet- impact sleep, general insomnia, nonoccupational circa-
erinary surgery impacts patient safety and practice func- dian rhythm disorders, parasomnia, hypersomnia, sleep-
tion. Occupational practices such as extended workdays, related breathing disorders, and sleep-related movement
on-call schedules, inadequate staffing levels, and poorly disorders were excluded.
scheduled overnight shifts result in lack of physiological
rest and recovery, with acute and chronic sleep deficits
affecting surgeons' performance. Too often, hospital sys- 1.2 | Labor law and veterinary medicine
tems rely on fatigued clinicians and trainees to cover ser-
vices without assessing potential impairment.2–4 While this The federal Fair Labor Standards Act5 created the right
topic is poorly discussed in veterinary-specific literature, to a minimum wage, overtime pay eligibility, child labor
veterinary surgeons should understand how fatigue affects standards for private and governmental employees, and
their capabilities and patient safety. The objective of this defined the workday (8 h) and week (40 h). These rights
review is to summarize the evidence documenting the apply to “any individual employed by an employer,” but
impact of occupational sleep insufficiency on functions rel- not to business owners, independent contractors, or vol-
evant to veterinary surgeons such as work performance, unteers.5 White collar or “professional” employees were
patient safety, and team dynamics. A secondary objective is also exempted from these mandatory overtime provisions
to suggest ways to mitigate the occupational pressures asso- under this legislation. When the law was enacted in 1938,
ciated with impaired performance and clinician burnout. most work involved physical labor, so the Act's focus was
on physical fatigue as the primary cause of reduced work
performance and safety. Because physical fatigue accu-
1.1 | Search strategy mulates steadily across the duration of physical work and
dissipates progressively during rest breaks, regulations
Two search procedures were followed to find publications focused on prescribing maximum durations for work
that informed the goals of this narrative review. One shifts and minimum durations for time off related to the
author (MS) searched online databases Medline and Goo- effects of physical labor.6 Healthcare professionals such
gle Scholar using combinations of “sleep deprivation and as physicians and veterinarians have been exempted from
veterinary” and “sleep deprivation and surgeon.” We these standards because their work was not perceived as
restricted the initial search to the past 5 years (2017– “physical”, which classified them as white-collar profes-
2022) to select contemporary evidence. Manual scoping sionals. In addition, attending physicians have histori-
focused on original research manuscripts, meta-analyses, cally practiced as independent contractors rather than
systematic reviews, and recent physician sleep society hospital employees. Exempt status has generally been
consensus statements. The paucity of profession-specific considered desirable within the medical profession, pro-
reports prompted us to expand the search to include the viding more autonomy to set individual schedules balan-
terms “sleep loss”, “sleep insufficiency”, “fatigue”, cing patient care and personal needs. However, this
“chronic”, “acute,” “performance impact”, “healthcare”, attitude has been evolving in response to changes in
“physician”, “resident”, “surgical”, “surgery”, “on call”, working patterns and corporate ownership. In addition,
“extended work hours” and “medical error.” We incorpo- white collar work, especially healthcare, is now recog-
rated fundamental research obtained by manual scoping nized as having equally consequential physical, physio-
of cited studies from articles identified in the initial logical, and mental health impacts as physical labor.
searches and subsequent date-unconstrained focused Resident clinicians lack the professional autonomy of
topic searches as needed to improve understanding. Eligi- an independent contractor as well as legal protections
bility criteria included peer-reviewed, full-text articles associated with student classification (rather in most resi-
written in the English language examining occupational dency programs they are hospital employees who are also
 1532950x, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13943 by CochraneUnitedArabEmirates, Wiley Online Library on [26/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
STEFFEY ET AL. 3

apprentice trainees), exposing them to excessive work been reported after 28 hours without sleep or a blood
hours. The impacts of long work hours by resident alcohol concentration of 0.10%.17 As a reference, a blood
physicians on patient care and safety were broadly alcohol concentration of 0.08% is considered legally
re-evaluated by the public and the medical profession after drunk in most U.S. states. The performance of clinical
a highly publicized patient death in 1984. This incident and nonclinical tasks by physicians working consecu-
and subsequent discussion led to the enactment of the tively for 24 hours was rated 1.5–2 standard deviation
Libby Zion law, legally mandating resident physician work below that of rested individuals in a meta-analysis of sleep
hour restrictions in New York state. Work hour restrictions loss and physician performance.18 In another study, sleep-
for resident physicians were subsequently enacted nation- ing ≤6 hours per night (χ2 = 4.34, relative risk(RR) = 1.3)
ally in 2003 by the Accreditation Council for Graduate or working ≥70 hours weekly (χ2 = 8.74, RR = 1.5) were
Medical Education (ACGME). However, these restrictions associated with higher rates of medical errors among phy-
remain controversial as they were not fully data-driven sicians.19 In this study, each hour of sleep reduction corre-
and do not include all physicians.7,8 The current culture in sponded to a 27% increase in the odds of reporting medical
medicine tends to venerate sleep deprivation as a sign of errors (odds ratio (OR) = 1.27, 95% CI = 1.27–1.53).19
strength, dedication, ambition, and endurance.9,10 “Sleep Surgeons who were awake the night prior to testing took
is for the weak” or “I'll sleep when I'm dead” are refrains 14% longer to complete a simulated laparoscopic task and
of a machismo culture10 perpetuated through all levels of made 20% more errors than colleagues who slept undis-
medical and veterinary training programs. turbed.20 In another study of 220 surgeons and gyne-
cologists, sleep restriction (<6 h) was associated with
complications in 82/1317 (6.2%) post-night duty procedures
2 | S LE E P L OS S A ND compared to 19/559 (3.4%) when physicians had more than
OCCUPATIONAL IM PACTS 6 hours of sleep (OR = 1.72, 95% CI = 1.02–2.89).21

Quantitative sleep loss is most commonly characterized as

either acute continuous loss (sleep deprivation) or chronic, 2.1.2 | Chronic sleep loss
partial loss or restriction. However, this classification does
not fully characterize insufficient rest, which also encom- Chronic sleep insufficiency often goes under-recognized,
passes disruption of sleep continuity, irregular sleep sched- but leads to similar, dose-dependent reductions in cognitive
ule, circadian disruption, extended work hours, after-hours performance as acute sleep deprivation. Even a mild acute
shifts, and on-call duty.1,11 Regardless of its cause, insuffi- reduction (of only a few hours) of sleep over a few days
cient rest has dose- and time-related cognitive and emo- can impact neurobehavioral function. For example, sub-
tional effects affecting function in the clinical setting. jects undergoing a 10-day period of daily 30% sleep reduc-
Impairments affect emotion regulation and recognition, tion universally exhibited deterioration in all recorded
executive function and decision-making, as well as capacity behavioral, motor, and neurophysiological measures.22 A
for risk–benefit analysis. Associated signs in affected indi- week of recovery subsequent to the studied sleep restriction
viduals include increased risk-taking behavior, reduced did not fully restore function.22 In another study, sleeping
higher cognitive functioning and throughput, reduced mul- <6 hours/night and <4 hours/night for 2 weeks resulted in
titasking abilities, and reductions in attention, alertness, cognitive abilities similar to individuals with one and two
and memory, with increases in sleepiness and fatigue.12–16 nights of total sleep deprivation, respectively.23 Impor-
tantly, these individuals did not perceive their level of
sleepiness despite objectively measured performance defi-
2.1 | Extended work hours, acute and cits, illustrating the inability of individuals with chronic
chronic sleep loss sleep insufficiency to detect their own impairment.23 In
physician house officers, response times deteriorated both
2.1.1 | Acute sleep loss over a single 24–30 hour shift and also cumulatively with
successive overnight/extended work shifts.24 The exacerba-
Acute sleep insufficiency is generally defined as a reduc- tion of performance loss when chronic sleep deficiency is
tion in the usual total duration of sleep over a short superimposed with acute deprivation can be extrapolated
period (usually 1–2 days), with an awake state extending to periods of after-hours duties for surgeons who may
beyond 16–17 hours/day. An individual who remains already be chronically sleep restricted for professional or
awake for 17 hours has the same cognitive performance personal reasons. By contrast, increased alertness and
as someone with a blood alcohol concentration of reduction in medication errors have been documented
0.05%.17 A similar decline in hand-eye coordination has when continuous duty is limited to 16 hours.25,26
 1532950x, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13943 by CochraneUnitedArabEmirates, Wiley Online Library on [26/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
4 STEFFEY ET AL.

2.1.3 | On-call and overnight shifts cognition, grogginess, and disorientation commonly
experienced when awakening.33 Sleep inertia is particu-
Healthcare needs are not limited to regular business hours, larly relevant to surgeons, who are required to complete
requiring extended coverage via either 8–12 hour long shifts, complex processes immediately after waking at night,
or on-call duty rotas. Workers assigned to after-hours shifts including evaluative thinking and quick, high-impact
cover a set number of nontypical hours (commonly charac- decision-making. These effects are most apparent during
terized as occurring between 6 p.m. and 7 a.m.), with defined the initial 10–15 minutes after awakening; they can
periods of rest in between shift assignments. By contrast, off- take hours to dissipate and are more pronounced when
site or “home” on-call duties are commonly used as an alter- combined with sleep debt.34,35 The impairment of sleep
native to provide veterinary surgical care out of regular busi- inertia is occupationally relevant, as changes in cognitive
ness hours. Clinicians may sleep while on-call but must be performance are comparable with those due to alcohol
reachable and available to work if needed. However, home intoxication and can exceed those seen after 24 hours of
on-call time is not physiologically equivalent to rest time. continuous wakefulness.33 Clinicians making vital decisions
While on call, individuals experience disrupted sleep and shortly after waking up are predisposed to fatigue-related
poor quality rest, whether called to duty or not.27,28 In addi- errors. This evidence should prompt health organizations
tion to sleep loss, the employees' experience of being on-call to question the value of on-call duties and consider struc-
translates into stress, fatigue, work-home interference, and tured shifts to provide quality after-hours medical care.28
high work strain.29 In a study of 34 pediatric residents, indi-
viduals assessed after on-call duties sustained deficits in
attention, vigilance, and driving abilities that are comparable 2.3 | The fatigue paradox
to those associated with blood alcohol levels of 0.04%–
0.05%.30 The impacts of extended duty hours were demon- Healthcare team members are generally reluctant to
strated in a study of 20 medical interns who slept 5.8 hours acknowledge the negative impact of fatigue on patient
per week more (p < .001) and exhibited a >50% reduction in care. Contrary to published evidence, most clinicians are
attentional failures (p = .02) when on a limited duty hours not cognizant of the inaccuracy of one's own assessment
schedule (mean weekly work hours = 65.4, range = 57.6– of fatigue-related impairment and underestimate the cog-
76.3) compared to the traditional schedule (mean = 84.9, nitive impact of their own sleep restriction. Instead, they
range = 74.2–92.1).25 Surgery residents on call for 17 hours tend to overestimate their own performance readiness
and with disturbed sleep performed more unnecessary while sleep restricted, a phenomenon termed the “fatigue
movements and committed twice as many errors during paradox.”15,36 This paradox was detected in residents par-
simulated laparoscopic procedures than well-rested peers.31 ticipating in a sleep study: When asked whether they had
Sleep debt accumulates rapidly when on-call duty is com- fallen asleep during formal study testing, their self-
bined with regular day scheduling. Cognitive and neurobe- perception of whether they had remained awake or not
havioral consequences of chronic partial sleep insufficiency was no better than chance.37 The common belief that
are difficult to overcome and last longer than one might fatigue-related impairment can be overcome by motiva-
expect.22 Fatigue impacts empathy and executive function- tion and personal stamina is not supported by evidence.
ing, exacerbating workplace tensions and stressors, extend- Instead, several reports document the inability of human
ing its impact beyond the sleep-deprived individual. beings to adapt or “learn to function” on inadequate
Although poorly documented, several factors, such as sleep.16,38 This fatigue paradox is sustained among
genetics, gender, and age, seem to influence the stress healthcare professions by the construct of ‘the indefatiga-
caused by on-call work.1,32 Younger workers seem more ble clinician,’ dismissal of fatigue-related events, and
susceptible to a single night of acute sleep loss, whereas framing of fatigue as a personal failure, contrasted by the
older workers are more vulnerable to sequential sleep celebration of fatigue as evidence of hard work.36 In a
loss.1 Individuals exhibit considerable intrinsic differences recent publication, clinicians felt confident that their
in sleep needs and patterns, which are further influenced methods of practice ensured that fatigue did not affect
by a complex interplay between chronological age, matu- patient care, but conversely, acknowledged their ten-
ration stage, concurrent medical illness, behavioral, envi- dency to deviate from their usual practices when tired.36
ronmental, and social factors, all fluctuating with time.1 The veterinary profession has not yet assessed the causa-
tive role of fatigue when reviewing adverse events or near
misses, although fatigue is among the first considerations
2.2 | Sleep inertia when undesirable outcomes are audited in other profes-
sions.39,40 The absence of explicit discussions about
Functionality during on-call duties may also be impacted fatigue contributes to the blind spot maintaining the
by sleep inertia, described as a state of impaired fatigue paradox in healthcare.36
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STEFFEY ET AL. 5

3 | H O U S E O F F I C ER TR A I N I N G of sleep per night during clinical weeks compared to off-

PROGRAMS clinic rotations, sleeping approximately 6 hours/night
after 11–13 hour workdays.2 Most assessed that fatigue
3.1 | Human medicine had affected their technical skills, clinical judgment, and
ability to empathize at some point during the 4 weeks
Physician residency programs must adhere to the maxi- preceding the survey.2 Eighty percent of those respon-
mum weekly work hours required by the ACGME to dents also reported sleeping <7 hours/night when on
maintain accreditation in the U.S. These regulations, clinic duty, with poorer quality of sleep when on-call.2
established in 2003, were revised in 2011 and again in The number of reported hours worked per day was nega-
2016. The current ACGME regulations are outlined in tively associated with sleep quantity (Pearson's correla-
Table 1. tion coefficient =
0.54; p < .01).2 Small animal surgery
residents were more likely to work 7 days/week than
other residents (OR = 9.17; 95% CI = 3.93–21.43;
3.2 | Veterinary medicine p < .001) and were more likely to receive ≥3 calls/night
(OR = 4.96; 95% CI = 2.25–10.93; p < .001).2 Conversely,
No guidelines have been established regarding work only 6% of house officers felt that their training program
hours for U.S. veterinarians. In a recent survey of veteri- did not interfere with their sleep schedule in the preced-
nary house officers, most reporting working 11–13 hours ing 4 weeks.2 While most house officers (68% [198/290])
per weekday, and approximately one-third had clinical reported that their current sleep habits were somewhat or
responsibilities 7 days/week.2 The number of consecutive much worse than prior to their program, small animal
workdays and the frequency of late finishes are known surgery residents were even more likely to report “much
to affect fatigue levels.50 House officers working 8– worse” sleeping habits (OR = 4.33; 95% CI = 2.01–9.33),
10 hours/day were more likely to report ≥7 hours of sleep and that their training program “extremely” interfered
(Pearson's correlation coefficient =
0.54; p < .001).2 In with current sleep habits (OR = 4.12; 95% CI = 1.75–
the same survey, house officers reported reduced duration 9.69).2 In another report, veterinary trainees in corporate

TABLE 1 Best scheduling practices in human healthcare and other industries at risk for fatigue impacting human health and
safety.41–49

Minimum
Maximum Maximum consecutive rest
work consecutive work time between Minimum Other
time/week hours shifts time off/week specifications
US railroad 6 d consecutive 12 h 8–10 h
operators
US airplane pilots 34 h flight time 8–10 h flights, 16 h 10–12 h 10 h minimum
(1–2 pilot total duty rest
airplanes) immediately
before duty
US interstate truck/ 60 h 10–11 h driving, 8–10 h 34 h consecutive
bus drivers 14–15 h total duty every 7 d
US nuclear power 72 h 16 h 8h 34 h consecutive
plant operators every 9 d
Physicians: 48 h 13 h 11 h
European Union
and UK
Physicians: 50 h 10 h Minimum of 8 h 24 h consecutive
Australia continuous sleep every 7 d
Physicians: US 80 h 24 h (+4 h if needed 10 h 24 h consecutive On call not
to manage every 7 d scheduled more
necessary care than 1 in every
transitions) 3 nights

Abbreviations: d, days; h, hours.

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6 STEFFEY ET AL.

and private practice received 2–3 more days off per and is accepted as the working standard for all hospi-
month and 3–4 hours more sleep in the prior 48 hours tal doctors and trainees. Monitoring the health of phy-
than those in academia.51 Forty percent of trainees sicians exposed to after-hours work and extended
expressed concerns over making major medical errors in working hours is also recommended. 43 Physician work
the 3 months prior to the survey.51 Current evidence sug- hours are not nationally regulated in Canada; instead,
gests that programmatic moderation of veterinary surgery contracts are negotiated between residents' associa-
resident working hours is needed. Discussion on whether tions and the provincial jurisdictions in which they
acceptable limits should also be clarified at the national train.59
level (similar to the ACGME regulations for resident phy-
sicians) or left to individual program oversight is
warranted. 5.2 | Regulations of physicians' schedule
in the United States

4 | R IS K M A N A G E M E N T The duration of work performed by nonresident physi-

cians is not monitored or regulated by most U.S. medical
Analyses of human error focus either on the person or institutions. However a 2016 review found that physician
the system.52 In the first case, the blame is placed on residency programs implementing duty hour restriction
an individual whereas the second approach accepts interventions and allowing time for them to take effect
that humans are fallible and focuses on building prior to assessment identified improvement in patient
defenses into the system to increase safety. The ‘blame safety and resident well-being.60 In a study of 15 276 resi-
culture’ has long been the typical style of risk man- dent physicians comparing cohorts before and after
agement in U.S. healthcare, including veterinary ACGME duty reform, motor vehicle crashes were
medicine. While mistakes and near misses occur, fear reduced by 24% (RR = 0.76, 95% CI = 0.67–0.85), percu-
of punishment inhibits disclosure and discussion.53 taneous injuries by more than 40% (RR = 0.54, 95%
Medical errors, adverse events, and near misses likely CI = 0.48–0.61), and attentional failures by 18% (inci-
occur at similar rates in veterinary medicine than in dence rate ratio = 0.82, 95% CI = 0.78–0.86).61 Although
human healthcare, but lack of reporting prevents sta- aiming in the right direction, ACGME regulations are not
tistical analyses, development of classification tools, founded on ethical and evidence-based practice, prompt-
and understanding of the causes and predisposing fac- ing debate regarding the magnitude of restrictions pro-
tors.39,54–57 Fear and belief that incident reporting will posed.7,62–64 Changing these regulations may be impeded
make no difference are cited as the two most impor- by cultural norms and concerns about discontinuity of
tant barriers to error reporting, affecting individual care, apprehension of the possibility of reduced case
and organizational learning, and therefore prevention exposure affecting resident training, fiscal concerns, and
of recurrences.39 insufficient evidence of reductions in medical error rates
or resident stress in some studies.3,40,65–68
Long working hours during clinical training programs
5 | R E G U L A T I O N S RE L E V A N T T O have traditionally been considered inevitable to ensure
T H E SC H E D U L I N G OF CL I N I C A L competency and instill professionalism. Surgeons have
DUTIES voiced concerns about possible compromise in the quality
of resident training and operative experience if working
5.1 | Regulations of physicians' schedule hours are limited during the set number of years assigned
in Europe and Canada to the program.3,65,68 As a result, many physician training
programs have implemented the ACGME duty hour
In Europe and the United Kingdom, physicians follow restrictions in manners that have used a workload com-
the European Working Time Directive (details pro- pression strategy (attempting to fit similar clinical
vided in Table 1). While these physicians may work responsibilities into fewer working hours).69 Workload
longer hours than specified by signing an opt-out compression, however, increases risks of fatigue and
clause, this option is only recommended for indepen- burnout, and a variety of aspects of modern practice (ris-
dent physicians who can determine their own working ing patient numbers, increased case complexity and
hours.41,42,58 The Australian Medical Association Code intensity of care per admission, more intensive medical
of Practice (last revised in 2016), is a voluntary record documentation) already lead to healthcare pro-
national code that recommends thresholds for unsafe fessional work compression irrespective of duty hour
hospital work practices (details provided in Table 1) limits.70–72 Limiting work hours without commensurately
 1532950x, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13943 by CochraneUnitedArabEmirates, Wiley Online Library on [26/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
STEFFEY ET AL. 7

decreasing workload logically can only exacerbate the methodologies were inconsistent with notable impacts.
existing work compression experienced by clinicians. The The FIRST trial reported no change in the incidence of
training effect of potential cumulative clinical exposure death or serious surgical complications associated with
reductions with work hour restriction during residency shift limits among first-year physician surgical resi-
remains poorly examined. However, it must also be rec- dents.67 However, these residents' roles would be similar
ognized that inadequate rest negatively impacts learning to those of rotating veterinary interns, with limited to no
and memory consolidation.1 The benefit of exposure to primary procedural responsibility. Additionally, studies
clinical knowledge by virtue of longer hours must be comparing shifts with a minimum of 12 hour duration
balanced against increased fatigue as well as reduced are already associated with fatigue and elevated risk;
opportunities for didactic study and the consolidation of comparing longer shifts of more than 12 hours simply
knowledge that occurs only during sleep. A review pub- compares fatigued clinicians with more fatigued clini-
lished in 2011 provided evidence of the positive impact of cians.79 Unpredictability and variability of compliance
work hour limits for surgical residents without adversely with resident work hour regulations and ACGME moni-
affecting operating room experience.73 In a subsequent toring80 is another variable confounding the ability to sta-
study, physicians trained for 90–100 hours/week had no tistically detect outcome differences. Finally, circadian
better patient outcomes (readmission rates, mortality, or rhythm disturbances and the specifics of handover pro-
cost of care, in a study of nearly 500,000 patients), than cesses should be taken into consideration when compar-
those whose training hours were limited by ACGME ing studies. Indeed, more medical errors were
restrictions.74 Despite theoretical concerns of reduced documented when ICU resident physicians worked
inpatient admissions volumes negatively impacting trainee 62 hours/week compared to residents working 68 hours/
education and clinical care, another study emphasizing week, but the former rotated between between day and
workload reduction strategies (reducing the number of night shifts.66 Impacts of circadian rhythm disturbances
patient encounters per trainee), found that education and due to shift-switching on quality of rest, is an important
care quality outcomes were improved.69 Although limited, performance-influencing variable that may have affected
this evidence justifies efforts to reduce fatigue while main- study results.44,66,81 Handover processes were not stan-
taining training experience. Such approach focuses on dardized and the study authors noted that variation in
improving educational resources, including skills courses medical error outcomes between study sites may have
and the use of simulators.42,75 also been related to site-specific differences in handover
The acquisition of professional values, attitudes and processes.66 The authors also noted that the residents
behaviors through observation of mentors and role working 62 hours carried a heavier daily workload than
models has been termed the “hidden curriculum” in those following 68 hour shifts, and reported evidence that
healthcare education.76 Conflicts between the hidden and “when ICU physicians care for more than seven patients
formal curricula create dilemma for trainees; such situa- per day, patient safety may deteriorate.”66 It should be
tion occurs when the behaviors trainees observe in their noted that it is generally more difficult to statistically
mentors are at odds with the education received about demonstrate a positive association rather than to fail to
best practices.77 Resistance by mentors to reasonably demonstrate an association, and many of these difficul-
restrict their work hours may be considered a lost oppor- ties are associated with study design constraints.
tunity to lead by example, perpetuating long-term pat- Evidence supporting regulations of work hours in
terns of behavior that are no less strong for being healthcare was summarized in a systematic review,
informally communicated or unspoken. where safety outcomes were improved by shorter physi-
Critics of work hour limits note that some well- cian shifts in 74% of the studies included while worse
known studies such as the Flexibility In duty hour outcomes associated with shorter shifts were documented
requirements for Resident Trainees (FIRST) or individu- in 6% of the studies.62 Failure to identify outcomes differ-
alized Comparative Effectiveness of Models Optimizing ences with work hour restrictions may be associated with
Patient Safety and Resident Education (iCOMPARE) tri- a lack of perceived benefit as limiting clinicians' work
als did not detect a reduction in recorded medical errors hours commonly result in work compression. Unless
by resident groups on reduced work hour schedules.67,68 responsibilities are concurrently adjusted, clinicians must
However, the validity of these conclusions is affected by complete their normal workload within the reduced time,
several limitations. First, risks of type 2 errors due to increasing stress and affecting the perception of benefit.51
insufficient sample size affect the value of the iCOM- Notably, surveyed physicians preferred their own family
PARE trial.68,78 Second, study design should be consid- members to be cared for by a team working on a shift
ered in terms of level of training and conditions of work; schedule rather than traditional call schedule.82
 1532950x, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13943 by CochraneUnitedArabEmirates, Wiley Online Library on [26/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
8 STEFFEY ET AL.

5.3 | Veterinary medicine baseline for practice logistics, nor put associates or trainees
in the position of having to compromise personal health
The occupational structures and logistics of most practic- and professional capability to regularly ensure coverage.
ing veterinarians (from an institutional employment rela- Limiting work hours alone may not eliminate fatigue but
tionship context) could be considered as most equivalent mitigates the likelihood that work schedules alone will
to physicians in general practice (who do not usually have cause unacceptable levels of fatigue.83 While the dangers
after-hours coverage requirements) or emergency rooms. of ≥24-hour shifts and insufficient sleep have been well
These physicians generally work under a defined schedule, established in a wide variety of occupations including
typically in 8–12 hour shifts, which differs from most vet- human healthcare, conversely, little to no objective data
erinary surgeons with after-hours responsibilities. Also by support the necessity or safety of such scheduling. Poor
contrast with physicians, the adoption of universal work work schedules have a profoundly negative impact on
hour recommendations is further complicated in veteri- employees, resulting in performance, effectiveness, produc-
nary medicine by costs of staffing relative to client costs, as tivity, job satisfaction, morale, and safety reductions,
well as a variety of species- and specialty-specific practice increased medical errors, absenteeism, presenteeism, inef-
styles and needs. As legally-exempt employees, institution- fective teamwork, and degraded quality of life.6 The evi-
ally employed veterinarians that are not trainees (whether dence summarized above documents levels of impairment
academic faculty or practice associates) lack labor code due to sleep deprivation that are similar to those induced
protections.5 They also lack self-protections inherent to by alcohol, yet the latter would lead to dismissal while sim-
work as independent contractors, as well as established ilar impacts of sleep deprivation are tolerated by veterinary
cultural norms provided by national duty hour oversight surgeons and their employers. Management must already
for training programs. These employees are therefore at accommodate and plan for a certain amount of allowable
higher risk for excessive work hour requirements. In a sur- time off and staff illness. The principle for sleep is the
vey about adverse events experienced in veterinary medi- same; it is a matter of affirming that excessive clinician
cine, 65% (368/564) of veterinarians surveyed indicated a fatigue (whether acute or chronic) is not acceptable and
desire to reduce their work hours.55 Veterinarians and that a certain amount of rest is imperative, not negotiable.
physicians who perceive they have had adverse events or Another contribution to chronic clinician fatigue
near misses in their care of patients commonly experience could result from the incomplete use of allocated per-
stress and anxiety, reduced job satisfaction, sleeping diffi- sonal time off. Without overtly limiting individual time
culties, reduced professional confidence, and even depres- off, contract language in production-based compensation
sion and professional burnout.55 systems in particular may discourage or inhibit full use of
personal time due to clinician concerns for the conse-
quences of negative accrual, leading to situations where
6 | PRACTICE MAN AG E ME N T clinicians only feel comfortable using time off right
ISSUES AND SUGGESTIONS before the calendar year ends in order to ensure that
residual negative accrual has been erased. Clinicians and
The magnitude of interindividual differences in the effect practice management may wish to consider mechanisms
of sleep loss on occupational performance and personal whereby appropriately allocated personal time off is
health raises complex ethical dilemmas for practice man- excluded from calculations that result in negative accrual.
agement. How should scheduling occur to ensure patient Institution of quarterly time off check-ins by manage-
safety and protect clinician mental and physical health ment could also help to ensure that clinicians are aware
while still providing necessary coverage? Despite cultural of their personal time off reservoir and feel empowered
portrayals of surgeons as “indefatigable”, there is no evi- to benefit from these allowances. Appropriate practice
dence that surgeons as a population are over-represented staffing and mechanisms to ensure trusted continuity of
in the relatively small subset of humans that exhibits a rel- patient care are also fundamental to clinician utilization
ative resistance to the effects of prolonged wakefulness.45 of personal time.
Individual surgeons are just as prone to the normal human While poorly managed changes in care assignment
variations that convey an increased vulnerability to sleep between shifts (known as handovers) could undermine
deprivation effects, including genetic trait polymorphisms, patient safety benefits achieved by reducing clinician
sleep disorders, health conditions, and other inter- fatigue, handovers can be done safely and effectively with
individual differences.45 In general, veterinary surgeons emphasis on formal handover rounds and practical elec-
are highly committed and hardworking professionals, tronic sign-over systems.65,66 Implementation of formal
however, practice management should not depend on indi- handover programs is associated with reductions in
vidual altruism and professional dedication as a chronic medical-error rates and improvements in communications
 1532950x, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13943 by CochraneUnitedArabEmirates, Wiley Online Library on [26/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
STEFFEY ET AL. 9

at change of shift.84–86 Routine use of a structured elec- T A B L E 2 Summary of recommendations from the Institute of
tronic handover tool resulted in a decrease in communica- Medicine report (2009) on sleep physiology and physician work
tion errors among surgery residents by 50% (from 13 ± 3% hours: Healthcare facility work redesign and cultural changes.89
to 7 ± 2%; p = .04).87 Concerns over handover can there- Summary of recommendations from the Institute of Medicine
fore be addressed through protocols and training, by con- report on sleep physiology and physician work hours
trast with the negative impacts of fatigue, which cannot. • Maximum shift length:12–16 h
Given the lack of evidence in veterinary medicine, • Minimum off-duty time between shifts:10 h
consideration of alternative scheduling of work duties • Actively solicit clinician input into work redesign
requires some extrapolation from professions where • Design schedules to adhere to principles of sleep and
errors also carry significant consequences. Among these, circadian science; consider carefully effects of multiple
consecutive night shifts and provide adequate time off after
management of occupational risks in aviation include
night work
regulations regarding rest and scheduling practices that
• Do not schedule clinicians up to the maximum permissible
take circadian variables into consideration.50 Strategies limits; anticipate that emergencies frequently occur that will
found beneficial to physician surgeons include the lengthen scheduled shifts
re-organization and redistribution of after-hours care by • Anticipate the need for iterative improvement with new
addition of surgical nocturnist, “night-float,” and/or hos- schedules; be prepared to learn from the initial phase-in, and
pitalist positions, recognition of on-call as work time change the plan as needed
rather than rest time, and maintenance of adequate surgi- • Bring “home call” under the overall limits of working hours;
monitor workload and hours to ensure that clinicians on
cal staffing.41,88 Consecutive on-call duties (e.g., ≥3 days)
home call are getting sufficient sleep
are discouraged due to the likelihood of cumulative sleep
• Formalize a moonlighting policy. Include internal and
deprivation impacts despite the common inability of cli- external clinical moonlighting work hours in working hour
nicians to personally note these effects.66 For the same limits and actively monitor
reasons, scheduling elective procedures should be • Educate clinicians fatigue-related injury prevention,
avoided after overnight call duties; alternatively, sleep including increased risks of motor vehicle crashes when
loss should be disclosed and options to reschedule offered driving home after longer shifts and that clinicians' ability to
to the patient (or client).44,89 judge their own level of impairment is compromised when
fatigued
At the instruction of Congress, the Institute of Medi-
• Provide transportation to all clinicians who report feeling too
cine/National Academy of Medicine90 examined the scien- tired to drive safely
tific evidence surrounding the impact of sleep deprivation • Train attending and resident clinicians in effective
in healthcare.91 Recommendations derived from this handovers of care
review included new scientifically-based limits on resident • Create uniform processes for handovers, tailored to meet
physician work hours and workload, increased supervi- each clinical setting; handovers should be done verbally and
sion, a heightened focus on physician safety, training in face-to-face, but also utilize written tools
• When possible, integrate hand-over tools into electronic
structured handovers and quality improvement, and more
medical records
rigorous external oversight of work hours (details provided
• When feasible, handovers should be a team effort including
in Table 2).42 However, the subsequently revised ACGME nursing care providers
2011 and 2016 regulations fell short of these recommenda- • Quality improvement/patient safety concepts should be
tions, an ongoing source of controversy and discussion integral to the (veterinary) medical school curriculum and
among U.S. physicians. In academic settings, resident duty reinforced throughout internship/residency
hour limits without concurrent staffing and systems Abbreviations: h, hours.
changes can negatively affect faculty workload, teaching,
and risks of burnout, leading to serious issues with clini-
cian retention.69,92–94 serious and urgent consideration of strategies to remedy
Residents and faculty in veterinary academic settings these limitations and ensure adequate workforce to train
report higher working hours and fewer hours of sleep future veterinarians and surgeons.
than their counterparts in the private sector.51 These dif- For resident physicians, ACGME-accredited programs
ferences may reflect declining state support and other are expected to monitor and comply with established
budget limitations, organizational fiscal structures, opera- residency guidelines in order to maintain program
tional efficiencies, and staffing levels relative to caseload. accreditation. This is usually accomplished by having res-
Other management decisions, differences in residency idents self-report duty hours on a weekly basis, informa-
structures, conflicting holdovers in institutional cultures, tion which is aggregated at the program level and then
and administrative expectations may also contribute to reported to the ACGME for review.95 Oversight is depen-
these differences. However, these findings should prompt dent upon accurate reporting by both individual residents
 1532950x, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13943 by CochraneUnitedArabEmirates, Wiley Online Library on [26/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
10 STEFFEY ET AL.

and programs. Reported deterrents to accurate duty hour legislated work hour regulations.50 It has been suggested
reporting by residents has included fear of programmatic that rather than application of strict universal duty hour
punitive measures, poor peer perception or judgment, limits, residency program accreditation could instead be
desire to retain control of their surgical education, and frus- contingent on measures of resident workload, indirectly
tration with the administrative burden following viola- permitting a reduction in work hours with greater flexi-
tions.95 In addition, studies have demonstrated effects of bility in scheduling.70,72 This concept holds promise but
recall bias associated with distorted time perception result- requires individual clinician and organizational man-
ing from long work hours and inconsistencies in the accu- agement buy-in that sleep is a practice quality indicator
racy of self-reported work hours, with self-reported work that must be prioritized. Best practices and working pat-
hours for the week prior consistently 9 hours (SD = 8.6) terns that require review and risk management
lower than those that were automatically app-recorded (Figure 1) have been defined in other industries. Scien-
(p < .001).96 Improvements in duty hour compliance were tific evidence informing design of safe and effective
seen with programmatic intervention in major domains workplace practices has grown substantially in recent
including (1) improving the accuracy and transparency of years, and global methods have evolved.6,9,79,98 Cultural
work hour reporting, (2) facilitating more timely interven- change has already occurred in aviation and other
tions, and (3) structural schedule changes that included industries; once the concept of appropriate rest as an
transition to a night float model, providing additional time occupational imperative becomes normalized, the sys-
off for more junior residents, and redesigning the model of tem demonstrably adapts.
clinical coverage.97 These types of issues should be consid- We do not minimize the impacts of altered practice
ered in the structuring of duty hour oversight programs. logistics on staffing, budgets and training, and in the face
Because of the complexity of fatigue prevention, local of cost of care concerns, practice economic impacts, and
systems of fatigue risk management that are broader, staffing shortages, solutions are neither simple nor uni-
more flexible and better tuned to modern scientific find- versal. However, while there are strong economic and
ings on fatigue may be preferable to one-size-fits-all practical arguments for long duty hours, work

F I G U R E 1 Indicators in the rail

industry that schedules or working
patterns need review and risk
management adjustment. Adapted from
information provided by Folkard et al.44
 1532950x, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/vsu.13943 by CochraneUnitedArabEmirates, Wiley Online Library on [26/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
STEFFEY ET AL. 11

compression, and limited personal time off as solutions AUTHOR CONTRIBUTIONS

for veterinary surgery practice challenges, the preponder- Steffey MA, DVM, DACVS-SA: Contributed to concep-
ance of scientific evidence does not support such allow- tion and design, data acquisition, analysis & interpreta-
ances.83 If adequate clinician rest cannot be tion, manuscript preparation, and approved the final
accommodated, whether it be in a private or academic version of the manuscript. Risselada M, DVM, PhD,
setting, this is an unambiguous indicator that the existing DECVS, DACVS-SA: Contributed to analysis and inter-
practice model of veterinary medicine is fundamentally pretation, manuscript preparation, and approved the
flawed. Regardless of historical norms within veterinary final version of the manuscript. Buote NJ, DVM,
surgery, evidence should be used to inform creative reas- DACVS-SA: Contributed to analysis and interpretation,
sessment of scheduling and coverage while also addres- manuscript preparation, and approved the final version
sing the integrity and feasibility of workplace of the manuscript. Scharf VF, DVM, DACVS-SA: Con-
operations.6,9,98 For example, practices that do not have a tributed to analysis and interpretation, manuscript prep-
heavy after-hours caseload sufficient to justify increased aration, and approved the final version of the
staffing and shift assignment, might wish to consider manuscript. Winter AL, BVSc, DACVS: Contributed to
regional multi-practice affiliations for the purpose of after- analysis and interpretation, manuscript preparation,
hours caseload coverage. This would permit aggregation of and approved the final version of the manuscript.
emergency caseload and resources in order to permit shift Zamprogno H, DVM, MS, PhD, DACVS-SA, DECVS:
assignment of participating veterinarians and support staff, Contributed to analysis and interpretation, manuscript
rather than each practice chronically maintaining its own preparation, and approved the final version of the man-
individualized on-call coverage. Anecdotally, there have uscript. Griffon D, DVM, PhD, DECVS, DACVS: Con-
been increasing numbers of small animal veterinary sur- tributed to analysis and interpretation, manuscript
geons who elect mobile surgical practice instead of tradi- preparation, edited the draft, and approved the final
tional practice, and a desire to avoid traditional on-call version of the manuscript.
structures and unstructured/unlimited after-hours care
responsibilities may be one contributing factor driving this ACKNOWLEDGMENTS
shift. This has the unintended impact, however, of placing This review was compiled by the 2022 leadership of the
increasing after-hours burdens on those who remain in Association of Women Veterinary Surgeons (AWVS).
centers that offer 24-hour care.
CONFLICT OF INTEREST
The authors declare no conflicts of interest related to this
7 | C ON C L U S I ON report.

The veterinary profession should recognize the impact of ORCID

fatigue-related impairments as a management rather Michele A. Steffey https://orcid.org/0000-0003-0852-
than a personal issue, especially in predisposed sectors, 0644
such as emergency care and surgery. This step is crucial Marije Risselada https://orcid.org/0000-0003-1990-4280
to enhance patient safety because self-assessments of Valery F. Scharf https://orcid.org/0000-0002-5011-9005
fatigue and performance are demonstrably as unreliable Nicole J. Buote https://orcid.org/0000-0003-4623-3582
as those done under the influence of alcohol. This limita- Alexandra L. Winter https://orcid.org/0000-0003-0103-
tion justifies the establishment of professional guidelines 095X
and policies to replace self-policing of fatigue. Such
restriction would likely be supported by the general pub- RE FER EN CES
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