Laparoscopic skills suffer on the first shift of sequential night shifts: program directors beware and residents prepare

Ann Surg. 2008 Mar;247(3):530-9. doi: 10.1097/SLA.0b013e3181661a99.


Objective: Research evaluating fatigue-induced skills decline has focused on acute sleep deprivation rather than the effects of circadian desynchronization associated with multiple shifts. As a result, the number of consecutive night shifts that residents can safely be on duty without detrimental effects to their technical skills remains unknown. A prospective observational cohort study was conducted to assess the impact of 7 successive night shifts on the technical surgical performance of junior residents.

Methods: The interventional strategy included training 21 residents from surgery and allied disciplines on a virtual reality surgical simulator, towards the achievement of preset benchmark scores, followed by 294 technical skills assessments conducted over 1764 manpower night shift hours. Primary outcomes comprised serial technical skills assessments on 2 tasks of a virtual reality surgical simulator. Secondary outcomes included assessments of introspective fatigue, duration of sleep, and prospective recordings of activity (number of "calls" received, steps walked, and patients evaluated).

Results: Maximal deterioration in performance was observed following the first night shift. Residents took significantly longer to complete the first (P = 0.002) and second tasks (P = 0.005) compared with baseline. They also committed significantly greater numbers of errors (P = 0.025) on the first task assessed. Improved performance was observed across subsequent shifts towards baseline levels.

Conclusions: Newly acquired technical surgical skills deteriorate maximally after the first night shift, emphasizing the importance of adequate preparation for night rotas. Performance improvements across successive shifts may be due to ongoing learning or adaptation to chronic fatigue. Further research should focus on assessments of both technical procedural skills and cognitive abilities to determine the rotas that best minimize errors and maximize patient safety.

MeSH terms

  • Clinical Competence / standards*
  • Cohort Studies
  • Curriculum
  • Endoscopy / education
  • Fatigue
  • Internship and Residency*
  • Laparoscopy / standards*
  • Personnel Staffing and Scheduling*
  • Prospective Studies
  • User-Computer Interface
  • Work Schedule Tolerance