On-call work schedules, sleep knowledge, and sleep quality in medical trainees: results from a UK pilot study

Introduction

Medical trainees frequently face regular and extended night shifts that lead to acute sleep deprivation, resulting in decreased attention (1,2), reduced alertness (3,4), and impaired executive function (5,6). Furthermore, shift work can lead to chronic sleep deprivation, circadian rhythm disruption (7), and health hazards including impaired cognitive (8) and memory (9) functions, increased risk of cardiovascular diseases, and even cancer (10,11). Additionally, it impacts negatively on mood, and increases the risk of depression (12) and burnout (13).

These issues do not only affect the person, medical trainees, but they also cause an increased risk of medical errors (14-17), thereby impacting patients, diagnostics and treatments, and clinical outcomes via the quality of care.

An increasing number of countries have recognized the negative impact of extended working hours on medical trainees and patients, and have consequently implemented regulations to limit work and shift durations (18-20). In 2003, the Accreditation Council for Graduate Medical Education (ACGME) in the United States stipulated that resident physicians must not exceed 80 working hours per week, with individual shifts limited to no more than 24 hours (21,22). In Europe, medical trainees’ working hours are generally restricted to 48 hours per week (average over several months) (19,20). Other countries and regions have established similar working hour regulations and limitation measures (23-25).

Overall, working hour restrictions have demonstrated positive effects on medical trainees’ health and performance (26,27). However, existing evidence shows considerable heterogeneity. Some studies indicate that merely limiting work hours does not consistently improve patient care or trainee well-being. For example, isolated reductions in consecutive work hours may inadvertently increase the frequency of night shifts, reduce rest periods, or even elevate medical errors; this could adversely affect resident doctors and patients (28,29). Conversely, compressed work schedules can diminish teaching opportunities, negatively impacting trainees’ education (29,30).

So far, an optimal work shift scheduling strategy remains debated. In medical training, “on-call” work typically refers to “scheduled periods outside regular daytime working hours during which clinicians are required to remain available to provide clinical care, either on-site or on standby, often including evenings, nights, weekends, and public holidays”. Furthermore, a solid understanding of sleep hygiene, routine, physiology, and sleep disorders is essential for medical trainees to fully recognize the value of sleep, and the risks of continued abnormal sleep patterns, and adopt effective measures to safeguard their own health.

However, structured research and data on the effect of on-call work in medical trainees on their sleep remain scarce. To address gaps in the current knowledge, we sought to conduct a cross-sectional online survey to study medical trainees’ sleep knowledge and the impact of on-call work on their sleep quality and overall health. We present this article in accordance with the SURGE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0288/rc).

Methods

The study was registered on ClinicalTrials.gov (NCT06706453; first registration 11/09/2024) and approved by the Research Ethics Committee at King’s College London (No. MRA-23/24-45277), in accordance with the Declaration of Helsinki and its subsequent amendments, and the protocol has been peer-reviewed and published (31). Participants had to indicate their consent in the introductory section of the online survey with a mandatory stop-go question.

Study design and participants

This was an anonymous online cross-sectional survey study conducted over a 6-week period between February and April 2025. The questionnaire covered four sections: (I) demographics and place of work, (II) basic knowledge and perception of sleep, (III) sleep routine during “on-call” and “off-call”, and (IV) sleep-related questionnaires [Epworth Sleepiness Scale (ESS) and Insomnia Severity Index (ISI)].

The survey (Appendix 1) contained 100 questions and took about 30–45 minutes to complete; there were three different types of questions. Fifty-one questions were single-choice, 36 were open-ended (text) questions, and 13 were scale-based. The scale questions were mainly included in section II, basic knowledge and perception of sleep, which contained 13 items using a 0–10 rating scale. These questions primarily assessed self-perceived knowledge about sleep, as well as subjective ratings of sleep quality, early awakening, sense of well-being, and dozing off at work. In general, a score of 0 indicated “never”, “no”, or “very poor”, while a score of 10 indicated “always”, “outstanding”, or “very frequent”. Participants were asked to mark the scale based on their subjective perception.

Medical trainees were eligible at any stage of training, aged ≥18 years, if they agreed to participate and had internet access to complete the survey. Medical trainees were recruited through online distribution of the survey link via professional networks, institutional mailing lists, and trainee groups. Participants could withdraw at any time without providing a reason.

In order to retain as much data as possible, we conducted item-level analysis, with each question analyzed based on the actual number of responses received. The corresponding sample size for each item is indicated in the results section.

Statistical analysis

Continuous variables that follow a normal distribution will be expressed as mean ± standard deviation (SD), while non-normally distributed data will be presented as median [interquartile range (IQR)]. Categorical data will be displayed as number and percentage.

Between-group comparisons of continuous variables were undertaken using independent samples t-tests for normally distributed data and the Mann-Whitney U test, a non-parametric test, for non-normally distributed data.

For three-group comparisons, normality and equal variance were tested. Non-normal data were analyzed with the Kruskal-Wallis test, followed by Dunn’s post hoc test for pairwise comparisons, with Bonferroni correction for multiple testing.

Proportions were compared using Fisher’s exact test (2×2 tables) or the Fisher-Freeman-Halton exact test (2×3 tables), due to small expected frequencies. Pearson’s correlation coefficient was used to assess relationships between normally distributed continuous variables. For non-normally distributed variables or ordinal data, Spearman’s rank correlation was applied. IBM SPSS Statistics 29.0 for Windows was used for descriptive analyses and the Monte Carlo simulation method of the exact test. GraphPad Prism 10.4.0 was used for performing t-tests, Mann-Whitney U tests, Fisher’s exact tests, and for generating statistical graphs. JASP version 0.19.3.0 was used for normality tests as well as the Kruskal-Wallis test and Dunn’s post-hoc test. A P value <0.05 was considered statistically significant.

Results

The study was open for a 6-week period (02–04/2025) and a total of 107 participants completed the online questionnaire. Comprehensive responses were primarily provided by around 51 participants (Figure 1).

Figure 1 Flow diagram of respondents for the entire survey, and for subsections (I–IV). The number for each section is the maximum sample size for each subsection. Section I: demographics and place of work; section II: basic knowledge and perception of sleep; section III: sleep routine during “on-call” and “off-call”; section IV: sleep-related questionnaires (ESS and ISI). ESS, Epworth Sleepiness Scale; ISI, Insomnia Severity Index.

Demographics and place of work (section I)

The participants were young-to-middle-aged adults with a median age of 31 (IQR, 28, 34) years, with a relatively balanced gender ratio, non-obese, with almost three-quarters living in a relationship and about one-third having children (Table 1).

Lifestyle habits

The majority (64%) of participants reported drinking alcohol with an average weekly intake of 4.5 (IQR, 2.0, 4.5) units of alcohol; 33% reported not drinking any alcohol and 4% preferred not to say. 82% had never smoked, 12% were former smokers, 2% were current smokers, and 4% preferred not to say. Those who had been smoking had about mean ± SD 8.2±4.3 packyears with 7.0±7.6 cigarettes per day.

Workplace

Most participants, 91%, were employed in hospitals, 5% worked in medical schools, and 5% in other institutions. Eighty percent lived in urban and 14% in suburban areas, and 7% in mixture areas; none lived in rural areas. Sixty-seven percent resided in large cities (populations exceeding five million). In terms of job positions, 82% were resident physicians, 9% were fellows, 5% were interns, and 5% were others. The average time since graduation was 7 (IQR, 5, 10) years and the average time working in the current role was 2 (IQR, 1, 3.5) years. 80% reported currently being on call while filling in the survey.

Commute

The average one-way commuting time was 0.5 (IQR, 0.5, 1) hours and the primary mode of transportation was public transit, such as trains (28%) and buses (17%), as well as driving alone in a car (19%) and walking to work (13%). A total of 35% of participants reported having fallen asleep during their commute in the past.

Medical specialty

The most common specialties were General Medicine (14.0%) and Respiratory Medicine (11%), followed by Neurology (9%), Pediatrics (9%), and Anesthesiology (9%).

On-call frequency

Fifty-three percent defined being “on-call” as work outside sociable hours, 16% as overnight work, 16% as on-site presence, 6% as weekend or holiday duty, and 9% chose “other” definitions. Concerning on-call duty characteristics, the regular on-call duration was 13 (IQR, 12, 13) hours, with the shortest on-call shifts averaging 12 (IQR, 9, 13) hours and the longest averaging 13 (IQR, 12.5, 13) hours. Regarding sleep allowance during on-call shifts, 61% reported being allowed to sleep. Forty-nine percent reported following a certain rotation format concerning on-call shifts over the last 6 months, while 5% reported none. Thirteen percent reported they were offered flexible on call shifts (e.g., during leave, childcare needs), while 56% reported no, 25% reported some flexibility, and 6% reported that this was unknown. For regular non-on-call working days, the average daily working hours were 9 (IQR, 9, 10) hours, while the daily working time on-call was significantly higher with 13 (IQR, 12, 13) hours (P<0.001).

Basic knowledge and perception of sleep (section II)

Participants demonstrated a moderate overall level of sleep-related knowledge. The average score for general sleep knowledge was 6 (IQR, 5, 7), for knowledge of obstructive sleep apnea (OSA) it was 7 (IQR, 6, 8), and for knowledge related to shift work, insomnia, and other sleep disorders, it was 6 (IQR, 5, 7) points.

The Kruskal-Wallis test showed the level of knowledge of OSA was significantly higher than that of shift work, insomnia, and other sleep disorders (with Bonferroni correction, P=0.04).

The score for coping with a heavy workload was 5.7±2.6 (scores are out of 10, higher scores indicate better coping ability) and the score of subjective experiencing burnout symptoms was 6.1±2.2 (scores are out of 10, lower scores indicate fewer burnout symptoms) points. The frequency of having experienced any health issues during night shifts was 5.4±2.6 (scores are out of 10, with higher scores indicating a higher frequency of experiencing health issues) points. The current average sleep quality rating score was 3.6±2.2 points, which was lower than the score prior to working in medicine (6.6±2.4 points; scores are out of 10, with lower scores indicating poorer sleep quality; P<0.001) (Figure 2).

Figure 2 The current average sleep quality rating score was significantly lower than the score prior to working in medicine (P<0.001). Scores are based on a 10-point scale, with higher scores indicating better sleep quality. ***, P<0.001.

A significant proportion of participants reported night shift-related issues. Current levels of excessive daytime sleepiness were reported by 35% of participants. Eighty-three percent felt more tired following their night shifts, and 93% of the respondents reported that night shifts caused sleep problems. Additionally, 77% thought that night shifts caused them stress, and 40% stated that they had problems controlling their weight due to shift work. Sixty percent of the respondents felt that night shifts negatively impacted their social relationships. A total of 52% of participants reported experiencing family conflicts due to shift work. Considering the demographics, 38% of single participants reported experiencing family conflict related to night shifts, with 25% reported no conflict and 38% were unsure. In contrast, among participants who were not single, 57% reported such conflicts, 43% reported no conflict, and none were unsure (P=0.03). Similarly, 40.0% of participants without children reported experiencing family conflict related to night shifts, with 45% reporting no conflict and 15% uncertain. Among participants with children, 88% reported experiencing this type of conflict, 13% reported no conflict, and none were unsure (P=0.06).

However, when asked whether night shifts improved their performance and advanced their career, the score was 3 (IQR, 1, 6.75) points (out of 10). Waking up too early received a score of 5.7±3.1 points, and a sense of well-being was scored at 5.2±2.0 points. The average score for the frequency of dozing off at work was 1 (IQR, 0, 5) point. Responses for dozing off while driving after at least 2 days off from work were 0 (IQR, 0, 4) points. Participants thought that an “ideal sleep duration” was 8 (IQR, 8, 9) hours (Table S1).

Knowledge about OSA was negatively correlated with early awakenings (Spearman r=−0.378, P=0.043) and with ESS total score (Spearman r=−0.429, P=0.046), while it was positively correlated with sense of well-being (Spearman r=0.426, P=0.03). One-way commuting time was negatively correlated with current sleep quality rating scores (Spearman r=−0.492, P=0.01).

Sleep routine during “on-call” and “off-call” (section III)

Sleep during regular work

The average sleep duration when not on-call was 7 (IQR, 6.5, 8) hours. Difficulty falling asleep was reported by 27%, while 69% reported no difficulties, and 4% were unsure. Difficulty maintaining sleep during this period was reported by 23%, but 73% had no such issues, and 4% were unsure. Daytime napping when not being on call was reported by 12%, while 89% did not require any naps. Among those who took naps, the average number of naps was 0.9±0.8 each day, and the average nap duration was 0.33 (IQR, 0.02, 1.00) hours.

Sleep when on-call

During on-call or shift duty, the average sleep duration was 6 (IQR, 5, 7) hours. Difficulty falling asleep during on-call duty was reported by 70%, while 30% reported no difficulties. Difficulty maintaining sleep during on-call duty was reported by 63%, with 37% reporting no issues. Daytime napping during on-call periods was observed by 50%, while the remaining 50% did not require any naps. Among those who had to take naps, the average number of naps was 1.2±0.9 naps per day, and the typical nap duration was 0.5 (IQR, 0.25, 0.75) hours (Table 2).

Sleep restriction (<7 hours) was highly prevalent during on-call periods (71%), compared to 27% when not on-call.

The average regular working hours when on-call were 13 (IQR, 12, 13) hours, and they were significantly higher than those when not being on call with 9 (IQR, 9, 10) hours (P<0.001). The percentage of having difficulty falling asleep on call (70%) was significantly higher than that of not on call (27%, P=0.005). The percentage of difficulty maintaining sleep during on-call (63%) was significantly higher than that of not on call (23%, P=0.006). The percentage of daytime napping during on-call (50%) was significantly higher than that of non-on-call (12%, P=0.006). 19% of the respondents had an interest to see a sleep doctor for their sleep issues, but 58% preferred not to, and 23% were unsure. In terms of pre-existing sleep disorders, 20% of participants reported having been diagnosed with a sleep disorder, and 15% were currently using sleep medication.

Sleep-related questionnaires (section IV)

ESS

The average score on the ESS was 5 (IQR, 3, 8) points, with scores ranging from 0 to 15 points (Table 3).

ISI

The average score on the ISI was 7 (IQR, 4, 14) points, with scores ranging from 1 to 23 points (Table 4).

Discussion

In this UK pilot study, we have shown that regular working hours were significantly longer during on-call periods, leading to poor sleep quality, which included shorter sleep duration, difficulties falling asleep, as well as staying asleep, and significantly increased requirements for daytime naps. The extent to which respondents mentioned problems about coping with the workload, as well as burnout symptoms, was concerning. Encouragingly, knowledge about sleep apnea was associated with lower symptom scores. Interestingly, there was no consensus about the definition of “on-call” periods, with most respondents labelling it “out of social working hours”. Only the minority of medical trainees thought that overnight or on-site presence defined “on-call” work. While about a third of our respondents felt sleepy during regular work, this number increased to more than four out of five respondents following a night shift on call, and more than nine out of ten respondents complained about sleep-related problems after night shifts. Overall, medical trainees the ESS remained largely within normal range, but the results of the ISI implied substantial difficulties for at least a quarter of the respondents. Night shift and on-call work did not seem to fulfil the purpose for medical trainees in terms of progressing the career; it affected their sleep and physical health, which in turn affected their mental health. Whilst public transport was reported being the most common method of commuting, more than a third reported falling asleep during the commute, and it was noted that people with longer one-way commutes reported a worse sleep situation compared to others.

Clinical significance of findings

Demographics

Most of our participants were young junior doctors, either interns or resident physicians. They generally reported healthy lifestyles, with the majority indicating that they had never smoked. Although commuting times via public transportation were not excessively long, more than one-third of respondents reported having fallen asleep during their commute, a clear indication of fatigue and daytime sleepiness.

Previous studies showed that sufficient sleep for an individual influences overall health and well-being. Sleep affects any component of health, including but not limited to cognitive performance, physical health, emotional response (34), and resident doctors are amongst healthcare workers who face high levels of stress (35). The studied cohort population typically falls in the category of young adults and may experience higher sleep irregularities due to modern lifestyle demands (36). It is important, and not unexpected, that relationship status and children matter when it comes to on-call work, a fact that, however, has long been undervalued.

Definition of “on-call”

Interestingly, there was notable variation among participants in how they defined “on-call” work. The majority considered “on-call” to indicate working outside of sociable hours, while a minority associated it with traditional overnight shifts. This highlights the limited acceptance of a ubiquitous understanding of “on-call” duties across different healthcare settings even within one country (37,38).

More importantly, even the concept of “sociable” or “regular working hours” varies significantly across countries, institutions, and clinical settings. Where there is a lack of clear definitions for such working hours times may be set by individual hospitals or employers, making it difficult to ensure fair, sustainable, or balanced schedules for medical staff.

Knowledge about sleep

Medical trainees generally demonstrated a relatively higher level of knowledge about OSA compared to other areas of sleep medicine. This may be attributed to the fact that OSA is commonly included in medical training programs, making interns and residents more familiar with the condition. Additionally, the survey results suggested that greater knowledge about OSA was associated with fewer symptoms of sleepiness and a better overall sense of well-being. This highlights the need to enhance education and awareness about other sleep-related topics, such as insomnia and shift work disorder, in future medical training. Strengthening knowledge in these areas may help medical trainees better manage their own sleep and improve overall sleep quality. This is consistent with previous studies that observed that better sleep health-related knowledge highlights the potential benefit of sleep education and adequate resting times for residents during shift work (39).

Symptoms when on-call

The frequency of burnout symptoms reported in this survey, although not excessive, is concerning. Medical trainees, a group generally expected to begin their medical careers with enthusiasm and motivation, exhibited a moderate to moderately-high level of professional burnout. The consequences of burnout among doctors have often been underestimated. It not only hinders improvements in the quality of care, but can also lead to early attrition from the medical profession. A bi-directional relationship has been reported between occupational experiences contributing significantly in terms of heavy workload, which may lead to burnout, and affecting sleep and reducing sleep quality. More recent studies indicate that reduced sleep quality leads to burnout by increasing perceived stress levels (40). In this survey, a large majority of respondents (77–93%) reported that night shifts cause sleep disturbances and increase stress. Furthermore, more than half of the participants felt that night shifts offered little benefit to their career development (e.g., with regards to education). These findings are in line with previous studies, with night shift work being a major contributor to the disruption of the circadian rhythms and causing negative impact on mental health and physical health outcomes (41). Challenges during night-time shift work were seen as less positive for any career progression (42).

Sleep routine

Being on-call has a significant impact on sleep scheduling, planning, quality, and quantity. Working hours during on-call shifts were significantly longer than those during off-call periods. This was associated with shorter sleep duration, higher rates of difficulty falling asleep, difficulty maintaining sleep, and daytime napping. The risk and responsibility of on-call medical work contribute to a high prevalence of insomnia symptoms during these periods. As demonstrated in earlier studies, demands on healthcare professionals contribute significantly towards the causation of sleep-related health by means of chronic sleep deprivation and subsequent deterioration in sleep health (34). Social relationships are similarly impacted by night shifts, leading to increased levels of psychological stress and rising family conflicts due to sleep deprivation-driven emotional instability (43). In resident doctors, the chronicity of sleep disturbances has led to the acceptance of chronic sleep deprivation as the “new normal” (44). Extended long days and night shifts contribute to significant reduction in sleep time and reduction in sleep quality (45). From initiating sleep to maintaining it, sleep was overall affected by the disruption of the circadian rhythm, which is a core mechanism leading to poor sleep-related outcomes (46). Moreover, a significant proportion of our respondents experienced daytime sleepiness while being on call. Sleepiness and lack of concentration can compromise patient care and safety, potentially leading to medical errors (18). These findings highlight the urgent need for policies that ensure more reasonable scheduling of on-call shifts, not only to protect the health of medical trainees but also to safeguard patients and reduce the risk of medical errors and adverse events. Targeted interventions for sleep-related issues like improving the scheduling practices for on-call shifts, keeping a sleep diary, educating doctors in sleep and sleep hygiene, and to provide pathways to access sleep-focused medical support, may help to ameliorate the adversity of night shift medical work (42).

Limitations

This was a pilot study initially enrolling 107 participants, with more substantial data on about half the respondents. We can acknowledge that a key finding of the pilot was that the progressive attrition across survey sections suggests that the questionnaire length and completion burden may have been significant barriers to full participation. In addition, the importance and relevance of the study objectives may not have been sufficiently appreciated by participants at the time of completion. These findings, however, allow us to recognize the importance of feasibility data and will directly inform the design of a future larger study, in which the questionnaire can be optimized to reduce respondent burden and improve data completeness. Incomplete data are an acknowledged issue of online surveys, but it does not invalidate the current findings. Future iterations of this survey should optimize the questionnaire (e.g., reducing items) to improve feasibility and facilitate worldwide implementation (including other languages, like Spanish, French, and Chinese). Limited data on subgroup samples have been explicitly indicated in the results. Provided the high-dimensional data (numerous variables) and the pilot nature of this study, the primary focus was on identifying trends rather than drawing definitive conclusions. Formal multivariate regression analysis was not conducted due to insufficient statistical power.

Conclusions

On call periods of medical trainees significantly impact on sleep quantity and quality, leaving trainees at risk of insomnia and sleepiness. This has knock-on effects on their performance at work and may cause medical errors; furthermore, it has an impact on their social lives. Sleep knowledge and education may help to improve sleep and social relationships with consecutive effects on the quality of life of medical trainees and the potential to increase staff retention in healthcare for this vocation.

Acknowledgments

We are grateful for the support of the British Sleep Society, the Royal College of Physicians (London) and London NHS hospitals for helping to disseminate our survey. We also acknowledge the support of the World Sleep Society in coordinating the authors working group.

Footnote

Reporting Checklist: The authors have completed the SURGE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0288/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0288/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0288/prf

Funding: This work was supported in part by the National Institute for Health Research (NIHR) through the contribution of Professor Steier.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-1-0288/coif). J.S. serves as an unpaid editorial board member of Journal of Thoracic Disease. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Research Ethics Committee at King’s College London (No. MRA-23/24-45277). Participants had to indicate their consent in the introductory section of the online survey with a mandatory stop-go question.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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