Publication - Independent report

Junior doctors - 48-hour maximum working week (without averaging): expert working group report

This report was led on by Professor Philip Cachia to consider the challenges of the maximum 48 hour working week and provide recommendations for the Scottish Government to consider.

Junior doctors - 48-hour maximum working week (without averaging): expert working group report
Appendix 8. References for 'Evidence of Fatigue and relationship to hours of work and rota design

Appendix 8. References for ‘Evidence of Fatigue and relationship to hours of work and rota design

1. Yazdi Z, Sadeghniiat-Haghighi K. Fatigue management in the workplace [Internet]. Industrial Psychiatry Journal2015;24(1):12. Available from:

2. Krueger GP. Sustained work, fatigue, sleep loss and performance: A review of the issues. Work & Stress 1989;3(2):129–41.

3. General Medical Council. National Training Survey 2019: Initial Findings Report [Internet]. 2019. Available from:

4. Health, Executive S. Managing shiftwork-Health and safety guidance. 2006;

5. Morrow G, Burford B, Carter M, Illing J. The impact of the working time regulations on medical education and training: literature review. Durham: Centre for Medical Education Research [Internet] 2012;Available from:

6. British Medical Association. Fatigue and sleep deprivation – the impact of different working patterns on doctors [Internet]. 2018. Available from:

7. Caruso CC. Possible broad impacts of long work hours. Ind Health 2006;44(4):531–6.

8. Folkard S, Tucker P. Shift work, safety and productivity. Occup Med 2003;53(2):95–101.

9. Folkard S, Lombardi DA. Toward a “Risk Index” to Assess Work Schedules. Chronobiol Int 2004;21(6):1063–72.

10. Folkard S, Robertson KA, Spencer MB. A Fatigue/Risk Index to assess work schedules. Somnologie - Schlafforschung und Schlafmedizin 2007;11(3):177–85.

11. Barger LK, Cade BE, Ayas NT, Cronin JW, Rosner B, Speizer FE, et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med 2005;352(2):125–34.

12. Ayas NT, Barger LK, Cade BE, Hashimoto DM, Rosner B, Cronin JW, et al. Extended work duration and the risk of self-reported percutaneous injuries in interns. JAMA 2006;296(9):1055–62.

13. Williamson AM, Feyer AM. Moderate sleep deprivation produces impairments in cognitive and motor performance equivalent to legally prescribed levels of alcohol intoxication. Occup Environ Med 2000;57(10):649–55.

14. Folkard S, Lombardi DA, Tucker PT. Shiftwork: safety, sleepiness and sleep. Ind Health 2005;43(1):20–3.

15. Cappuccio FP, Bakewell A, Taggart FM, Ward G, Ji C, Sullivan JP, et al. Implementing a 48 h EWTD-compliant rota for junior doctors in the UK does not compromise patients’ safety: assessor-blind pilot comparison. QJM 2009;102(4):271–82.

16. Landrigan CP, Rothschild JM, Cronin JW, Kaushal R, Burdick E, Katz JT, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units. N Engl J Med 2004;351(18):1838–48.

17. Barger LK, Ayas NT, Cade BE, Cronin JW, Rosner B, Speizer FE, et al. Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. PLoS Med 2006;3(12):e487.

18. Lockley SW, Cronin JW, Evans EE, Cade BE, Lee CJ, Landrigan CP, et al. Effect of reducing interns’ weekly work hours on sleep and attentional failures. N Engl J Med 2004;351(18):1829–37.

19. Jena AB, Farid M, Blumenthal D, Bhattacharya J. Association of residency work hour reform with long term quality and costs of care of US physicians: observational study [Internet]. BMJ2019;l4134. Available from:

20. Kecklund G, Axelsson J. Health consequences of shift work and insufficient sleep. BMJ 2016;355:i5210.

21. Bannai A, Tamakoshi A. The association between long working hours and health: a systematic review of epidemiological evidence. Scand J Work Environ Health 2014;40(1):5–18.

22. Vyas MV, Garg AX, Iansavichus AV, Costella J, Donner A, Laugsand LE, et al. Shift work and vascular events: systematic review and meta-analysis. BMJ 2012;345:e4800.

23. Virtanen M, Heikkilä K, Jokela M, Ferrie JE, Batty GD, Vahtera J, et al. Long working hours and coronary heart disease: a systematic review and meta-analysis. Am J Epidemiol 2012;176(7):586–96.

24. Anothaisintawee T, Reutrakul S, Van Cauter E, Thakkinstian A. Sleep disturbances compared to traditional risk factors for diabetes development: Systematic review and meta-analysis. Sleep Med Rev 2016;30:11–24.

25. van Drongelen A, Boot C, Merkus S, Smid T, Beek AJ. The effects of shift work on body weight change − a systematic review of longitudinal studies [Internet]. Scandinavian Journal of Work, Environment & Health2011;37(4):263–75. Available from:

26. Gan Y, Yang C, Tong X, Sun H, Cong Y, Yin X, et al. Shift work and diabetes mellitus: a meta-analysis of observational studies. Occup Environ Med 2015;72(1):72–8.

27. Proper KI, van de Langenberg D, Rodenburg W, Vermeulen RCH, van der Beek AJ, van Steeg H, et al. The Relationship Between Shift Work and Metabolic Risk Factors: A Systematic Review of Longitudinal Studies. Am J Prev Med 2016;50(5):e147–57.

28. Knutsson A, Kempe A. Shift work and diabetes – A systematic review [Internet]. Chronobiology International2014;31(10):1146–51. Available from:

29. Davari MH, Naghshineh E, Mostaghaci M, Mirmohammadi SJ, Bahaloo M, Jafari A, et al. Shift Work Effects and Pregnancy Outcome: A Historical Cohort Study. J Family Reprod Health 2018;12(2):84–8.

30. He C, Anand ST, Ebell MH, Vena JE, Robb SW. Circadian disrupting exposures and breast cancer risk: a meta-analysis. Int Arch Occup Environ Health 2015;88(5):533–47.

31. Lin X, Chen W, Wei F, Ying M, Wei W, Xie X. Night-shift work increases morbidity of breast cancer and all-cause mortality: a meta-analysis of 16 prospective cohort studies. Sleep Med 2015;16(11):1381–7.

32. Rao D, Yu H, Bai Y, Zheng X, Xie L. Does night-shift work increase the risk of prostate cancer? a systematic review and meta-analysis. Onco Targets Ther 2015;8:2817–26.

33. Wang X, Ji A, Zhu Y, Liang Z, Wu J, Li S, et al. A meta-analysis including dose-response relationship between night shift work and the risk of colorectal cancer [Internet]. Oncotarget2015;6(28). Available from:

34. Bokenberger K, Sjölander A, Dahl Aslan AK, Karlsson IK, Åkerstedt T, Pedersen NL. Shift work and risk of incident dementia: a study of two population-based cohorts. Eur J Epidemiol 2018;33(10):977–87.

35. Monk TH, Folkard S. Making Shiftwork Tolerable. CRC Press; 1992.

36. Akerstedt T. Shift work and disturbed sleep/wakefulness [Internet]. Occupational Medicine2003;53(2):89–94. Available from:

37. Pilcher JJ, Lambert BJ, Huffcutt AI. Differential Effects of Permanent and Rotating Shifts on Self-Report Sleep Length: A Meta-Analytic Review [Internet]. Sleep2000;23(2):1–9. Available from:

38. Sallinen M, Kecklund G. Shift work, sleep, and sleepiness - differences between shift schedules and systems [Internet]. Scandinavian Journal of Work, Environment & Health2010;36(2):121–33. Available from:

39. Wright KP Jr, Bogan RK, Wyatt JK. Shift work and the assessment and management of shift work disorder (SWD). Sleep Med Rev 2013;17(1):41–54.

40. Vedaa Ø, Harris A, Bjorvatn B, Waage S, Sivertsen B, Tucker P, et al. Systematic review of the relationship between quick returns in rotating shift work and health-related outcomes. Ergonomics 2016;59(1):1–14.

41. West M, Coia D. Caring for doctors Caring for patients [Internet]. General Medical Council; 2019. Available from:

42. Fletcher KE, Saint S, Mangrulkar RS. Balancing continuity of care with residents’ limited work hours: defining the implications. Acad Med 2005;80(1):39–43.

Lewis Hughes and Luke Yates