Effect of Naps on Decision Making of Residents.
Condition: Internship and Residency; Sleep; Decision Making
Study type: Interventional

Summary: 
      Sleep deprivation produces changes including alteration of mood, irritability, fatigue, less
      focus and disorientation, also perceptive distortions, visual hallucinations and considering
      tasks harder and less pleasant. In resident physicians, these alterations have been shown to
      affect their work performance. Naps have proved to improve arousal and attention, alertness
      and performance. Those longer than 90 minutes promote a learning process similar to that
      occurring in REM sleep. Therefore a nap schedule could improve the decision making of
      residents during their working hours.
    

Detailed description: 
      Sleep deprivation produces changes including alteration of mood, irritability, fatigue, less
      focus and disorientation, also perceptive distortions, visual hallucinations and considering
      tasks harder and less pleasant. Extenuating working hours provoke sleep deprivation, which
      deteriorates work performance, produces mood disorders and increase chances of error.

      In a survey performed to 3600 resident physicians in the USA it was observed that working
      more than 24 continuous hours was related with a higher risk of traffic accidents, as well as
      a higher tendency towards medical mistakes due to overstress, the most common being a
      diminished capability of performing a previously known procedure; also there were
      difficulties to solve problems generated by coworkers or relatives. Other study determinated
      that after a night shift the levels of daytime sleepiness were similar or higher than those
      of patients with narcolepsy or sleep apnea. The lack of sleep affects the performance of
      tasks, producing alterations similar to those in alcoholic intoxication, with a decline in
      visual attention, reaction speed, visual memory and creative thinking. Even though the
      effects of sleep deprivation in resident have been difficult to quantify due to confounders,
      there are indicators as decline in performance, which seems higher in less experienced
      physicians, with a higher alteration in reasoning and reaction time. It has been found in
      physicians in training (anesthesiology residents) that mistakes in administration of epidural
      anesthesia are more frequent after sleep deprivation; and a resident performing monitoring
      tasks after a night shift was more liable to mistakes that after a resting night, being also
      less likely to recognize arrhythmias in an electrocardiogram. Sleep deprivation affects
      coordination and skill, as observed in laparoscopist surgeons who took more time to complete
      a procedure after sleep deprivation than those who had rested. This results made the ACGME to
      establish a limitation in working hours during the residence.

      Naps from 30 minutes to 4 hours improve alertness and performance. Studies comparing naps and
      caffeine have shown that naps not only improve arousal and attention but also helps to
      consolidate memory in those longer than 90 minutes. Furthermore, naps with slow wave and REM
      sleep are partially equivalent to a night's sleep, restoring the damage from baseline. It has
      been proven that naps promote a learning process similar to that occurring in a complete
      night sleep, which correlates with phase 2 of REM sleep. Therefore a nap schedule could
      improve the decision making of residents during their working hours.
    

Intervention name(s): nap from 0:00 to 3:00 hours; nap from 3:00 to 6:00 hours
Intervention type(s): Behavioral; Behavioral
Intervention description(s): A nap from 0:00 to 3:00 hours during a night shift.; A nap from 3:00 to 6:00 hours during a night shift.
Allocation: Randomized
Intervention model: Crossover Assignment
Masking: Single (Investigator)
Primary purpose: Prevention
Keywords: Residents; Naps; decision making