Clinical Performance in Critical Care Simulation Under Sleep Deprivation: Effects of Power Napping in the R-NAP Randomized Controlled Trial

Citation:

Schmidt L, Genty F, Delaire T, Valero B, Rey I, Galan L, Mairet-Mabboux S, Douplat M, Schlatter S, Rimmele T, Mazza S, Lilot M. Clinical Performance in Critical Care Simulation Under Sleep Deprivation: Effects of Power Napping in the R-NAP Randomized Controlled Trial. Anesthesiology. 2026; doi:10.1097/ALN.0000000000006135.

In this single-centre randomized controlled trial, anesthesia and intensive care residents finishing an overnight on-site shift were assigned either to a brief supervised nap opportunity or to quiet wakefulness before a high-fidelity critical care simulation. The nap group achieved higher overall and non-technical performance scores without reported harms, but the trial is small, uses simulation rather than real patient outcomes, and has some missing data, so confidence in the size of benefit is moderate and the findings mainly support, rather than replace, broader fatigue management strategies.

Study at a glance

- Design and setting: Prospective individually randomized parallel-group behavioural trial conducted in a single French university simulation centre, comparing a supervised thirty-minute nap opportunity versus quiet wakefulness after an overnight on-site shift in anesthesia and intensive care residents.

- Participants: Thirty-five second to fifth year anesthesia and intensive care residents were randomized (nineteen to nap, sixteen to no nap); twenty-seven with complete actigraphy sleep data were included in the primary adjusted analysis, with similar baseline characteristics between groups.

- Primary outcome: Overall simulated clinical performance (sum of technical and non-technical scores, range zero to two hundred) after the overnight shift was higher with a nap; the adjusted mean difference was 14.84 points in favour of the nap group, with a ninety-five percent confidence interval from 2.8 to 26.88 and a P value of 0.018, yielding moderate certainty that a brief nap improves overall simulated performance.

- Key secondary outcomes: Total non-technical skills score (zero to one hundred) was higher with a nap, with an adjusted mean difference of 11.03 points (ninety-five percent confidence interval 2.22 to 19.84; P value 0.016). Among Ottawa Global Rating Scale subscales, Overall performance (mean difference 0.77; ninety-five percent confidence interval 0.05 to 1.48; P value 0.036), Leadership (0.73; ninety-five percent confidence interval 0.05 to 1.41; P value 0.037), and Resource utilization (1.02; ninety-five percent confidence interval 0.03 to 2.00; P value 0.043) favoured the nap group, whereas purely technical checklist scores showed smaller, imprecise differences.

- Harms and safety: No intervention-related adverse events or harms were reported in either the nap group (zero of nineteen) or the control group (zero of sixteen) during or after the brief nap or quiet wakefulness periods.

- Risk of bias and certainty: Overall risk of bias was judged as having some concerns, mainly due to missing outcome data (eight of thirty-five randomized residents excluded from the primary model because of missing actigraphy) and lack of participant blinding, although assessors were blinded and outcomes were structured and video-based. Using this and the reasonably precise effect estimate, certainty in the primary outcome was rated as Moderate.

- Applicability and limitations: Findings apply most directly to anesthesia and intensive care residents in similar academic settings and to high-fidelity simulation; they are indirect for attending physicians, other specialties, or real-world patient outcomes. The trial is small and single-centre, with multiple secondary and exploratory analyses without adjustment for multiplicity, so apparent benefits on individual subscales should be interpreted cautiously and used to support, not replace, broader fatigue risk management policies.