Rest after night shift and call: what the rules say

Why rest rules belong in the rota

Rest after a night or a 24-hour call is easy to agree with and easy to break by accident. It usually goes wrong in the gaps: a clinic booked the morning after call, a late shift followed by an early one, or a swap that quietly removes someone's recovery day. The fix is to treat rest rules as checks that every draft rota must pass, just like cover. First, though, you need to know which rules apply to you.

EU Working Time Directive 2003/88/EC

The Working Time Directive sets minimum standards that EU member states put into national law. The key articles for rota planning are:

• Daily rest (Art. 3): a minimum of 11 consecutive hours of rest per 24-hour period.
• Breaks (Art. 4): a rest break where the working day is longer than six hours, with details set by collective agreements or national law.
• Weekly rest (Art. 5): per seven-day period, an uninterrupted 24 hours plus the 11 hours of daily rest. Member states may average this over a reference period of up to 14 days (Art. 16).
• Maximum weekly working time (Art. 6): an average of no more than 48 hours per seven-day period, including overtime. The reference period for the average may be up to four months (Art. 16), with longer periods possible only under the conditions in Articles 17 to 19.
• Night work (Art. 8): normal hours for night workers must not exceed an average of eight hours in any 24-hour period. "Night time" is a period of at least seven hours that includes midnight to 05:00, and a night worker is someone who normally works at least three hours of their daily working time during it (Art. 2).

Two features matter for hospitals. First, Article 17(3)(c)(i) allows derogations from the daily rest, break, weekly rest and night work articles for hospital care, including doctors in training, but only if workers get equivalent compensatory rest or, in exceptional cases, appropriate protection (Art. 17(2)). Article 17(4) allows similar exceptions at shift changeovers. Second, Article 22 lets a member state allow individual opt-outs from the 48-hour average under strict conditions. So the national rules in your country may differ from the headline numbers, and the compensatory rest they require is where you need to look.

On-site on-call is working time

Two Court of Justice judgments shaped how hospital on-call is counted. In SiMAP (C-303/98), the Court found that on-call time spent by primary care doctors who had to be present at the health centre was working time. In Jaeger (C-151/02, 9 September 2003), it held that on-call duty where a doctor must be physically present in the hospital is working time in its entirety, even if the doctor may sleep when not needed. For rota planning, that means a resident on-site on-call night counts in full towards the 48-hour average, and the hours spent there are not rest.

ACGME requirements for US residents

In the United States, accredited residency programmes follow Section 6 of the ACGME Common Program Requirements (Residency). The current version (with FAQs incorporated, effective 1 July 2026) says:

• 80 hours per week (6.20), averaged over four weeks, including in-house work, clinical work done from home and all moonlighting.
• Eight hours off between scheduled periods (6.21): this one is worded as "should", not "must".
• 14 hours free after 24 hours of in-house call (6.21.a).
• One day in seven free (6.21.b), averaged over four weeks; at-home call cannot be assigned on those days.
• 24 hours maximum continuous scheduled clinical assignment (6.22), plus up to four hours for transitions of care and education, with no new patient care responsibilities in that time (6.22.a).
• In-house call no more often than every third night (6.27), averaged over four weeks.
• At-home call (6.28): time spent on patient care counts toward the 80 hours; it is not subject to the every-third-night limit but must respect the one-day-in-seven rule.

The appended FAQ adds two practical points: averaging is done per rotation (over four weeks, a month or the rotation if shorter), not as a rolling average, and vacation or leave days are removed from both sides of the calculation. Specialty Review Committees can set stricter limits, and the ACGME has a major revision of these requirements in progress, so check the current document for your specialty.

England: the 2016 resident doctor contract

Resident doctors (formerly "junior doctors") in England work under the 2016 terms and conditions. The BMA handbook on the 2016 contract and the NHS Employers FAQs summarise the rota limits:

• A maximum average of 48 hours a week and no more than 72 hours in any 168 hours.
• A maximum shift length of 13 hours (on-call periods up to 24 hours).
• Normally at least 11 hours of continuous rest between shifts; if breached, time off in lieu within 24 hours.
• A maximum of seven consecutive shifts, then at least 48 hours of rest (up to eight by agreement of the doctors on the rota).
• A maximum of four consecutive long shifts (over 10 hours), then at least 48 hours of rest.
• A maximum of four consecutive night shifts (at least three hours between 23:00 and 06:00), and at least 46 hours of rest after nights. The BMA handbook applies this whether nights are rostered singly or consecutively; the original 2016 text required it after three or four consecutive nights, and some summaries, including the NHS Employers FAQ, still use that wording.
• Weekends: all reasonable steps to avoid more than one weekend in three, with an absolute limit of one in two.
• On-call: no more than three on-call periods in seven consecutive days unless agreed locally, and the day after an on-call period must not be rostered to last longer than 10 hours.

Scotland, Wales and Northern Ireland have their own contracts, so these numbers apply to England only.

Worked examples

England, a run of nights. A resident doctor works four nights, Monday to Thursday, 21:00–09:00. Each shift is 12 hours, under the 13-hour cap, and four is the maximum run. The last night ends at 09:00 on Friday, and 46 hours later is 07:00 on Sunday, so the earliest next shift starts on Sunday morning. The four nights total 48 hours, so any seven-day window containing them leaves room for no more than 24 more hours under the 72-hour limit.

US, a 24-hour call. A resident starts in-house call at 07:00 on Monday. Scheduled clinical duty ends at 07:00 on Tuesday, and handover and education may run until 11:00 at the latest. If they leave at 11:00, the 14 hours free take them to 01:00 on Wednesday, so in practice the next duty is Wednesday morning. Tuesday should carry no clinic or theatre list.

EU, a heavy week. A 60-hour week is not by itself a breach of the 48-hour average if the average over the national reference period stays at or below 48. It still has to respect daily and weekly rest, or the compensatory rest your national rules require.

Turning rules into rota checks

• Write down the rule set that applies (law, contract, programme) and the reference periods it uses.
• Block the rest period after every night run and every 24-hour call before assigning anything else.
• Check the gap between every pair of consecutive shifts against your minimum rest.
• Check rolling and averaged hours, counting on-site on-call as working time.
• Re-run all checks after every swap, not only when the rota is first built.

For the fairness side of call rotas, see how to make a fair on-call schedule for residents; for nurse patterns and forward rotation, see the nurse shift schedule template. To try a balanced call list quickly, the free call schedule generator runs in your browser and your data stays in the browser.

Sources

• Directive 2003/88/EC (EUR-Lex): definitions (Art. 2), daily rest (Art. 3), breaks (Art. 4), weekly rest (Art. 5), 48-hour average (Art. 6), night work (Art. 8), reference periods (Art. 16), derogations (Art. 17, 19) and opt-out (Art. 22).
• Case C-303/98, SiMAP (EUR-Lex): on-call with required presence at the workplace is working time.
• Case C-151/02, Jaeger (EUR-Lex): on-site hospital on-call is working time in its entirety.
• ACGME Common Program Requirements (Residency), 2026, with FAQs: sections 6.20–6.28 (80 hours, rest, days off, 24+4 hours, call frequency, at-home call) and averaging FAQ.
• BMA, Resident doctors' handbook on the 2016 contract: hourly limits, consecutive shift and night limits, 46-hour rest, weekends, on-call rules.
• NHS Employers, FAQs for the 2016 doctors in training contract: 72 hours in 168, 13-hour shifts, seven consecutive shifts, four consecutive nights, weekend frequency.