Learning how to manage a night shift will protect you and your patients, says Sara Dawson
Dr Lauren Connelly had come off duty after a gruelling night shift at Inverclyde Royal Hospital and was driving home when she veered off the M8, crashing her car. Unfortunately, Dr Connelly died as a result of the injuries she sustained.
Dr Connelly’s father Brian claims that she was suffering from fatigue after working more than 90 hours without a day off. The case has caused much debate across the blogosphere. The Scottish government responded, saying it supports NHS boards in ensuring doctors’ rotas comply with the European Working Time Directive.
Night work requires doctors to remain awake and alert, when physiologically programmed to be asleep. Many studies of human efficiency and mental agility have shown significant dips between 10pm and 6am, and the risk of injury is 30% higher on a night shift compared to a morning one.
On the one hand, working nights is a great learning opportunity for new doctors to cover unfamiliar specialties, have increased clinical responsibility and deal with acutely ill patients for the first time. But on the other, it is associated with sleep deprivation, insomnia, disorientation, irritability, digestive trouble and poorer mental agility.
While the EWTD, which limits working hours to 48 hours a week, is technically implemented in most UK hospitals, it has been alleged that provisions are haphazard for covering sick colleagues and coping with heavy workloads.
Before a night shift:
- Be organised – Sort out personal issues, such as paying bills, etc, before starting a week of nights.
- Be healthy – The Health and Safety Executive (HSE) found that offshore oil rig workers who worked a split shift system – seven nights, then seven days – had a higher risk of heart disease, than those who worked 12 nights or days. So generally living a healthy and active lifestyle may reduce the negative effects of working nights.
- Be prepared – Several common clinical problems occur on night shifts, including shortness of breath, chest pain, hypertension and hypotension, confusion and agitation, fever, hyperglycaemia and hypoglycaemia, pain and common postoperative conditions.
- Get plenty of sleep – A doctor who has no sleep during the day leading into a shift will have gone 20-25 hours without sleep. This could reduce their psychomotor performance to the level of someone with an alcohol concentration of 0.10% – the legal limit to drive is 0.08%.
- Avoid your bedroom – Associate your bedroom with sleeping, by playing video games, etc, in another room.
- Socialising – See your friends or undertake a sporting activity
"A doctor who has no sleep during the day leading into a shift will have gone 20-25 hours without sleep"
During a night shift:
- Eat and drink properly – Follow a similar eating pattern to the one you follow in the day. Eat a main meal before you start, have “lunch” halfway through the shift and an easily digestible meal when you get home.
- Double-check – Your response is not as safe as it is during the day, so repeat calculations, double-check drugs, etc.
- Staff support – Although MDTs are becoming commonplace, there are still fewer nursing staff on the wards, so patients are not as closely observed as they would be during the day.
- Ask for help – If you need help ask for it. Grappling with a cantankerous consultant is better than having to deal with an adverse incident that leads to a patient’s death. The one thing you don’t have is experience.
- Caffeine – The circadian nadir is between 3am and 6am, so it may be tempting to drink more coffee to keep awake, but remember if it is consumed four hours before the end of your shift it will make it harder to sleep.
- Take naps – Short naps have shown to provide positive benefits for shift workers, but they should not last more than 45 minutes. Set an alarm beforehand to prevent you falling into a deep sleep. By taking a small dose of caffeine before your nap, you should start to feel the effects when you wake up, which may help overcome the sleep inertia you will feel after a nap.
- Maximise exposure to light – Exposure to bright light has an alerting effect on the brain and improves performance.
"If you’re planning to drive home, consider the risks of doing so. If in doubt take a taxi"
After a night shift:
- Limit the effects – Our bodies are controlled by our body clock, situated in the suprachiasmatic nucleus (SCN) in the hypothalamus. It generates circadian rhythms that regulate the physiological processes in the body. Working nights causes a mismatch between the circadian timing system and environmental synchronisers. Circadian rhythms are strongly influenced by natural light and dark, so wearing dark glasses on your way home, using earplugs, blacking out curtains and turning off your phone will limit the effects and make it easier to sleep during the day.
- Be extra vigilant – If you’re planning to drive home, consider the risks of doing so. If in doubt take a taxi.
- Sleeping pills are not recommended – They can cause hangover-like symptoms and addictive effects. Consult your GP if you think they are necessary; never self-prescribe.
- Horrocks, N and Pounder, R, Working the Night Shift: Preparation, Survival and Recovery: A Guide for Junior Doctors, Royal College of Physicians (2006)
If something goes wrong on a night shift, fatigue is no defence. A mistake by an overworked and tired doctor is still a mistake. Exhaustion is no defence for poor decision-making. Doctors who adequately prepare for a night shift minimise the risks for themselves and their patients, and reduce the likelihood of making errors.