Night and twilights shifts are integral part of our beloved and noble specialty. We obviously could not imagine emergency care not being delivered anywhere in the world on a 24/7 basis so love it or hate it, you will have to embrace the fact that as an emergency physician or an ED nurse, you will be undertaking some unsocial shifts.
It is probably fair to say that some of us hate working night shifts. This strong statement is based on a personal observational study I recently conducted on social media (Thanks Nicola for allowing me to use this).
For others however, working night shifts might be more convenient because of child care issues or because of a second job.
You should make no mistake though, unsocial hours do take their toll on both your physical and mental health. If you do not follow some basic rules on sleep hygiene and coping techniques, you are likely to suffer from burnout, depression and potentially other health problems.
In recent years, there has been some analogy drawn (rightly? wrongly?) between our profession and the aviation industry but this is could be a separate blog post on its own right (see further reading section below).
In this post, I am attempting to cover some tips you can use to prepare for your night shifts and how to recuperate from them.
The circadian rhythm: an intro
You will remember from your medical school studies that our bodies are regulated by an internal body clock located in the hypothalamus. The self-sustained oscillations created are spread out over a 24-hours period. They regulate everything from your body temperature or your blood pressure, your coordination/reaction time to even your testosterone secretion or bowel movements!
Thinking about this cycle, it is easy to understand why it is so unnatural to work a night shift and then sleep during the daytime. The circadian oscillations can however be adjusted to the local environment by external triggers, like light and temperature, and this is extensively used by NASA for their astronauts and lately in civil aviation too: the new Dreamliner jet by Boeing has internal cabin lights that adjust not only to external lights but also the season outside the plane.
Working a twilight or night shift therefore means fighting against these natural rhythms. Although you can somewhat adjust your internal pacemaker, it usually requires a few days of adaptation and effort. In the UK, most of night shifts for emergency medicine physicians are now split into two blocks Monday – Wednesday and Thursday – Sunday. I however was “lucky” enough to work in the old system as a trainee where we used to work a full block of a week of night shifts.
The below post is based on no or little evidence but mostly on my own experience in the relatively short decade and a half I have spent working in emergency medicine and its related fields.
BEFORE STARTING YOUR NIGHT SHIFTS
No big night out
Going out for a heavy night out with your friends or a Chardonnay-rich dinner the night before you start your night shifts is not a such great idea. Spend some time relaxing and allow time spent with your friends and family as you might not have the opportunity to see them for a short while as you start your nights.
Get some sleep before your start
Make sure you sleep plenty the night before your shift. Wake up following your natural pattern as dictated by your body clock (no lazy lie in!) and do something productive until the afternoon when you should try and have an afternoon nap. This technique should allow you not to mess up your internal rhythm before you even start your nights.
Replacing traditional night shifts with “casino shifts” may help. These are often comprised of 2 short shifts from 10pm-4am and 4am-10am with the notion that each provider would get sleep during the “anchor period” of the circadian cycle, 2am-6am. Small studies have shown this feasible, preferred by many, and perhaps perceived as better.
Again, have a look at our blog post on how to maximise your sleep here.
Prepare your granary
As you will be mostly work at night and sleeping during daylight hours, try to cut out on wasted time spent shopping in supermarkets after a shift by loading up your fridge with (healthy!) food and drinks in advance. Online shopping, you say? Forget it for when you are on nights: there’s nothing more annoying than the buzzer going off to let you know your weekly shopping has arrived when you have just managed to fall asleep.
Be aware of your downtime
Your deepest sleep is programmed in your above-mentioned biological pacemaker at around 2AM so try and take that mid-shift break at around this specific time period if possible. This should hopefully minimise the risk for clinical errors too. Your lowest body temperature is at around 4AM so a hot drink or that fleece would be welcome at this time.
What to eat/drink and what to avoid
Remember that “lunch”for you will be in the middle of the night so pack something you’ll enjoy ahead of your shift. Treat yourself but avoid spicy and heavy foods as they are more likely to contribute to fatigue. As always some sugar is good, too much is bad so go for a balanced diet. Make sure you stay well hydrated as you are likely in our profession to be on your feet all night.
Do not forget to use the toilets (easily done on a busy shift!).
I was surprised to read some weeks back that you can feel the effect of coffee within half hour of ingestion (some placebo effect too maybe?) and the effects can last up to twelve hours! So remember this and go easy on coffee and caffeine loaded energy drinks.
Also remember that tea is not necessarily a better option: it does contain more caffeine than coffee so it will all depend on how diluted you have it. Herbal tea is caffeine-free and an alternative option.
Try to avoid conflicts if you can. Remember that we are all tired in the middle of the night so conflicts probably happen more often during a night shift. This is true between healthcare professionals but also between us and frustrated patients/relatives. Take a deep breath, smile before you try to defuse a difficult situation. Use de-escalation techniques. Consider attending a conflict resolution training day if you have not come across this yet. Seek the help of a senior early before you lose your temper!
AFTER YOUR NIGHT SHIFT
Getting home from work
I cannot emphasise this strongly enough: if you have a long drive ahead of you after a night shift, please think twice before getting behind the wheel to drive home! Exhausted drivers are a threat to themselves and other members of the public too. It is simply not worth the risk(s) and is a catastrophe waiting to happen. We tend to overestimate our driving skills and driving home after a night shift is not ideal as our reflex times are significantly impaired. Consider therefore leaving your car home and use public transport instead. If you have a lengthy commute to do, book a hospital accommodation or a hotel nearby even if it is only to sleep a few hours before heading home. Your family and friends will be grateful to have you back home unharmed after a night shift even if it means you get there a little later.
Getting into bed
If you have to work more nights, get to bed straight after a little snack and shower. Do not get sucked into distractions like TV: this is not the time to watch two episodes from the last season of Game of Thrones. Switch off your mobile phone, close your blinds and bedroom door to minimise noises. I am not a fan of ear plugs personally but consider them if like me you live in the buzz of a metropolitan city centre.
Use your own bed and sleep alone (no further comment here)! Avoid the couch in the living room.
Avoid smoking, caffeine or alcohol consumption as they are likely to impede on those important hours of sleep that you desperately need. Sleeping tablets? They are simply a bad idea!
Recovering after a night shift
I know of some junior doctor or nursing colleagues who after a set of night shifts try and stay up until sunset. I personally think it is a bad idea as at this stage you need to recuperate on those lost precious hours. You however probably do not need to sleep all through the day so it is OK to get out of bed after a couple of hours of sleep. This should also allow you to go to bed before midnight and reset your circadian rhythm back into its normal pattern sooner. Try and do something you enjoy doing in the afternoon if you are up and about: a little 5k stroll or a walk in the park will allow you to replenish on that sunlight you have missed in the past days.
And as a closure…
One shoe does not fit all and it is evident that not all of the above will apply to everyone as we are all different . The trick is to find the right and balanced combination that works for you to try and minimise the harms caused by the interruption of the circadian rhythm.
I hope you can take one or tips away from this latest post and make your night shifts somewhat more bearable.
Further reading and listening:
- Have we gone too far in translating ideas from aviation to patient safety? No http://www.bmj.com/content/342/bmj.c7310
- Have we gone too far in translating ideas from aviation to patient safety? Yes http://www.bmj.com/content/342/bmj.c7309
- Surviving the night shift BMA http://bma.org.uk/developing-your-career/foundation-training/real-life-advice/surviving-the-night-shift
- Waking up to the effects of fatigue in doctors http://www.bmj.com/content/347/bmj.f4906?hwoasp=authn%3A1447967880%3A4044171%3A1838282160%3A0%3A0%3A1gDj0Ml%2F1r4PDCIVQBIKxQ%3D%3D
- Listen to this podcast on night shift from the ERCast team https://www.acast.com/ercast/night-shifts