Sleep is absolutely one of my favourite things in the world.
It can also be one of the most elusive. Almost all ED docs, by necessity, work some sort of shift pattern. Given that pretty much every single website on improving your sleep starts with “go to bed at the same time every night”, it’s not hard to see that we could have some problems here.
Thankfully, there are things you can do to sleep better – and that will make you feel better, be healthier and perform better in your job.
Sleep is really important for health – important enough that a recently published study suggesting a correlation between having less than 7 hours sleep and contracting the common cold made national news this week.
Most people need around 7-8 hours sleep a night. Some will require less. But how much you need is less important than knowing that by getting less sleep than you need, you accrue a sleep debt and you underperform. One of the most often quoted studies suggested that performance on some tasks after 17-19hours without sleep was equivalent to or worse than a blood alcohol concentration of 0.05%. Which is really important when you’re about to get behind the wheel of a two tonne hunk of metal and drive home in it…
Understanding the impact your sleep patterns have not only on your health but also on your ability to practice places greater emphasis on taking responsibility for your sleep patterns and sleep behaviour. This means recognising and adapting behaviours which are impairing your effectiveness (like big nights out before work the next day). Take good care of yourself and you’ll be better at taking care of patients.
After a long night shift, bed is the most awesome place – but don't drive tired. Get a taxi – PLEASE #TipsForNewDocs
— Natalie May (@_NMay) July 1, 2013
The Royal College of Physicians has produced an excellent short guide to working night shifts and much of the advice below is derived from it. Have a read here.
Even if the rest of this post makes you want to sob in frustration (because you have kids whose routine means that you can’t just go straight to bed after a night shift), there are probably things you can do to improve your sleep hygiene and get a better rest.
The quickest, easiest fix is to improve the environment you sleep in. To get the best out of your rest, make your bedroom a room for sleeping in. Try to avoid undertaking other activities (like working) in the room if you can but definitely avoid doing them in bed (the first rule of sleep hygiene? “Beds are for sleeping and for sex“).
The room itself should be quiet, dark and not too hot. Blackout curtains are an excellent investment (although a sleep mask, if you can get used to wearing one, is cheaper). Earplugs are also helpful for daytime sleep and are worth getting used to.
If you are oncall and may need to answer your phone, consider having calls put through to a landline phone so you can turn your mobile phone off, or activating the “do not disturb” setting on your mobile (on an iPhone you can set this so it will only alert you for phonecalls).
Use of electronics is a no-no – there is evidence that light exposure is key to wakefulness through the suppression of melatonin production (more on this later) and this study suggests that it is blue wavelength light which has the most profound effect. The same findings have been replicated for e-Readers and for self-luminous tablets before bed.
Beyond the light itself, if your phone rings or buzzes or lights up overnight, it’s reasonable to see how that might disturb your sleep pattern – and this study suggested that computer or mobile phone use immediately before sleep was associated with problems drifting off. Part of this has to be the process of winding down, so taking time to declutter your active brain before asking it to shut itself off makes sense.
If you are someone who struggles to drift off, try sleep focused mindfulness exercises. The purpose of these mindfulness exercises is to focus the mind and, in addition to improving overall health and resilience, this often results in sleep. These may be particularly useful when returning home after a busy shift and are better for your sleep than alcohol, however tempting it might be.
Lastly, if you are struggling to sleep don’t stay in bed tossing and turning – get up and do something else. That doesn’t mean pick up your phone or start working, but consider relaxation exercises, a bath or some relaxing music and return to bed when you start to feel tired. Building an association between your bed and sleep is important and often neglected. If you have no idea where to start, apparently this is the most relaxing tune ever…!
Working Late or Night Shifts – Preparation
It can be tempting to go out on a big night out the evening before you lose a bit of your life to a series of late or night shifts, but this is counter-productive for a couple of reasons; sleep debt and the effect of alcohol.
During your night shift you will accrue a sleep debt and being underslept before you start will not help – especially if you have had poor quality sleep which is the gift that alcohol brings; at all doses alcohol seems to cause “a reduction in sleep onset latency, a more consolidated first half sleep and an increase in sleep disruption in the second half of sleep.” In practical terms this means being drunk the night before your first night shift will offset any benefit you get from sleeping in because your sleep will be of poorer quality.
The Royal College of Physicians recommends a late afternoon nap, ideally at least 2 hours’ duration, before your pre-shift routine begins. Once you get up, try to get some light exposure. Ideally get out in daylight but artificial light does seem to work as well – this will delay melatonin production. Exercise in the evening shifts melatonin production til later on, increasing wakefulness so if exercise is part of your normal routine (if it isn’t, try it!) it may help you to stay awake during the shift if you exercise in the evening before work.
On the Night Shift
Light is helpful in maintaining your alertness. In the ED this is not usually a problem (often to the annoyance of our patients) but in ward areas lights are usually switched off to preserve patients’ sleep/wake routines as much as possible (they have these issues too!). Thankfully studies suggest that intermittent exposure to bright light is almost as effective as continuous – so get out in the corridor every so often to keep yourself alert.
If you get a chance to sleep on your break, that’s great. Most EDs are bleep-free so we don’t have to worry about that sort of interruption – however, finding somewhere to get your head down for 20mins is a bigger challenge. If you are going to sleep during your break it is advisable to let senior ED staff (registrar/nurse in charge/consultant if present) know so that they know where to find you if there is an emergency. Power naps (<45mins) are best – deep sleep should be avoided if you might be expected to perform clinically with very little notice.
Eat and drink as normally as you can – ideally as if it was a day shift – and try not to be dependent on caffeine. Its effects are temporary and can make you feel more tired after they wear off. The RCP suggests that immediately after a nap is the most likely time caffeine will be useful.
Make sure you have eaten, had a drink, had a break. It’s easy to look at a waiting room full of patients and feel guilty about having time for yourself but don’t – your clinical performance will be better (and safer) if you are well-fed; human factors affect your ability to practice medicine.
#tipsfornewdocs Remember to HALT. Take a moment if you're hungry, angry, late or tired before doing procedures / making decisions.
— Dr Andrew Mackay (@drandrewmackay) August 8, 2015
First and foremost, at the end of your shift – don’t drive tired. Please! The consequences can be devastating. The risk is highest at the end of a run of night shifts, where the sleep debt is at its greatest and you are unable to accurately self-assess the degree of your impairment.
— Natalie May (@_NMay) June 26, 2015
When you get home, whether or not you are due back at work again that evening, aim to go straight to sleep, avoiding distractions as much as possible. If you are hungry, consider that eating a large meal before bed will also disrupt your sleep pattern – I used to have breakfast at work before going home.
Avoid smoking, alcohol and sleeping tablets before going to bed. It is normal to wake during the daytime (just as it’s normal to wake overnight) – if it happens, just relax (PUT THE PHONE DOWN!) and you will usually drift off to sleep again. If you can’t get back to sleep, get up after 30mins but keep the lights low and aim for a late afternoon nap of a few hours before work.
If you have finished nights (hurrah!), get up, get some light exposure and do daytime things. The RCP says that post-nights partying is out too – for most effective return to daytime wakefulness, go to bed that evening at a sensible hour and get up normally the following day.
Sweet Dreams Are Made Of This…
OK, so the likelihood of you doing all these things differently after reading this post is small but there are some important quick wins in here. Be honest about your sleep hygiene, take responsibility for your sleep’s wider effects on your life and consider what you can change.
The talk by Haney Mallemat at SMACC US covered some of this (in addition to tips for rota masters on writing work plans which favour productivity of your staff using staggered shift patterns) – check it out here.
Until then, sleep well, sweet dreams – and I hope you get the best from your rest.
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