Introduction
Good sleep is fundamental to every aspect of physical and mental health yet historically relatively little time has been given to teaching healthcare professionals about sleep.
Understanding the basics of sleep physiology, and common sleep problems is important for you as a paediatrician looking after children and families, where sleep difficulties, and the subsequent impact, can be a common reason for why children and young people might see a doctor.
However, as paediatricians in training, you will deliver acute and emergency NHS care 24 hours a day, seven days a week, 365 days a year. Working long shifts, particularly at night when it means working against your body clock, often leads to sleep deprivation, and to fatigue. Shiftworking and fatigue affect both your own health and safety, but may also affect the care that you deliver to your patients.
Strategies to identify and manage the impact of fatigue are therefore essential in the modern NHS.
This is a challenge for all of us, especially considering workforce issues, rota gaps and other issues facing paediatricians. This resource is intended to look at some of the consequences of being tired at work and to try to give some practical ideas which may help you. Tackling the workforce challenges will take time, but hopefully, some of these changes may help you start to improve how you work at night.
Risks to patient safety
Tired doctors can make mistakes – it’s a simple truth often hidden in plain sight.
There is concern that is not possible to sustain optimum levels of performance and ability for long periods without taking a break. The Highway Code tells us that drivers should not drive for longer than two hours without stopping for a 15-minute break for exactly this reason.
Close attention is paid to working hours and conditions for professions like pilots, where airlines will ground a plane rather than have a pilot fly in excess of their safe working hour limits.
When you work for long periods without a break, especially if this is at night when your brain and body are not expecting to be awake at all, your ability to do your job can be impaired. Thinking becomes slower and more sluggish, reaction times slow, judgment falters, and you may make riskier decisions. You will tend to perseverate, to continue to do things which aren’t working well. Your sense of empathy, critical to delivering good care to your patients, may become blunted as your levels of fatigue rise. Your ability to deliver safe, effective, efficient care to your patients begins to drop sharply the more tired you become.
This means that paying attention to staff fatigue is critical to delivering patient care appropriately.
Your own safety
While shift work is necessary in order to deliver 24 hour care, it has been shown to be bad for your health. So how can healthcare staff look after their own health?
Regular periods of rest and breaks during our working days and nights shouldn’t be a luxury. They are an essential component in being able to deliver patient care safely, effectively and efficiently. Achieving this can be challenging, especially in the face of significant pressures in our healthcare system – but working without breaks can increase the risk of harm both to your patients and to yourself.
You should expect to get two 30 minute breaks during every shift of 9 hours or longer, at least 75% of the time. In addition, any doctor who works a night shift lasting 12 hours or more, should receive a third 30-minute paid break. This is formally included in the terms and conditions of the new junior doctors’ contract in England, but should be the minimum expectation of every healthcare worker.
We are not superhuman. Our physiology is as normal and as vulnerable as our patients. If we don’t look after ourselves, we cannot look after our patients as well as they deserve.
An example of a campaign intended to stress the importance of regular breaks to healthcare is the HALT: Take A Break campaign at Guy’s and St Thomas’ NHS Trust. HALT is a work in progress, but it is beginning to change the culture around staff breaks, emphasising these are essential to provide safe, effective and efficient care to patients
Driving Tired
When you drive (or cycle) home after a night shift, the levels of fatigue commonly experienced produce a similar effect on your driving ability as if you are driving at the legal drink/drive limit. This means your risk of a road traffic accident, including serious ones, significantly rises.
Tragically, this means healthcare workers still die simply getting home after night shifts.
Surveys of healthcare workers, such as this one looking at the experience of fatigue on anaesthetists in training confirm that more than half of respondents have experienced a ‘near-miss’ when driving home after a night shift. Many of those who regularly travel by car say that they have felt too tired to drive home.
The survey also emphasised the impact of fatigue on every aspect of their personal and professional lives:
- Nearly 75% reported effects on their physical health or psychological wellbeing
- More than two thirds reported effects on personal relationships
Working the night shift
Most adults in the UK are chronically sleep deprived, by about one hour per night on average. This is equivalent, for most, to missing one entire night’s sleep per week.
For shift workers, and those on night shifts, this means that they often start the shift with a ‘sleep deficit’. Part of this can be tackled by embracing good sleep practices, from creating a good sleeping environment to a good sleep routine including exposure to as much natural daylight as possible, exercising, eating regular meals and minimising exposure to your phone and other electronics before bed.
Preparing yourself for a night shift is critical, but people’s ability to cope with working at night varies. Some of this variation is genetic – you probably know if you’re a morning ‘lark’ or a night-time ‘owl’, and this is largely inherited. When you work at night, trying to work at night-time as if it is day despite your brain telling you that you should be asleep, you are going against your body clock. Physiologically, it is equivalent to working while significantly jet-lagged. It’s no surprise then that it can leave you feeling sluggish, exhausted and physically uncomfortable.
This means that for many there is no ‘good’ way to work at night, there are simply ‘less bad’ ways to cope with the demands of the night shift.
Simple strategies applied consistently before, during and after a night shift, and in the post-nights recovery period, with an understanding of basic sleep and circadian physiology can help to offset some of the impacts of fatigue and sleep deprivation.
The essential requirement to take regular breaks becomes even more important when working at night, and robust systems should be in place to both emphasise and permit this. The skill of being able to ‘power nap’ during short breaks is a useful one to attain and develop.
Here are some suggestions about what you can do before, during and after a night shift.
Preparing for the night shift
- Maintaining a good core sleep routine
- Rest with an afternoon nap or lie in before starting a night shift
- Drink and eat well
- Exercise in the morning which may encourage napping in the early afternoon.
During the night shift
- Work as a team to provide effective cover for breaks.
- Avoid high calorie, high fat and high carbohydrate foods – night shift calories do count.
- Try to keep to your normal eating patterns and times as much as possible.
- If you can, try not to eat too much between midnight and 6am, and if you do need to snack choose healthier options such as fruit, nuts, soups, etc.
- Drink lots of water.
- Aim to stick to a consistent routine during shifts.
- Let patients sleep – keep light and noise to a minimum in clinical areas.
- Use your breaks to rest or nap if possible.
- Watch out for the 4am dip, this is when both you and your patients are at their lowest physiological ebb. Take time to double check all critical calculations.
After the night shift
- If you are too tired to drive, don't.
- When you drive (or cycle) home after a night shift, the levels of fatigue commonly experienced produce a similar effect on your driving ability as if you are driving at the legal drink/drive limit. This means your risk of a road traffic accident, including serious ones, significantly rises. Tragically, this means healthcare workers still die simply getting home after nightshifts. For doctors working to the NHS England junior doctors contract, there is a legal obligation for employers to provide either an appropriate place for them to sleep after a night shift, or provide alternative arrangements for safe travel home, if they feel too tired to safely drive.
- Use public transport where possible, and if you can wear sunglasses on the way home – daylight will encourage your brain to feel awake and reduce your chance of getting good quality sleep (but be cautious about wearing sunglasses if you’re driving).
- Aim to be in bed as quickly as possible after your shift ends, the later you get to sleep, the less total sleep you will have.
- Try not to use electronic devices and try to keep your phone in a different room on airplane mode.
- Have something to light to eat and make sure you don’t go to bed hungry.
- If you share a house or flat, make sure they know you’re working night shifts and when you’re trying to sleep.
- Avoid alcohol, nicotine and caffeine.
- When you wake, make sure you’re exposed to bright light for the first 20 minutes after waking.
- After your final night, aim for a short morning nap (1-2 hours), ideally before midday then get up and try to keep to as ‘normal’ day as possible, including normal eating and exercise patterns as well as aiming for as normal a bedtime as possible. You’re likely to need two ‘normal’ nights to re-establish a usual sleep pattern.
More detailed information is available here: Managing the effects of shift work on your health
What could employers do to help?
I believe paediatric departments and hospitals could put in place measures to support their staff and teams with respect to fatigue and nightshift working.
This could include:
- Including teaching at induction for all trainees on sleep, shiftwork and fatigue
- Adopting a positive attitude to shiftworking, particularly at night
- Support staff to be able to take short ‘power naps’ during statutory breaks at night
- Designing rotas that:
- take into account circadian physiology (ie forward rotating (day-evening-night) designs)
- provide adequate recovery time after nights to re-establish normal wake/sleep patterns
- minimise frequent transitions between day and night shifts
- Ensure staff are compliant with current rest/break entitlement/requirements
- 1 x 30 minute break for a shift lasting >5 hours
- 2 x 30 minute breaks for a shift lasting >9 hours
- 3 x 30 minute break for a night shift lasting 12 or more hours.
- Actively support and encourage mechanisms to highlight where this is not being achieved (i.e. exception reporting/Guardian of Safe Working in England)
- Encouraging team based, multidisciplinary, ‘hospital at night’ approach, including bleep filtering and tailored protection facilities to support all members of the team being able to take appropriate breaks
- Provide appropriate rest areas and facilities, especially overnight, which allow staff to ‘power nap’ during breaks if they choose to
- Provide access to good quality, healthy, food for night staff
- Provide an appropriate place to sleep, free of charge, for staff who are too tired to drive home after a night shift (or make appropriate alternative arrangements where this is not possible)
- Offering regular screening, via Occupational Health departments, to all shift workers for sleep disorders
If you would like to contact me about presentations that you could use in your training, please email me on michael.farquhar@gstt.nhs.uk.