The below article has been reproduced from a BMJ series to help medical students make the leap to budding doctors. In this article, Geoffrey Robinson and co-authors provide advice on surviving night shifts.

Working through an entire night is now a standard part of most junior doctors’ rosters. The competing needs of service provision and limited hours has resulted in the widespread introduction of night shift systems; a junior doctor will cover several hospital wards, as well as manage acute admissions, between the hours of 10 pm and 8 am.¹

The doctor may be required to work up to seven such shifts in a row, a system that has been designed to reduce the effects of sleep deprivation on clinical decision making and improve patient safety.^1,2 However, working at night for a week is inherently stressful and may drastically affect the wellbeing of junior medical staff and their patients.^1,3

It’s not easy

Occupational physicians have long recognised that regular night shifts have a negative impact on physical and psychological wellbeing. Junior doctors work intermittent night shifts only and are therefore not at risk of many of the chronic health effects of regular night work.¹ However, intermittent night shift work for doctors is also associated with tiredness, sleep deprivation, low mood, and increased stress.^1,4

Before the shift

Although night shifts are supposed to improve patient care by avoiding 24-hour shifts, working up to seven night shifts in a row often generates serious sleep deprivation.^1,5 Many of the other stressors of night shift are exacerbated by tiredness, see below ^4,6 for some suggestions to minimise risks while on nights.

During the shift

A structured approach to night duty can limit the stress of the experience. We recommend developing a routine based on the suggestions outlined below.^4,6 While most of the suggestions are self-evident, they can be forgotten or omitted in the situation of competing requirements and requests during the night shift.

Attending to clinical issues

Night shifts present a great learning opportunity. For many new doctors, night shifts will be when they are exposed to an acutely ill patient for the first time and have to make clinical decisions. However, with this increased responsibility comes a decreased margin for error, and this can be daunting for new house officers. Several clinical problems commonly present on night shifts, and we suggest you revise the management of these conditions before starting night duty. These include shortness of breath, chest pain, hypertension and hypotension, confusion and agitation, fever, hyperglycaemia and hypoglycaemia, pain, and common postoperative conditions, such as fluid balance.

Although junior doctors often carry a cardiac arrest pager while on regular duty, they are more likely to be first on the scene at night. Therefore we also suggest revision of resuscitation protocols. Most importantly, carry or have access to an emergency medical manual.

Possible pitfalls

Some situations can trip up an inexperienced doctor at night, and we urge you to be aware of these. Make sure you call for help when it is needed—the one thing you do not have and are not expected to have is experience. Therefore when in doubt, ask for help. Options for second opinions include the senior house officer, the registrar, the consultant and the intensive care team. Even the grumpiest response from a consultant in the middle of the night is better than having to deal with a preventable serious adverse event or a patient’s death. Make sure you return to review acutely ill patients—remember that there are fewer nursing staff at night; therefore your very unwell patient may not be as closely observed as he or she would be during the day. Hopefully, as more hospitals introduce out-of-hours multidisciplinary teams, sufficient staff will be available at night, with leadership to protect the patients and staff from harm.^9,10

A matter of understanding

It is important to ensure that patients’ notes contain good documentation. The day team needs to know if you have treated their patient during the night, and so just charting medications is not sufficient. Where possible, do not give verbal orders for medications. Try to see patients and their notes first, especially if you are asked to chart night sedation. In general, try to avoid unilaterally changing management plans instituted by day teams. For example, don’t stop long-term medications in the middle of the night unless an acute indication arises—discuss the issue at handover instead.

Patients who are sick during the night need managing in the same way as if they had been admitted during the day. A patient with suspected subarachnoid haemorrhage needs a computed tomography scan even if it means waking up the radiologist—they are on call too. The same approach applies to routine investigations that are clinically indicated. Examples are doing electrocardiograms for patients with chest pain, blood cultures for febrile patients, and arterial blood gases in patients requiring oxygen treatment.

Night shift work is a fact of life for junior doctors today. It has its own set of stresses and difficulties, most of which are related to tiredness. We hope that this set of basic suggestions will help new house officers cope better with these and be more able to take advantage of the considerable learning opportunities that occur in the hospital at night.

Original authors:
Geoffrey Robinson, general physician and chief medical officer, Capital and Coast District Health Board, Wellington, New Zealand
Sharmila Bernau, senior research fellow
Sarah Aldington, senior research fellow
Richard Beasley, general physician, Medical Research Institute of New Zealand, Wellington.

We gratefully acknowledge the BMJ for permission to reproduce this article.

References

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3. Horrocks N, Pounder R. Working the night shift: an audit of the experiences and views of specialist registrars working a 13-hour night shift over 7 consecutive nights. http://www.rcplondon.ac.uk/news/EWTD_nightshift. pdf (accessed Jul 2006).
4. Horrocks N, Pounder R on behalf of an RCP Working Group. Working the night shift— preparation, survival and recovery: a guide for junior doctors. Clin Med 2006;6:1-7.
5. Veraiah A. Weeks of nights give the illusion of working fewer hours. BMJ 2005;331:515.
6. British United Provident Association. Making shifts work for you. http://www.bupa.co.uk/health_information/html/hea lthy_living/sleep/shiftwork.html (accessed Jul 2006).
7. Arnedt JT, Owens, J, Crouch, M, Stahl, J, Carskadon, MA. Neurobiological performance of residents after a heavy night call vs. after alcohol ingestion. JAMA 2005;29:1104-6.
8. Rollinson DC, Rathelev NK, Moss M, Killiany R, Sassower KC, Auerbach S, et al. The effects of consecutive night shifts on neuropsychological performance of interns in the emergency department: a pilot study. Ann Emerg Med 2003;41:400-6.
9. Royal College of Physicians. The development of the out-of-hours medical team (OoHMT.)RCP statements. http://www.rcplondon.ac.uk/college/statements/ewt d_developOOOmt.asp (accessed Jul 2006).
10. NHS Modernisation Agency. Findings and recommendations from the hospital at night project Other negative psychological April 2004. http://www.modern.nhs.uk/workingtime/17 048/WhatisHospitalatNight/1_1.pdf12 (accessed Jul 2006).