From triple helix - summer 2006 - Surviving a Week of Nights [pp16-17]
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The prospect of working every night for a week is daunting to say the least! After working nights in several specialties as a GP trainee, I offer these thoughts and coping strategies in the hope of reducing anxiety for anyone starting out on weeks of nights.
The creation of weeks of nights was almost accidental. The New Deal of the late 1990s reduced junior doctors' hours, but left the on-call system intact. Then the imposition of the European Working Time Directive in 2004 made the on-call system unsustainable, since it stipulates eleven hours compulsory rest per 24 hours of work. Whole weeks of nights then evolved as hospital managers tried to reduce the number of working days lost by doctors taking compulsory rest.
This change has brought some advantages. There are few 24 or 32-hour shifts. Doctors working nights for a sustained period may be able to adapt their body clocks to their shifts. Training may be improved by having a number of weeks with no night working at all, so minimising disruption to ward rounds, theatre lists and clinics.
But there have been some difficulties. Some have found that arranging leave has become difficult. If swapping night shifts is banned (as in many trusts), serious problems may be caused for those who need, say for family reasons, to be on annual leave at specific times. Some firms are adversely affected during the ordinary day, particularly if the registrar is on nights.
Murray et al suggest that the 91 hour week that can be clocked up when doing seven consecutive nights is dangerous for both patients and doctors. They presented evidence from the USA suggesting that serious medical errors increase by one third when doctors' hours lengthen from 65 to over 80 in a week. In addition, the risk of being involved in a road accident whilst commuting was shown to rise by 16 percent for those working these longer hours.
Many of us also have difficulties with our family lives during night shifts.Working six weeks of nights during my first year of marriage has been difficult, but such problems are difficult to avoid. One successful strategy is to plan specific time together just before and after a block of nights. In addition, my wife has tried, where possible, to make any evenings and nights when she has be to away from home coincide with my weeks of nights.
The physical impact of night shifts can be reduced with preparation. Re-setting your body clock is difficult. Some shift based rotas, such as those worked by many A&E doctors, may aid body clock adjustment by scheduling a half-night shift, for example six pm to two am, in the run up to nights. However, in most cases, nights are started at the end of a week of ordinary days.
Ensure you are not overtired before your week of nights starts. Don't start the week with no petrol in the car and no food in the house. Accept that you will do little else between shifts than travel, eat and sleep. It may be best to go to bed at midday and get up at 7.30pm, much as if day and night were reversed, but this can be difficult if it is too light or noisy at home.
Make sure you don't dehydrate. Many of us try to survive nights with urine outputs that would have nurses calling for a doctor urgently! I always try to eat during a shift, and find that I get very tired if I don't. However, some find eating makes them sleepy, and it can be difficult to eat healthily at 3am!
I personally find sleeping in quiet patches helpful, but not everyone agrees. There is some evidence that short naps do help: Murray et al quote a NASA field study amongst pilots which suggested that a 40 minute nap produced a 34 percent increase in performance and a 54 percent increase in psychological alertness when compared with no nap.
The manner in which you work makes a big difference.Working efficiently is vital. Take a handover, familiarising yourself with the sickest patients. Get routine jobs sorted out first, so that only emergencies need concern you in the early hours of the morning. Along with your senior, set a plan for any difficult patients at the beginning of the shift; that way they have more chance of rest and you can work more quickly. There is not time to 'wait and see' if you are busy, so ward emergencies are best treated definitively when you first see them. Many investigations can wait until morning, but be prepared to argue your case (graciously) with technicians for the few that cannot.
I have learned some lessons only through bitter experience. My judgment is worse during night shifts, particularly between about 3 and 7 am - I've learned to double-check my work.
Try to foster a good relationship with A&E. Often the same A&E SHO is on throughout your week of nights: a friendly attitude can lead to more cooperative A&E calls, so fostering a better working relationship.
I cannot hope to be refreshed if I do not leave on time. A clear handover makes it easier to get away promptly. In a shift system, it is inevitable that we will pass on some work and not complete everything ourselves.We should not feel guilty about this, but in turn we must be prepared to take on handed over work ourselves at the start of our shifts. In some jobs, you will be scheduled to work until 10 am in order to participate in a post-take ward round. However, if those ward rounds have a habit of going on past the end of your shift, you may need to ask to leave on time. I have found most consultants to be reasonable about this but you may have to take up any problems with whoever is responsible for monitoring your hours.
How can your relationship with God fit into such busy weeks? Church and house group meetings are almost impossible to attend when on nights. Even formal quiet times may be difficult. However, our relationship with God is not just a function of scheduled activity.We are commanded to pray constantly. Gaps during work allow prayer, and these may be more frequent at night. In addition, it is possible to pray whilst working, perhaps when waiting for a bleep to be answered or for the blood gas machine to process your ABG. There is often time to read a pocket Bible or some devotional material such as the Doctor's Life Support, which is also available on the CMF website.[4,5]
Looking outwards, I have found more opportunities for meaningful conversations at night, particularly with other staff. Night shifts may therefore be an exercise in practising the presence of God, learning to depend more on his personal relationship with us, as our usual faith props are temporarily unavailable.We need to trust that God's promises are enduring, and that he will not withdraw from us simply because we are tired and can't be at church. He is with us 'to the end of the age'.
Ultimately, obedience to God must take priority. Frequent blocks of nights have an impact not only on our relationship with God but on fellowship with other believers. If we feel called to career choices that will involve many years of night work, then we must evolve sophisticated coping strategies and trust God to help us do this. But, if having tried some of these coping strategies, nights as a seasoned junior are still proving a serious stumbling block, then perhaps God is leading you to serve him in a less acute specialty.
Before the week starts
After each shift
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