Is sleeping on nightshifts just a dream?

Authors: Anne Gulland 

Publication date:  02 Mar 2017


A lack of beds and negative attitudes towards sleeping at work may be putting doctors at risk, Anne Gulland reports

While the days of doctors doing week long runs of night shifts may be over, the pressure on rotas and increased workloads mean that many doctors are coping with a lack of sleep.

The General Medical Council’s national training survey found that 25% of its 55 000 respondents said that their working patterns left them sleep deprived on a daily or weekly basis.[1] This compares with 17% of respondents in 2015.

Mike Farquhar, a consultant in paediatric sleep medicine at Evelina Children’s Hospital in London, is on a mission to educate doctors about fatigue.

“This is physiological. When you ask someone to work a night shift it’s like putting them on a plane to Sydney and expecting them to run an intensive care unit when they get off,” he says.

Last year, every new foundation trainee at his own trust of Guy’s and St Thomas’ was taught about the effects of fatigue and how to manage nightshifts. And next month, to coincide with World Sleep Day, the trust is launching an initiative to encourage everyone to take breaks during the night.

Nick Schindler, a paediatric registrar at Ipswich Hospital, arranged for Farquhar to deliver his workshop on fatigue to around 90 paediatric senior house officers in the East of England. It was apparent that there was a range of attitudes towards sleeping during shifts. Some hospitals encouraged doctors to take breaks and short naps but others didn’t. Some hospitals didn’t have on-call rooms, and at some of the hospitals that did, doctors didn’t know about them.

This anecdotal evidence is backed up by a survey Farquhar conducted last year which found that only 16% of 104 paediatric trainees said that naps at night were supported by their hospital.[2] A further 31% said that naps were actively discouraged. Many reported a lack of on-call rooms.

Schindler says, “In Ipswich there are on-call rooms and if I wanted to I could sleep in there all day. A number of hospitals have taken away on-call rooms and our first battle is to stop that from happening.”

While facilities are important, a culture shift is also necessary, says Schindler.

“The nurses have a positive culture where they cover for each other. They take short breaks and they’re protective of that time. Doctors have this misplaced sense of pride and we martyr ourselves,” he says.

Farquhar says that a lack of sleep is most relevant to junior doctors on rotations, who may end up facing a long drive home after a night shift.

The death of Ronak Patel, a trainee anaesthetist at Norfolk and Norwich Hospital, is a reminder of the dangers of driving when tired. A police investigation concluded that he probably fell asleep at the wheel after a night shift before veering into the path of an oncoming lorry.[3]

This incident prompted a survey of anaesthetists to investigate the impact of fatigue. The results will be published this summer and Emma Plunkett, chair of the Group of Anaesthetists in Training at the Association of Anaesthetists of Great Britain and Ireland, hopes that it will prompt a culture shift.

“Doctors should be enabled and encouraged to take a rest at work. If someone has a long commute and has been up all night we should remind them to use the rest facilities before driving home,” she says.

Junior doctors may also have an unlikely ally in their new contract, says Farquhar. The contract has introduced the new role of a guardian of safe working hours and stipulates that doctors should get at least 48 hours’ break after three consecutive night shifts.

“The new contract puts in place specific safeguards, but the challenge will be sticking to it,” says Farquhar. “What the new contract will show is that we cannot deliver the standard of care which is minimally acceptable for patient safety. The new contract gives us a lot of things to work with to emphasise how pressured the system is,” he says.

David Evans, vice president of training and assessment at the Royal College of Paediatrics and Child Health, says that it’s important that the guardian is seen to be protecting junior doctors’ hours.

“People tend to only report breaches of hours if they feel it’s going to make a difference. If there are successes and they’re publicised, people will report,” he says. He has also called for the centralised collection of reporting so that it can be properly monitored, and adds that enabling doctors to sleep is about more than just good working practices. “We’re talking about protecting doctors but this is also about patient safety,” he says.

Night shift tips[4]

  • Aim to stick to a consistent routine during each shift

  • Work as a team to provide cover for breaks

  • Consider the use of “bleep filtering” systems to minimise interruption to team members on breaks

  • Avoid high calorie, high fat, and high carbohydrate foods: night shift calories do count, and contribute significantly to increased risks of impaired glucose tolerance and cardiovascular disease

  • Try to maintain your normal eating patterns as much as possible when working nights

  • Aim to minimise eating between midnight and 6 am where possible, and when you do eat choose healthy, satisfying options

  • Keep well hydrated: carry a water bottle and drink regularly

  • During breaks, have short (15 to 20 min) naps

  • Use caffeine carefully

  • Don’t drive home if tired, find somewhere to have a short nap

References

  1. Rimmer A. Workloads threaten to undermine doctors’ training, GMC finds. BMJ  2016;355:i6495. [Link]   [Link] .
  2. Rimmer A. NHS needs culture shift regarding sleeping at work. BMJ Careers 2016 [Link] .
  3. Ronak Patel “had been singing to stay awake” before fatal crash. 2016 [Link] .
  4. Farquhar M. Fifteen-minute consultation on problems in the healthy paediatrician: managing the effects of shift work on your health. Arch Dis Child Educ Pract Ed  2016;edpract-2016-312119.. [Link]   [Link] .

Anne Gulland BMJ Careers

 agulland@bmj.com

Cite this as BMJ Careers ; doi: