You aren’t evolved to be awake at night.
Your brain and body expect to be asleep during your biological night, so they can get on with the business of sleep, the essential caretaking tasks sleep does for you, when your eyes close and you dream the night away,
The physiological drive that pushes you into sleep at night, and keeps you awake by day, is your circadian rhythm, your body clock. You get a feel for how powerful circadian drive is when you cross timezones and experience the discombobulation, irritability, fatigue, upset stomach, clumsiness, slowing of mind and memory, body and soul that herald jet lag … and the fact that it takes many of us several days to really feel as if we’ve reorientated our sense of self to the new time zone our bodies find themselves in. As every seasoned traveller knows, our body clock takes time to readjust when it finds itself out of sync with the world.
When you work a night shift, you are being asked to do exactly the same thing. In the space of a day, you are expected to flip your body clock 180 degrees, to function at night as if it was day.
If you travel from London to Sydney, it would be rational to give you a few days to acclimatise to your new timezone before expecting you to head into the emergency department or intensive care unit to start work. The same consideration is rarely applied to night shift working – but the physiology is the same, meaning that shift workers can be affected by what is effectively ‘nightshift jetlag’.
Working at night is essential to provide safe, effective healthcare to all those that need it, 24 hours a day, 7 days a week, 365 days a year. We can’t change that. What we can do better is acknowledge that working at night has consequences, both on our ability to safely deliver patient care, but also the risk that it poses to our own health, as we fight against our body clocks to stay awake when our brains are shouting at us that we should be asleep, and try to reduce that where we can.
When we are tired and sleep deprived, our thinking is impaired. Our reaction time is slower; when you have been awake for 16-18 hours, your reaction time is the same as if your blood alcohol level were at the legal drink/drive limit. Our ability to process information, particularly new information, is reduced. We are more likely to make riskier decisions. Crucially, our insight into that is also lacking – we don’t acknowledge how affected we are. It adds significant risk to both patient and personal safety.
At its worst, personal consequences can be catastrophic. Doctors and nurses are at significantly increased risk of road traffic accidents driving home from night shifts. Fatal outcomes are still all too frequent a news story.
Some reduction in those risks can be achieved by healthcare workers making changes in their own daily routines to optimise the quality of their core sleep, alongside strategies they can adopt while working nights to reduce effects of nightshift jetlag. That must be supported by policies and strategies from employers which acknowledge that working at night is fundamentally different to working in the day, and needs to be thought about in its own specific way.
Regular breaks and rest are absolutely essential to safely deliver patient care, especially at night. Breaks are not optional, are not a luxury and, fundamentally, are there to protect our patients.
The ‘hero’ attitude, that the needs of the patient always take priority over the needs of the staff trying to care for them, is well-intentioned but misguided. Senior clinicians and managers should model and reinforce this message – regular breaks for every member of the team should be seen as an essential sign of a safe, effective working culture. In the same way patients were empowered to ask if their doctor or nurse had washed their hands before seeing them, we should encourage them to ask if the healthcare professional about to assess and treat them has had enough rest within their shift so far to do their job to the best of their ability.
Where health services are under increasing pressure, there is a temptation to see breaks as optional. The exact opposite is true – regular rest is even more essential when systems, and the staff within them, are under extreme pressure; healthcare workers will often fill in gaps in resources from their own personal reserve, until they simply have no more left to give and burn out.
As healthcare professionals, we are used to thinking about our patients’ physiology, and working to correct and compensate it when it is off balance. We must be better at recognising when our own physiology is acting against our ability to deliver safe, effective, efficient care, and compensate accordingly.
Making changes in how we work at night is challenging but even small steps towards making things better can result in patient and personal safety improvements.
Addition 12th February 2017
Mike suggested the following Storify as further illustration of the importance of this issue.
A guide to strategies individuals and employers can consider to try to reduce the impact of working against our body clocks can be found here:
Managing the effects of shift work on your health (https://ep.bmj.com/content/early/2016/12/16/archdischild-2016-312119.abstract)