Preparing for night shift

In this podcast, Stephanie Anderson talks to Dr Paul Hamor about how to prepare for night shift on the wards.

Summary Writer:  Jenny Liu

Editor:  Paul Hamor

Interviewee:  Paul Hamor

Paul is a Respiratory & Sleep Physician and Network Director of Physician Training at the Prince of Wales Hospital. He has had a long involvement in prevocational and undergraduate medical education. Paul has interests in the formulation of educational programs, presentation skills, delivering best evidence based-practice to the ward, as well as change methodology. He is also a strong advocate for work-life balance and has been looking at the prevention and management of junior doctor burnout and programs to promote resilience.

This podcast was originally released on 17 June 2015.

Tips on preparing for night shift

 With Dr Paul Hamor, Respiratory & Sleep Physician and Network Director of Physician Training at the Prince of Wales Hospital, Sydney, Australia*

Case

You are a junior doctor starting your relief term in a busy tertiary hospital and you are rostered to work your first week of nights in three days’ time.

  • Background context: many doctors outside of Australia would have to work a whole day and then do night shift overnight and will have to catch some sleep while managing the wards – managing this sleep cycle is very difficult. However in Australia most doctors work a block of 3-7 nights in a row, followed by a block of days off to catch up on sleep. The advice given below will be in reference to preparing for working a block of night shifts.
  • Important to understand the physiology of sleep. The 2 big drivers of sleep are
    • sleep debt: similar to hunger/thirst – builds up over time. If you have restricted sleep for several nights in a row you may need to catch up on sleep due to accumulated sleep debt. A small nap after many hours of staying up will repay some of the sleep debt.
    • circadian rhythm: built into all living creatures, based upon the earth having a 24hr cycle. Human circadian rhythm varies between individuals and is based upon ‘clock genes’. Most people have a 25hr circadian rhythm which is brought back into a 24hr cycle by light and social cues. Light suppresses melatonin. As light fades away melatonin starts to rise which induces sleepiness.
  • Knowing if you are a person who is sensitive to sleep debt, and knowing how your circadian rhythm works is important to prepare for night shift.
  • Are you a night or morning person?
    • If you are a night person – your circadian rhythm is more likely a 25hr cycle as you find it easier to stay awake late at night.
    • If you are a morning person who wakes easily at a fixed early time in the morning – you have a strong circadian rhythm and sleep debt might be harder for you to accumulate.
  • Most people have a strong sleep debt drive and a 25hr circadian rhythm. Night shift preparation advice for these people:
    • Paying off sleep debt and building resilience: In preparation for night shift, stay up later each night before night shift. Try and sleep in as much as you can in the morning of starting the first night shift. In the afternoon before night shift, close the blinds and get a nap to reduce any sleep debt before night shift.
    • Prep your environment for nights: use heavy blockout curtains or aluminium foil taped to windows to block out as much light as possible in the bedroom to make it dark. Some people are very light sensitive and even a small amount of light after working nights will confuse their circadian rhythm and suppress melatonin.
    • Reduce disruptions during the day: Buy some earplugs and let your family/housemates know you are going to be working nights so they can keep noise down during the day.
  • Do what your body tells you to do.
  • Some will be so sleepy they just need to rest.
  • If you are doing 7 nights in a row, on the first day sleep immediately after the shift, but on subsequent days go to sleep an hour later each day – this makes the transition back to days alot easier.
  • Do what you normally do when you work day shifts – if you have coffee before work usually consider coffee before night shift.
  • Caffeine is useful when used appropriately.
  • Caffeine is not useful if you are drinking energy drinks the whole night and you’re so pumped up you can’t sleep after the night shift.
  • Too much caffeine can interfere with the quality of your sleep at the end of night shift. Generally try to avoid caffeine in the 6 to 8 hours before your new sleep time.
  • Meals – try to align meals to your new sleep-wake phase especially if you are having difficulty adjusting the circadian rhythm. I.e. when you wake up have a breakfast type meal, and at the end of your shift have a dinner type meal. However, eating is a social experience so it is also common for some people to have a dinner type meal with friends before work. Do what works for you.
  • Snacking – a lot of wards will have sugary sweets on night shifts. This only gives a short sugar rush, followed by an energy dip that can cause fatigue. Try to avoid sugary snacks. Have low-carbohydrate/complex carbohydrate foods instead (fruits/vegetables).
  • Exercise is usually an awake-promoting activity.
  • If you exercise in the hour before sleep, the quality and quantity of sleep is reduced.
  • Exercise after a night shift can cause too much stimulation especially outdoors exercise where there is a lot of light and this will suppress melatonin and will make it more difficult to sleep immediately afterwards.
  • Exercise is useful when you wake up e.g. before you start the night shift in the evening.
  • My general rule is not to sleep – in case there is a patient emergency.
  • When you go home post-shift you should use your sleep debt you have accumulated during the shift to sleep better; if you pay off some sleep debt during the shift (with a nap) you find it more difficult to sleep after the shift.
  • However, if you are feeling very exhausted in the middle of your first night shift (falling asleep while re-charting medications) then a power nap on a couch (not bed) can be useful.
  • A true power nap is only 20-30min, if you sleep longer than that you go into deep sleep and it is very difficult to wake up refreshed from deep sleep.
  • If you are having a power nap, sleep on a couch and set an alarm for 20-30min, then get up when the alarm goes off to avoid progressing into deep sleep.
  • There is a higher risk of car accidents for those who do night shift.
  • To mitigate these risks, take a power nap at the hospital before going home.
  • Use stimuli e.g. drive during the light hours to stay awake.
  • The riskiest driving is highway driving and driving for longer than 20min.
  • If you live >20min away involving highways consider staying at JMO accommodation during the day or catch up on some sleep before driving. If you notice you are sleepy or microsleeping whilst driving you MUST PULL OVER and have a nap! (Don’t try push through – you could seriously harm yourself and others in the process).
  • Dr Hamor advises against sleeping tablets and tablets to keep you awake.
  • Sleeping tablets can cause a hangover effect – you can feel groggy after waking up.
  • Sleeping tablets are good for sleep initiation but the quality of sleep is not great and they are not good for sleep maintenance.
  • Do not use sleeping tablets in isolation – use in conjunction with the techniques already discussed e.g. dark room, adjusting circadian rhythms, etc.
  • Tablets for keeping you awake – not recommended for most. May be useful for those individuals diagnosed with shift work sleep disorder only under the guidance of a sleep physician.
  • Illegal drugs – definitely NO! If you find yourself in this position seek help from your family doctor. This is not a good situation to be in personally and professionally.
  • In summary, moving to night shifts is difficult but can be made easier with some planning. You need to know your body and how it responds to sleep stressors.

*this podcast was originally recorded in 2015, when Dr Paul Hamor was the Director of Prevocational Education and Training at Royal Prince Alfred Hospital, Sydney as noted at the start of the interview.

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Tags: #circadian rhythm,#junior doctors,#melatonin,#napping,#night shift,#power nap,#preparing for night shift,#respiratory medicine,#sleep,#sleep debt,#sleep stressors,#tipsfornewdocs,#working nights

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