Junior doctors' shifts and sleep deprivation
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7505.1404 (Published 16 June 2005) Cite this as: BMJ 2005;330:1404All rapid responses
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I was pleased to read in the BMJ this week that the dangers of driving home after night shifts are being officially recognised. After my night shifts my drive home takes me through Birmingham's "Spaghetti Junction" at rush hour and it is usually the sheer terror of the drive which keeps me awake. If hospital on-call rooms are no longer to be used at night then trusts should at least provide them free of charge for doctors to rest after night shifts until they feel safe to drive home, or for them to stay throughout the day until the following night's shifts.
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Read: Exhausted doctors prone to errors, Leigh Dayton, The Weekend Australian Health Section, Aug 27-28 2011
Whilst there is no compelling evidence that restricting physician work hours contributes to improved patient safety in hospitals (Exhausted doctors prone to errors, Leigh Dayton, The Weekend Australian Health Section, Aug 27-28 2011), such measures do anecdotally reduce risk of accidents involving fatigued and sleep-deprived doctors driving cars or riding push-bikes home after marathon shifts.
Sleep deprivation and fatigue leads to much reduced concentration and prolonged reaction times; I too, like Dr Fehlberg, have fallen asleep at the wheel after long night shifts. The menace, to themselves and road users, posed by a sleep deprived doctor continues after sign off from long shifts--I commend Dayton on highlighting intrusions on a doctors’ (and their partner and family) wellbeing of long shift scheduling. Even if enhanced patient safety from work hour restriction is not possible, surely patients would much rather see well rested, and more cheerful and happier, doctors.
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Across the country the range of skills provided by nursing staff and
medical staff will vary from trust to trust. My experience for example is
that PA catheter readings are a medical rather than nursing task. However
i would not imagine this to be true across the country.
You highlight infusion calculations. Quite rightly an important task
to get right. However the main difference between the type of decisions
made at night by junior medical staff and nursing staff is in the level of
support.
In my experience in numerous centres, the sort of nursing procedures
you mention involve two members of staff to check things. Concerns over
particular patients almost always have (more)senior nursing staff almost
immediately to hand. Thats not always the case for the Junior doctor. They
wont always have senior support easily available to back up or revise the
decisions, and the sort of decisions they have to make are the ones that
initiate the need for the monitoring and the infusions in the first
place..
Competing interests:
None declared
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As has been mentioned above, the UK is virtually unique in Europe in
actively trying to apply the EWTD to junior doctors.
The consensus on this forum clearly appears to favour the "24hr on,
24hr off" pattern of working. No one is happy with the current
arrangements, at any level.
Is it not time for the college to take a lead on this, ballot the
profession and then proceed (if consensus is acheived, which seems likely)
to reject en bloc the application of EWTD, Simap and Jaeger to our
profession?
Competing interests:
None declared
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I have been a junior doctor in various guises for twenty years and I
have worked every pattern of labour known to man. The proposed 'one night
on, with the day off before and the day off after', is devastating to
training and makes it almost impossible to arrange holiday and study leave
in a small unit. As for splitting the day up into five hour periods, like
many SpRs I live outside of the local area and it is 62 miles from home to
work. What would I do in the five hours off between split shifts, if I am
not allowed to work?
I am currently in the middle of a week of nights on call as middle-
grade in obstetrics and gynaecology. With a full shift system, and up to
three shifts on duty during the daytime, it can be difficult to follow how
women have been getting on in labour and what has been happening in the
unit during the day, even with written handover. The daytime is much
busier, and I quite understand why my day staff colleagues leave things
for the 12 hour night shift to complete - as one of my consultant
colleagues put it 'they shift work from one shift to the next'. For
example, I start my evening round by scanning women in early pregnancy to
see if they can go home, rather than spend a night in a hospital bed,
waiting for a scan next day, simply because they arrived in hospital after
ultrasound has closed at 5 pm. There may be some minor procedures waiting
to be done, but theatres have yet to grasp the change in our working
patterns and shut-down for safety reasons sometime between 10 pm and
midnight leaving operations on distraught women cancelled because the
proposed procedures are not life threatening. And so on.
This was not an option in the old 24 hours on, 24 hours off, because
the next shift was you! As this system is no longer allowed, a week of
nights may be the least of all evils; at least it's only every six weeks
or so. I submit that in my speciality, and probably most surgical based
specialties, the best system is '24 hours on, 24 hours off'. Because you
are focussed on what is going on for all that time, and have watched
clinical situations evolve. I think decision making might be better and,
more importantly, much safer. Things quieten down in the early hours and I
used to get far more rest under the old system not least because I knew
the patients much better and was in a better position to respond to the
concerns of my midwifery, nursing and junior colleagues.
Although the EU has kindly sheltered us from the rigours of
exploitation, it has got it badly wrong with imposing the EWTD for doctors
in training. Rather than pussy-foot around metaphorically rearranging the
chairs on the Titanic, why not think about patient safety and change
course entirely? I would bet my eye teeth that most surgical and
obstetrics and gynaecology trainees would jump at the chance of going back
to the 24 hours on, 24 hours off system, which was safer, better for
training, easier to arrange and gave much more job satisfaction.
Competing interests:
None declared
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I feel moved to correct a couple of incorrect assertions about nurses
and night duty. Shifts are often from 2100 to 0800 these days (11 hours
not 7, if you get away on time). My record stretch is 17 nights one after
the other, due to staff shortages. As a CCU charge nurse I have usually
not been able to take any break from the unit at all during nights as I
would be on duty usually with one other member of staff (often agency)who
would be too junior to leave alone. One respondant complains of constant
bleeps being stressful - try listening to a dozen cardiac monitors
chirping away all night! As for the implication that only doctors have
difficult decisions/tasks at night - how many have to take repeated IABP
or PA cath readings, or make repeated infusion calculations.
The reality is night duty is hard for everyone but it has to be done
by some health professionals. Sure, getting the best rota system is
important, but I am always amazed at how many people who complain about
nights are not taking some basic steps to make them easier: such as making
sure all work that can be done during the day is and that problems are
anticipated/communicated in advance where possible; also, on a personal
level, eating regular snacks, plenty of drinks, periodically having a face
wash and a walk around always seems to make a difference for me.
On a more controversial note - when writting off-duties I always had
several staff willing to do as many nights as possible. This was not
because they liked them but because they got paid more for them. That is
going with Agenda for Change.
Competing interests:
None declared
Competing interests: No competing interests
Sir,
The term 'a week of nights' amongst many medical staff is synonymous
with social isolation, sleep deprivation and clinical and personal risk.
The shifts are often extremely busy where junior staff are dealing
with unstable patients with little senior support. The onslaught is
relentless and time spent on necessary breaks is interrupted and has to be
justified to seniors and site managers.
During my last week of nights we managed one emergency after another.
For the sake of patient safety and due to the demand of moving patients
out of A+E to meet the four hour wait we worked without breaks and ate
toast on the ward to keep hunger at bay. By the end of the fourth night, I
fell ill with nausea, palpitations and dizziness and was unable to attend
for duty that evening. As I approach another week of nights I will take
measures to limit possible physical and mental abuse.
A balance between training, service and safety must be achieved, we
are often too tired at night to learn and manage patients we see
appropriately. The move of many trusts to remove doctor's rest rooms will
limit any effective rest time we magage to attain.
It is reassuring that the Royal College of Physicians are aware of
the effect of current work patterns on doctors training and heatlh. If
this information effects NHS managers at all remains to be seen.
Competing interests:
None declared
Competing interests: No competing interests
We welcome the editorial by Murray et al which addresses the problems
of working 7 consecutive night shifts and the importance of rest periods
during the night (1). We conducted a recent study examining circadian
adaptation to night shiftwork (2).
Our study assessed doctors’ adaptation to night shifts by examining
performance and sleep over 7 successive night shifts. Eighteen hospital
doctors worked 4 day shifts (week 1), followed by 7 night shifts (week 2),
3 rest days and then 5 day shifts (week 3). Performance measures included
subjective alertness score and a 4-choice reaction time task undertaken at
the start and end of the first and last shift of each week. Sleep was
assessed by actigraphy.
Night shifts were associated with lower overall alertness (p <
.01) and a somewhat greater decline as a function of time-into-shift,
compared to day shifts. Sleep quality was subjectively lower during the
night shifts but there was no change in sleep efficiency (actigraphy). The
main focus of our analysis was to compare changes between the beginning
and end of each of the 3 weeks of the study, for each of the outcome
measures. There was no evidence that the change in week 2 (nights)
differed significantly from changes over weeks 1 and 3 (days). Thus
doctors were apparently able to maintain performance and alertness between
the first and last of 7 successive nights.
Such findings would appear to contradict previous evidence of the
deleterious effects of many successive night shifts, as cited by Murray et
al. By way of explanation of our unexpected findings, we note that our
doctors’ napping times were similar to those found by the Royal College of
Physicians’ survey (3) with Registrars and SHOs napping an average of 3:47
and 1:15 hours per night. Examination of the association between
performance and napping revealed a trend towards napping improving
performance in the majority of cases, although statistical significance
was not reached, possibly due to small sample size.
We would suggest that the reason these doctors maintained their
levels of alertness and performance was because they were managing to nap
during the night shifts. This is supported by the positive trends
identified between napping and performance in our study and by aviation
industry research showing improvement in performance after just a 40
minute nap (4). We plan a larger study to test this hypothesis. If this is
the case, it would lend strong support to the case for keeping beds for
doctors to nap in and would support Murray et al’s suggestion of a 2 hour
rest period during the night shift.
References
1. Murray A, Pounder R, Mather H, Black DC. Junior doctors' shifts
and sleep deprivation. BMJ 2005;330:1404. (Jun 18.)
2. Tucker P, Davies G, Dahlgren A, Macdonald I, Blagrove M, Hutchings
H, Ebden P. Circadian adaptation in shift-working hospital doctors. Sleep
2005;28(Abstract Supplement):A66.
3. Mather H, Pounder RE. Coping with problems in acute medicine in
the post-WTD era—a survey of RCP College Tutors in December 2004.
www.rcplondon.ac.uk/professional/spr/spr_ewtd05.htm.
4. Rosekind MR, Graeber RC, Dinges DF, Connell LJ, Rountree MS, et
al. Crew factors in flight operations ix: effects of planned cockpit rest
on crew performance and alertness in long-haul operations. NASA Technical
Memorandum #108839. Moffett Field, CA: NASA Ames Research Center, 1994.
Competing interests:
None declared
Competing interests: No competing interests
Re: Junior doctors' shifts and sleep deprivation
Whilst there is no compelling evidence that restricting physician work hours contributes to improved patient safety in hospitals, such measures do anecdotally reduce risk of accidents involving fatigued and sleep-deprived doctors driving cars or riding push-bikes home after marathon shifts. Sleep deprivation and fatigue leads to reduced concentration and prolonged reaction times. The menace, to themselves and road users, posed by a sleep deprived doctor continues after sign off from long shifts. The intrusion imposed by long and unsociable shifts on a doctor’s, their partner and family’s quality of life impinges on the sustainability of medical careers. Even if enhanced patient safety from work hour restriction is not possible, surely patients would much rather see well rested, more cheerful and happier, doctors.
Competing interests: No competing interests