Middle-aged anaesthetist’s guide to surviving the night shift
Night working is an intrinsic part of an acute speciality like anaesthesia,
and can get harder as we age. But there are steps we can take to help.
When I was younger and applying for medical school, I never
really gave any thought to what working at night would be like.
It was just after the ‘New Deal’ for junior doctors was introduced,
hours were reducing and anyway as a teenager I was used to
staying up through the night studying (or socialising!).
Even as a
new junior doctor, while the nights were terrifying clinically they
weren’t bad in terms of fatigue - just something we did and got
through. However, as I became older I found that while the work
felt more familiar and I gained confidence, the fatigue and sleep
became worse.
I acquired a life and a family that didn’t always
fit around my shift patterns, and woke me up at strange hours!
I found sleeping during the day particularly hard, and would
consider myself lucky if I got three or four hours sleep, making
blocks of nights particularly hard. The thought of doing this for
over 20 more years is not appealing.
As Chair of the SAS Committee I am often asked “When can
I come off the rota?” The answer to this isn’t clear cut; there
is no legal or set guidance. And of course anaesthesia is an
acute specialty; there will always be babies to deliver at 2 A.M.,
appendices that need to be removed in the middle of the night,
and so on. Someone has to do this work, and if someone drops
it then others will need to pick it up. Against this, we know that
many SAS anaesthetists are working resident shifts well into
their 50s and even 60s, and that sleep gets worse for many as
we age. Adaptation to shift work becomes harder with age,
often starting between 40 - 50. The Association fatigue surveys
showed that this is a real problem for many of our members.
I often reply by suggesting that the correct question to ask is
“How do we make night work safer?”
Be aware of the impact of fatigue
The single biggest message that I have learnt from the
#fightfatigue campaign is that 2 A.M. is NOT 2 P.M.! We are
simply not designed to be awake and alert in the middle of the
night. And yet we work often longer, more demanding shifts, by ourselves at night than we do in the day. This is not traditionally
taught to medical students or trainees, but simply being aware
of the issue is a huge start. We shouldn’t expect to work the
same way or at the same efficiency at night, and we need to be
aware of the risks so that steps can be taken to mitigate them.
Conversely, by 9 A.M. our bodies are telling us to be awake and
alert, and so sleeping with the daylight and noises of the world
is not at all like sleeping at night! There are plenty of simple tips
and advice to help with sleeping during the day.
Get involved with designing rotas and job plans
Let’s be honest: being rota-master is a thankless task that few
look forward to. Job planning is approached with a similar
foreboding. However, I think that it is essential for all doctors
on a rota to be engaged with this, and for one to act as the rota
lead. Knowing about fatigue helps with designing the rotas and
job plans. Knowing about things such as forward rotation (shifts
moving progressively later), not front-loading weekly patterns
with long hours before nights, and allowing appropriate rest
and recovery time can make a huge difference. It is vital that
rotas consider the impact on fatigue, not just simply filling slots.
The standard SAS and consultant contracts are 10 PA, yet many
doctors are on far more than this, often without realising that
this can be reduced. This can be a real issue for those new to
the NHS. Doing a very intensive clinical job plan can lead to
decreased time for rest, and an accumulation of fatigue. This
is something that may change or evolve throughout our careers.
Be aware of changes as we age
It’s a common misconception that, as we age, we need less
sleep. Actually our sleep patterns and our response to fatigue
changes. It takes longer to fall asleep; there is a decline in
sleep quality and an increase in insomnia. So it can be harder
to fall asleep and stay asleep during the day when working nights, leading to more fatigue. Besides this, as we get older
we are perhaps more likely to have family and childcare
commitments, which while a joy can sometimes make sleep a
little challenging!
Copying the trainee rota won’t work
More than 60% of SAS and consultants in the NHS are over 45.
What I have learnt through all this is that what worked when I
was 25 may not work when I am 35, and definitely not at 45.
And so rotas, job plans and shift patterns need to take this into
account. SAS and consultants are a diverse group, with many
different ages, other responsibilities and so on. This leads to the
next point…
We don’t all need to work the same pattern
Of course it is much easier to have everyone on a rolling rota,
working the same pattern, but that’s not mandatory. In our
department we worked out our rota pattern the other way, by
looking at which shifts had to be covered (nights, lates and
weekends), and building the rota around that. The result is that
some people work more sessions, and others fewer nights;
some people do more nights in a row, others fewer. It has also
introduced a kind of escalator, so that as people leave others
can move up a slot if they wish. It clearly makes a lot more work
for the rota organiser (see earlier!), but the benefits are felt by
all of us.
Treat colleagues as individuals, not as slots
When job planning and writing rotas, it is important to get to
know colleagues and discuss their requests and issues around
the rota. Simply to treat them as individuals, rather than a slot
in a spreadsheet, is a great start. Personalising rotas is of great
benefit to the individual, but also to an organisation, as it boosts morale and promotes recruitment and retention. As people’s
careers develop, discuss with them how the patterns are
working out for them. Delegating the rota to ‘Admin’ or HR is a
sure way of not achieving this aim.
Look out for one another
Within our departments and hospitals we should look out for
each other, especially those on our rotas. Are they anxious
about night working or finding it increasingly difficult? Are they
worried about making mistakes working at night? Are there
simple things we can do to help such as splitting weekends
with them, reducing the runs of days, or other ideas? Do other
members of the team have suggestions that might help?
Night working is one of the less appealing aspects of our career
and specialty, but it is a necessary evil for most of us. Although
we don’t have a magic wand to make nights disappear or
change our circadian rhythms, there are simple steps to make
them a little more palatable as we move through our careers.
Hopefully some of the tips that I have learnt might be of use to
others.
More resources on fatigue
Thomas James
Chair of the SAS Committee, Association of Anaesthetists
Specialty Doctor, Harrogate District Hospital
Twitter: @SAS_gas_Thomas