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Downloaded from http://ep.bmj.com/ on December 21, 2016 - Published by group.bmj.com Education & Practice Online First, published on December 16, 2016 as 10. 1136/archdischild-2016-312119 BEST PRACTICE Fifteen-minute consultation on problems in the healthy paediatrician: managing the effects of shift work on your health Michael Farquhar Correspondence to Dr Michael Farquhar, “You’re not healthy unless your sleep is healthy”ors (eg, stress, depression), physical Department of Children’s Sleep Professor William Dement, Stanfordhealth factors (eg, pain) or common ill- Medicine, Evelina London University, one of the founders ofesses (eg, asthma, eczema). A primary Children’s Hospital, Guy’s and modern sleep medicine sleep disorder (eg, obstructive sleep St Thomas’ NHS Foundation Trust, London SE1 7EH, UK; apnoea, restless legs syndrome, narco- Michael.Farquhar@gstt.nhs.uk; lepsy) may also be present. Difficulties @DrMikeFarquhar ABSTRACT with sleep, including problems with Sleep is fundamental to good health. Healthcargetting to sleep and maintaining sleep, Received 20 October 2016 professionals receive little teaching on the are a common reason for adults to Revised 21 November 2016 Accepted 23 November 2016 importance of sleep, particularly with respectpresent to their general practitioner. their own health when working night shifts. Significant sleep disruption increases Knowledge of basic sleep physiology, together risks of cardiovascular disease, diabetes with simple strategies to improve core sleep aand obesity, reduces the effectiveness of 2 the ability to cope with working nights, can the immune system and impacts cogni- result in significant improvements both for tive function and emotional regulation. healthcare professionals and for the patients thDespite this, most healthcare profes- care for. sionals receive very little education about sleep,3and the importance of sleep to health. INTRODUCTION Thinking about healthy sleep is espe- Sleep is an essential active process. cially relevant for healthcare profes- We spend about a third of our lives asleep. We cannot survive without sleep. sionals, who often work shift patterns to Getting enough good quality sleep under- provide essential and emergency health- care 24 hours a day, 7 days a week, pins every aspect of physical and mental 365 days a year. Regularly working both health. Sleep deprivation rapidly takes its toll on even the healthiest and most night shifts and long daytime shifts will robust of people and can lead to an impact sleep routines and make achieving good quality sleep more challenging. inability to function effectively. The ‘hero’ attitude, that patient care is Moderate sleep deprivation—equiva- lent to being awake for 16–18 hours— always more important than appropriate can have the same effect on reaction time self-care, is well intentioned but misguided. It is absolutely paramount that this is under- as being at the legal blood alcohol limit stood by all staff and consistently reinforced for safe driving. by senior clinicians and managers. Up to 20% of road traffic accidents are thought to be fatigue related, and are sig- nificantly more1likely to lead to serious NATURAL SLEEP RHYTHMS harm or death. We function on a natural cycle of wake To cite: Farquhar M. Arch DiSymptoms related to poor sleep are and sleep. Our brains and bodies are Child Educ Pract Ed Publiscommon, particularly in healthcare evolved to primarily be awake by day and Online First: [please include Day Month Year] professionals. asleep by night. doi:10.1136/archdischild- Sleep quality can be affected by other Natural cycling of wake and sleep, cir- 2016-312119 health issues, including mental health cadian rhythm, is regulated by the Farquhar M. Arch Dis Child Educ Pract Ed 2016;0:1–6. doi:10.1136/archdischild-2016-3121191 Copyright Article author (or their employer) 2016. Produced by BMJ Pub lishing Group Ltd under licence. Downloaded from http://ep.bmj.com/ on December 21, 2016 - Published by group.bmj.com Best practice suprachiasmatic nucleus (SCN), the primary body Box 1 Risks and consequences of working night clock, in the hypothalamus. The SCN is affected by many cues, with the most important being environ- shifts mental light. Release of melatonin, which helps regu- late wake and sleep, is controlled by the SCN. Night shift workers: There is an independent need for sleep, which ▸ sleep less well and for shorter times in the day increases the longer we have been awake. This can ▸ are less alert and perform less well than day shift only be reduced by sleeping, just like hunger is only workers 5–9 reduced by eating. ▸ are more likely to make simple mistakes and avoid- When we act against our circadian rhythm we feel able errors, leading to increased risks to patient fatigued and function less effectively. We experience safety this sense of disorientation as ‘jet lag’ when we rapidly ▸ process information, particularly novel situations, move time zones via air travel. It can take up to a day slower for each time zone crossed for people to regain their ▸ have impaired alertness, vigilance and reaction time normal sense of wake and sleep. ▸ are more likely to make decisions that involve higher We cycle regularly through different sleep stages, degrees of risk principally light sleep (non-rapid eye movement ▸ have increased risk of road traffic accidents after a 10 (REM) stages 1 and 2), deep sleep (non-REM stage 3) shift and REM (or dream) sleep (figure 1). Long-term effects of night shift working include: Deep sleep is physically refreshing, and effectively ▸ increased risk of primary sleep disorders ▸ increased risk of obesity and diabetes ‘recharges your batteries’. REM sleep is important for 11 consolidation of learning, and emotional regulation. ▸ increased risk of cardiovascular disease Sleep is essential for learning—getting a good ▸ a possible relationship with increased incidence of night’s sleep will help you retain knowledge for cancer12 Membership exams far more than staying up into the early hours ever will! It is essential that professionals working night shifts, especially in intense, demanding hospital roles which WORKING NIGHT SHIFTS require an ability to respond rapidly and to make key decisions quickly and competently, take steps to opti- We are not physiologically evolved to function at mise their sleep and ability to function at night. night as we do in daytime, nor are we adapted to achieve good quality sleep during the day. There is a personal responsibility for professionals Working at night is equivalent to working while jet- to come to work having taken steps to ensure that they are able to function as effectively as possible. lagged: your body is trying to function on Sydney There is also a responsibility for this to be sup- time while your brain thinks that it is Greenwich Mean Time. ported by employers. Hospitals must consider strat- Working night shifts has associated risks and conse- egies, particularly around night shifts, to ensure that 4 staff are able to function at their best, and that their quences (see box 1). staff’s own safety is taken into account. There is The experience of feeling dangerously sleepy while driving home from work is very common among natural variation in how well individuals cope with hospital night shift workers, 13 and continues to result working night shifts. Employers should consider regular screening of shift workers for health conse- in fa14 15utcomes for National Health Service (NHS) quences of working shifts. staff. Effects of relative sleep deprivation, fatigue and of These ideas are not always well recognised in the working at night are well recognised by other profes- NHS, which needs a significant culture shift in how to approach working at night. 17 sions (eg, airline pilots), and are reflected in the Highway Code. 16 IMPROVING SLEEP Core sleep Establishing good sleep routine and habits is the foun- dation of addressing sleep difficulties. Investing time in getting sleep right every night, not just when working nights, is key to improving long- term sleep quality. Environment Figure 1 Hypnogram. REM, rapid eye movement. Adapted Sleep environment is important. Bedrooms should be from Luke Mastin. dark, cool, quiet and comfortable. 2 Farquhar M. Arch Dis Child Educ Pract Ed 2016;0:1–6. doi:10.1136/archdischild-2016-312119 Downloaded from http://ep.bmj.com/ on December 21, 2016 - Published by group.bmj.com Best practice Minimising environmental light and noise is even more important when attempting to sleep during the Box 3 Good sleep routine daytime. Key features about good sleep environments are ▸ Ensure as much natural daylight exposure as possible summarised in box 2. ▸ Regular exercise, but not too close to bedtime, sup- ports sleep—in adults with insomnia, regular exercise can be more effective than ‘sleeping tablets’ in Routine and habits Good quality sleep is maintained by regular routine. improving sleep quality Everyone’s need for sleep is different. Most adults ▸ Eat regular meals ▸ Do not eat your main meal within 2 hours of bedtime will need approximately 7–8 hours good quality sleep ▸ A light prebed snack (eg, a bowl of cereal, fruit, each night. If you are getting adequate sleep regularly, yoghurt) 30 min before bed can help prevent disrup- you should wake feeling refreshed at approximately the same time each morning whether an alarm is used tion from night-time hunger, but avoid evening ‘grazing’ or not. If you regularly ‘catch up’ sleep at the ▸ Minimise use of alcohol, caffeine and nicotine, par- weekend or on days off, or if you often have symp- ticularly in the evening period toms suggestive of sleep deprivation, this implies you are not allowing enough time for sleep each night. ▸ These can affect both the ability to get to sleep and This should be addressed as a priority. the quality of sleep obtained ▸ Set sleep and wake times that permit the amount of Regularly spending time in bed awake encourages sleep that is right for you your brain to associate being in bed with wake, which ▸ Aim to go to bed at roughly the same time each night can lead to difficulties in getting to sleep. Key features about good sleep routine are sum- and get up at the same time each morning marised in box 3. Minimise electronics use for the 30–60 min before bed ▸ Consider relaxation strategies to ‘wind down’ before bed Electronics ▸ Do not use your phone as your alarm clock Electronic device18in the bedroom can have a major ▸ Your phone should preferably be charged outwith impact on sleep. your bedroom while you sleep Light, particularly at the blue end of the spectrum, ▸ Avoid spending long periods of time awake in bed. has a direct effect on the primary body clock, which Your bed should only be for sleep or sex leads to suppression of natural melatonin secretion. ▸ If you are unable to sleep, get out of bed and do a Additionally, the stimulatory effect of engaging with quiet/relaxing activity (reading, jigsaw puzzle, building activities when the brain is trying to wind down and LEGO, etc) for 15 min, then return to bed and try to relax has an inhibitory effect on sleep. sleep again Box 2 Good sleep environment There should be an electronic curfew for at least 30–60 min before the intended bedtime. Electronic screens should be avoided in the bedroom. Your bed, including mattress and pillows, should be com- If this is not possible, then enabling features, such fortable and supportive Make your bedroom as dark as possible: as ‘Night Shift’ on Apple iOS devices or f.lux on ▸ invest in blackout blinds/curtains other devices, which reduce the amount of emitted blue light from electronic screens in the evening, may ▸ do not switch on main bright lights if you need to reduce some of the impact on sleep. Brightness set- get up through the night tings on devices should be as low as possible. ▸ consider a good quality eye mask for daytime sleeping External noise should be reduced as much as possible: NIGHT SHIFTS Improving how you function on night shifts involves ▸ consider use of white noise (eg, a fan, quiet relaxing thinking about preparing for the shift, the shift itself, music, a radio turned to static) what you do after the shift and how you recover after ▸ consider use of ear plugs ▸ your bedroom should be cool a run of nights (see boxes 4 and 5). ▸ aim for a temperature of ∼18–20°C During the night shift ▸ a warm bath, or wearing bedsocks, can encourage See box 5. peripheral vasodilation before sleep, which helps to optimise core body temperature Some natural remedies, such as lavender, can improve Rest, breaks and naps Breaks are not a luxury, especially when doing busy or sleep quality intense night work. Farquhar M. Arch Dis Child Educ Pract Ed 2016;0:1–6. doi:10.1136/archdischild-2016-312119 3 Downloaded from http://ep.bmj.com/ on December 21, 2016 - Published by group.bmj.com Best practice they may result in you entering deeper stages of sleep Box 4 Preparing for the night shift which can be more difficult to quickly wake from and increase the chance of ‘sleep inertia’ (grogginess on ▸ Maintain a good core sleep routine waking). Set an alarm, or ask a colleague to wake you. ▸ ‘Bank’ sleep in the 24 hours before starting nights; Prolonged sleep during a single night may also have a long lie, or try to have an afternoon nap affect your ability to sleep during the day, which is ▸ Exercise in the morning may help encourage napping particularly relevant when doing consecutive night in the natural circadian ‘siesta time’ in the early shifts. afternoon Not everyone is able to ‘power nap’ in this fashion, ▸ Ensure you are well fed and well hydrated in which case relaxation in a dark, quiet room may also be of some benefit. Naps during night shift breaks are supported by the Royal College of Physicians, the Royal College of Box 5 During the night shift Nursing and the British Medical Association. 20– 22 ▸ Aim to stick to a consistent routine during each shift Caffeine 23 ▸ Work as a team to provide effective cover for breaks Use caffeine carefully. Caffeine increases alertness ▸ Consider use of ‘bleep filtering’ systems to minimise but too much can lead to irritability and reduced interruption to team members on breaks effectiveness. Caffeine can reduce subsequent sleep ▸ Avoid high calorie/high fat/high carbohydrate foods— quality and duration up to 6 hours after ingestion, so night shift calories DO count, and contribute signifi- aim to use it mainly in the earlier part of your night cantly to increased risks of impaired glucose tolerance shift. and cardiovascular disease of working night shifts Taking caffeine just before a planned short nap ▸ Try to maintain your normal eating patterns/times as maximises its impact; caffeine takes 15–20 min to much as possible when working nights take effect, meaning it is just kicking in as you wake ▸ Aim to minimise eating between 24:00 and 06:00 up at the end of your nap to give you a double boost. where possible, and when you do eat/snack choose healthier satisfying options (eg, soups/ wholegrain After the shift sandwiches/yoghurt/fruit/salads/nuts, etc) If you are too tired to drive—DO NOT. See box 6. ▸ Keep well hydrated; carry a water bottle and drink Once awake for ∼16–18 hours, reaction times are regularly likely to be similar as if you are at the legal drink- Maximise exposure to bright light in non-clinical areas drive limit. Your ability to safely drive, and your ▸ Your patients need their sleep—keep light and noise judgement as to whether you think you can are disruption in clinical areas to a minimum impaired. Your breaks are essential Employers should have a policy on how to assist ▸ During breaks, have short (15–20 min) naps staff who feel too tired to safely drive. If alternative ▸ Use caffeine carefully provisions (eg, public transport) are not possible, then ▸ Watch the 4 am dip. This is when both you and your ideally a bed should be provided, free of charge, for patients are at their lowest physiological ebb. Take you to have enough sleep to then be able to safely time to double check all critical calculations in drive home. You should be aware of your employer’s particular policy. Recovery Regular rest is essential to ensure safe, effective You will have slept less, and less well, while you are patient care is delivered to the best of your capability. on nights. Unless critically ill patients require immediate atten- Your priority should be to re-establish your normal tion, your patients are always better served by clini- routine as quickly as possible. cians who have had appropriate periods of rest during See box 7. their shift. Use breaks to take short naps; 15–20 min naps HOW CAN HOSPITALS MAKE THINGS BETTER? during night shift can have significant positive bene- While professionals have a personal responsibility to fits. They can signi19cantly improve levels of alertness ensure they are able to function during night shift to and responsiveness and can reduce the risks to your work as effectively as possible, employers also have a health of working night shifts. They help to reduce responsibility to support their staff. Simple interven- risks to patients as a result of fatigued professionals. tions can make big differences. The right length of short nap will vary between Where health services are under increasing pressure, individuals. It is worth doing some experimentation even basic measures to support staff can be difficult to find the best for you. Longer naps are not better, as to achieve. Nevertheless, attention to appropriate, 4 Farquhar M. Arch Dis Child Educ Pract Ed 2016;0:1–6. doi:10.1136/archdischild-2016-312119 Downloaded from http://ep.bmj.com/ on December 21, 2016 - Published by group.bmj.com Best practice Box 6 After the night shift Box 8 How can hospitals make things better? If too tired to drive—DO NOT ▸ Use forward-rotating (day-evening-night) rota designs ▸ Use public transport if you can ▸ Minimise frequent transitions between day and night ▸ If possible wear sunglasses on the way home—day- shifts light will encourage your brain to feel awake and ▸ Provide adequate recovery time after nights to reduce your chance of getting good quality sleep re-establish normal wake/sleep patterns Be cautious of wearing sunglasses if driving however ▸ Provide basic education for staff at induction regard- ▸ Aim to be in bed as quickly as possible after your ing sleep and working nights, as well as general shift ends—the later you get to sleep, the less total healthy lifestyle advice and support sleep you are likely to get ▸ Ensure staff are compliant with current rest/break ▸ Resist the temptation to use electronic devices entitlement requirements: ▸ Have a light meal/snack about 30 min before going to – Current ‘New Deal’ contract: at least 30 min con- sleep—do not go to bed hungry tinuous rest after approximately 4 hours duty ▸ Avoid alcohol, nicotine and caffeine – New contract: at least one 30 min paid break for a ▸ If you share a house/flat with other people, make sure shift rostered to last more than 5 hours and a they clearly know you are trying to sleep second 30 min paid break for a shift rostered to ▸ Do not allow daytime deliveries during the time you last more than 9 hours expect to be asleep ▸ Encourage team-based ‘hospital at night’ approach, ▸ Your phone should preferably be in a different room including bleep filtering and protection policies to in airplane mode permit consistent breaks ▸ On waking ensure you are exposed to bright light for ▸ Provide appropriate rest areas (not necessarily an the first 20 min after waking ‘on-call room’) overnight, which allow staff to nap ▸ Try to do some light exercise during breaks if they choose to ▸ Provide access to good quality food for night staff ▸ Provide beds, free of charge, for postnights staff who Box 7 Recovery feel too tired to drive home ▸ Offer regular screening of shift workers for primary sleep disorders ▸ Postnights team breakfasts are not just a social event. They allow you to informally ‘decompress’ and reflect on events which may have occurred during your shifts. GET HELP IF YOU NEED IT Airing worries and anxieties in a supportive environ- Doctors and other healthcare professionals are at ment will likely help you sleep better increased risk of having formal sleep disorders. If you ▸ After your final night, aim for a short morning nap think you have a genuine sleep problem, see your own (1–2 hours), ideally before midday, then get up and doctor or occupational health service. Do not ignore do as many ‘normal’ activities as possible it—it will often just get worse. Re-establish normal eating and exercise patterns Avoid the temptation to self-medicate, whether with ▸ Aim for as close to your normal bedtime as possible prescription medication or non-prescription options, ▸ Aim for a short lie in only on the following morning; such as alcohol, sedative antihistamines or non- try to get up as close to your normal wake time as prescribed melatonin. possible, and to go to bed only slightly earlier than usual CONCLUSION ▸ You are likely to need two ‘normal’ nights to success- Finding a pattern of wake and sleep in preparation for, fully re-establish your usual sleep pattern ▸ …remember your judgement is likely to be a bit while working, and recovering from night shift is a very individual process. There are no universal ‘magic impaired after nights, so beware the attraction of the bullets’ that will improve the experience for everyone. postnights spending spree! Simple strategies by both professionals and employ- ers to support core sleep and while working night adequate rest and other factors to improve perform- shifts are likely to make working nights a bit less chal- ance during night shifts are not areas where com- lenging and to improve both personal health and promise can safely be made. The attendant risk of patient safety. fatigue-related error rapidly escalates when working in Further reading: A more comprehensive list of refer- pressured medical environments. ences is included in the Royal College of Physicians 17 It is absolutely paramount this is acknowledged and summary document ‘Working the Night Shift’. actively supported by senior healthcare and clinical leaders. See box 8. Twitter Follow Michael Farquhar @DrMikeFarquhar Farquhar M. Arch Dis Child Educ Pract Ed 2016;0:1–6. doi:10.1136/archdischild-2016-312119 5 Downloaded from http://ep.bmj.com/ on December 21, 2016 - Published by group.bmj.com Best practice Competing interests None declared. 12 Kamdar BB, Tergas AI, Mateen FJ, et al. Night-shift work and Provenance and peer review Commissioned; externally peer risk of breast cancer: a systematic review and meta-analysis. reviewed. Breast Cancer Res Treat 2013;138:291. 13 Johnson S. The Guardian, 26th July 2016 ‘I fell asleep at the wheel’: the dangers of doctors driving home. REFERENCES 14 Stewart S. The Daily Record, 16th October 2011. Worked to 1 http://www.rospa.com/road-safety/advice/drivers/fatigue/ death—exhausted young doctor veers off road and dies after road-accidents/ gruelling nightshift. 2 Besedovsky L, Lange T, Born J. Pflugers sleep and immune 15 BBC News webpage 12th July 2016 “Dr Ronak Patel had been function arch. 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Arch Dis Child Educ Pract Ed 2016;0:1–6. doi:10.1136/archdischild-2016-312119 Downloaded from http://ep.bmj.com/ on December 21, 2016 - Published by group.bmj.com Fifteen-minute consultation on problems in the healthy paediatrician: managing the effects of shift work on your health Michael Farquhar Arch Dis Child Educ Pract Ed  published online December 16, 2016 Updated information and services can be found at: http://ep.bmj.com/content/early/2016/12/16/archdischild-2016-312119 These include: References This article cites 13 articles, 6 of which you can access for free at: http://ep.bmj.com/content/early/2016/12/16/archdischild-2016-312119 #BIBL Receive free email alerts when new articles cite this article. 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