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Night shift, naps and naysayers – not all hours are created equal

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BY DR TESSA KENNEDY, CHAIR, AMA COUNCIL OF DOCTORS IN TRAINING

Night shift. It’s 4am, and the ward is finally quiet after a rush of clinical reviews. The lights are dim, patients are all in bed, the tea room chairs converted to makeshift stretchers for nurses napping on break. I sit staring bleary-eyed at the computer screen, raising my eyebrows to keep my lids from drooping shut. There’s nowhere to sleep, and if I do steal away to a couch in the office my absence will be noted. The head of department made it clear: you don’t get paid to sleep. Intermittently I startle as I nod off. This matters little sitting still at a desk – it matters a lot on the drive home, as sleep presses heavy on my arms, loosening my grip on the wheel.

There is increasing pressure to provide the same healthcare staffing and services 24 hours a day, seven days a week, in a bid to reduce hospital mortality associated with afterhours admission. This, combined with efforts to reduce unpredictable and onerous working hours associated with on-call arrangements means an increase in continuous cover provided by shiftworkers.

The dual aims of improving patient access to quality care and safer working hours for doctors are noble, but the changes made to practice in order to achieve them often create new problems by neglecting to acknowledge that not all hours are created equal, and should not be treated as such.

Working at night is fundamentally different to working during the day – two very different shifts can run ‘8 til 8’. It is clear to anyone who has worked night shifts or indeed parented a newborn that tasks completed in the middle of the night require much more effort and are much more prone to error than those performed in the middle of the day, as sleep deprivation and disrupted circadian rhythms conspire against our best efforts.

If we treat night shifts like just another day at the office, we place patients and practitioners alike at risk of harm.

Yet interns spend more time in orientation learning which bins take which kind of waste or how to operate a fire extinguisher than how to manage the challenges and risks inherent to shift work. How to best make use of sleep, caffeine and other strategies to perform the best they can at work, and make it safely home afterwards.

We think twice before waking the on-call team, but not for denying the night shift worker the cultural permission and facilities to sleep, trusting them to know when it’s the most appropriate use of their time.

Sadly, sleeping quarters traditionally utilised by doctors on call are getting absorbed by administrators who fail to realise that yes, I might be rostered ‘to work’, but I’m not a factory line worker for whom down time equates directly to reduced service. My job is far more complex, my cognitive powers my most important tool, and actually a nap in the 4am lull may provide the best chance of a successful resuscitation at 6am by offering more sound judgement and a steadier hand.

I’m in no way advocating for doctors who staff the wards overnight to sleep through everything but a Code Blue, but I am advocating for us to acknowledge the limits and mitigate the risks of humans operating in a high-risk field. Naps are not luxury or laziness, but akin to ensuring the defib is plugged in and fully charged so it’s ready to go. Ironically, sometimes the most productive thing a night shift worker can do is nothing.

We mustn’t move blindly towards a 24/7 model of healthcare without recognising and mitigating the associated risks for patient and practitioner, without taking care to decide which services are truly necessary to provide at any time, and which can be left til morning.

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