The art of the night shift

One of the foibles of critical care is that sick patients remain sick at all hours. Thus, somebody needs to take care of them at night.

In some smaller ICUs, this is addressed by off-service coverage (e.g. an in-house hospitalist or emergency doc available for crises), or by home call (i.e. a sleepy intensivist answering questions from home, and on rare occasions deigning to come in). In most centers, however, it means that someone needs to spend the night in the hospital.

Since most humans prefer to be asleep at night, this presents some practical challenges, which are worth discussing. While I doubt there’s any real secret to handling shift work, night shifts have been a part of my life since I worked on the ambulance, so I can share what little I’ve learned. I also conducted a series of Twitter polls to see what my fellow vampires are doing.

To sleep or not to sleep?

Probably the most important factor controlling your night shift is whether or not you’re able to sleep.

There’s a spectrum here. For some positions, sleep is simply off the table; for instance, emergency medicine providers usually expect and are expected to remain awake seeing patients for the entirety of their shift. Similarly, ICU coverage in some institutions is busy enough that even if napping is a theoretical possibility, in practice it doesn’t happen. Depending on your department, you may not even have a call room or other physical space to accommodate your drooping head.

In other roles, the demands of the typical night shift may be minimal, permitting a provider to arrive at work expecting to get something resembling a full night’s sleep. (Positions where this is the norm are probably the minority.)

The majority of cases fall somewhere between these extremes. You might easily spend the entire night awake, or luck out and spend much of it sleeping, but your typical shift will have a few hours of (heavily interrupted) sleep.

All sleep is not necessarily equal, of course. Even for “night folks” and late-to-rise types, there’s a difference between 11:00 PM (a whimsical, slumber party kind of hour) and 3:00 AM (true, indisputable night time). For almost everyone, even those semi-adapted to a nocturnal schedule, the period of around 2:00–4:30 AM is a deep, dark hole, when physical and mental slowing is virtually inevitable, and where you’ll probably want to sleep if you can. I blame dipping cortisol.

Starting your cycle

Outside of cruel and hopeful rare scheduling vagaries, nights are usually clustered in blocks; nothing is more abusive than an inconsistent stretch like night/off/day/off/night. (The exception, of course, is 24-hour-type shifts, which stand alone.)

So: you’re entering a stretch of nights. Presumably you live most of your life during the day, which means you’ll need to perform a transition. How should you handle this changeover?

This depends on the previous question. If you expect to get a hearty helping of sleep on your shift, you can play it like normal: rise at the usual time, spend your pre-call day awake, go to work, and sleep.

If you’re unlikely to catch a wink, however, you should do everything possible to set yourself up for your shift. For many, this means an afternoon nap; a couple hours of sack time before your shift can make a world of difference. Barring that, it’s wise to at least spend the day or two before your nights pushing your schedule ahead a little, staying up a few hours later than normal and waking up the same. Early to bed, early to rise is not a pre-call recipe for success.

The interstitial days

A related, but perhaps more difficult question is how to handle the days at home between night shifts. Certainly, unless you truly had a full night of interrupted slumber the night before, you’re going to sleep at home. But how much?

In this case, the driver is often how your previous night went rather than expectations about the upcoming one. If you were awake all night, you’re probably going to sleep for 6+ hours, and that’s just a fact. If you had plenty of sleep, however, you might do with much less.

Your final post-call day is a special case. as transitioning from your night shifts back to a diurnal cycle requires a thoughtful approach. Although you will inevitably be sleepy, your goal should be to quarantine the sleep disruptions to that day alone, making every effort to resume a normal schedule by the next morning. This means getting to bed at a normal time, and that usually means limiting your post-call sleep; if you nap until 6:00 PM, you’re probably not going back to bed until very late, and that will throw you off for the next day.

A method: the “In Between” system

For those of us whose nights are unpredictable, I favor the following approach. The goal here is to split the difference, allowing one to be awake and functional if their shift is busy, yet tired enough to sleep if it’s slow—because the only thing worse than being groggy at 2:00 AM is being wide awake with nothing to do.

Between shifts, strive to get about 50%–75% of a normal night’s sleep. Then during your shift, you can aim for an additional 2–3 hours. If you get that or more, great; you can trim your sleep the next day a little, and enjoy some bonus time awake at home. If you get less, then plan on a solid 4–6 hours the next day. So a sample three-day stretch might look something like this:

  • Pre-call day: Late to bed, late to rise. Personally, I no longer take an afternoon nap, which tends to hamper my ability to sleep at work. If you’re having caffeine, it should be no later than noon.
  • 1st shift: Come in at 7:00 PM, do some rounding, get to know your patients, put out any fires and plan for any brewing ones, tidy up orders for the next morning. Eat a late snack, then attempt to get to bed around midnight. (Before then, I find it difficult.) Sleep a little, or not.
  • 1st post-call day: As soon as you leave work, enter night mode. Wear sunglasses and start to unwind. Get home around 8:30. Have a quick shower, else your bed will gradually become stinky. Don an eyemask and earplugs and sleep from about 9:00–2:00. No coffee unless you’re up before 1:00 PM or so. Putter around for a few hours, try to be semi-useful, perhaps exercise. Take a proper shower, eat dinner, and return to work. Don’t make any plans; this “day” is really a night.
  • Day 2-3: Repeat.
  • Final post-call day: The best part of this system is that you can exit the cycle in the same way. No matter how your last shift went, try not to sleep past 2:00 PM; preferably, get up by 1:00, and have a little coffee. Following through on some low-key PM plans is usually achievable. A couple hours before bed, take about 1 mg of melatonin (if you’re having a big evening meal, take it before eating, or else absorption will be slowed by digestion). Get to bed by midnight and rise the next day on a normal schedule. Repeat the melatonin for at least 1–2 more nights, which I find helps prevent nighttime awakenings.

Life as a shift worker

At the end of the day, no amount of gaming will make this process completely painless. However, it’s not all frowns. In most departments there are a few people who actually prefer nights, even without a wage differential or other incentive. They have their own appeal: less routine “busywork,” so most of what you’re doing is either relaxing or dealing with problems or new patients (which tends to be more interesting than rounding and paperwork). For APPs and house staff, nights also tend to involve less supervision and hence greater autonomy. In many units there are more admissions at night, and universally, there is less administrative and managerial presence, which appeals to some people.

In the end, the golden rule for night-shift satisfaction may be this: you should never come to work expecting to sleep. You might hope for a bit of it, but once it becomes an expectation, the wheels come off. Physiology aside, you’ll start to see every phone call or admission (also known as “doing your job”) as an imposition, and that will stain your behavior as well as your worldview. You’re here to work, unfortunately. Accept it, have a little fun if you can, and just remember that you could have chosen an office job.

Happy shifting.

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