REST - Week 2

Residents & Fellows and Shift Work and Letting Go Techniques

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Weekly Sleep Topic

Everyone knows that residents and fellows work long and hard hours with frequent changes in their schedules as they are on call, changing clinical rotations, and working in different environments as part of their training programs. Often they are on rotations that require “shift work” that does not coincide with normal routine work hours between 7 am and 6 pm. This type of schedule can lead to shift work disorder.

What is shift work disorder?

Shift work disorder is a type of circadian rhythm sleep disorder where there is a mismatch between the body and the circadian rhythms that regulate the sleep-wake cycle.

Circadian rhythms are largely guided by natural light and darkness. During the day, when your retinas perceive sunlight they signal the brain to release cortisol to keep you feeling alert and energized. As the sun sets and light fades, your brain produces melatonin, which causes feelings of sleepiness and relaxation.

In shift work disorder, the circadian misalignment is related to a work schedule that overlaps with a traditional sleep-wake cycle. Insomnia, excessive sleepiness while awake, and recurring sleep loss are the defining symptoms of shift work disorder. Because residents’ and fellows’ schedules often include shift work and frequently they change schedules every month due to rotation changes, they are at high risk of experiencing shift work disorder.

Tips for Improving Sleep When Doing Shift Work

Sleep consistency is key for residents and fellows working night shift schedules. If you wake up at 5 pm for your night shift and normally go to sleep at 8 am after getting home from work, then you also should maintain this sleep-wake schedule on your days off (Yes, even on the weekends and holidays!) Obviously, this can be difficult to accomplish. Make sure significant others, children, roommates, and anyone else you live with understands the importance of your designated sleep time. They should not wake you up unless there’s a true emergency.

Light and noise exposure can also make sleeping during the day difficult. Draw the shades and blinds or sleep with an eye mask if your bedroom tends to be bright during the day. Earplugs and white noise machines can help block outside sounds. Unless you are on call, consider turning your phone off while you sleep.

Rather than immediately going to bed, some residents prefer to stay up for a few hours after arriving home as one might do after a day at work on a traditional 7 am to 6 pm schedule. This way, they can wake up closer to the time when they start their next night shift. For others, a split-nap schedule is more effective. This entails napping for a few hours after getting home in the morning and then sleeping for longer in the hours leading up to the next shift’s start time.

Before going to bed, consider a hot shower or bath, meditation, or another relaxing activity. Avoid drinking alcohol before bed as this can lead to disrupted sleep. This may seem counterintuitive as alcohol has sedative effects that can help you go to sleep more easily, but alcohol also causes sleep disturbances or fragmented sleep.

The key for good health is to get enough sleep every 24 hours. The National Sleep Foundation recommends 7 to 9 hours of daily sleep for most adults between the ages of 18 and 64. Although some adults can get by on slightly less or may need slightly more sleep, the National Sleep Foundation doesn’t recommend fewer than 5 to 6 hours or more than 10 to 11 hours of sleep per day.

Tips for Staying Awake During Shift Work

As a resident when you are at work during an irregular shift, strategies to stay refreshed and alert may include:

Caffeine in moderation

Caffeine can provide an energy boost during shift work, but it should be consumed carefully and in moderation. A cup of coffee or caffeinated soda is recommended at the beginning of your shift. The caffeine will usually take effect within 15-20 minutes. Moderate amounts of caffeine every one to two hours will be more effective than heavy amounts. Avoid drinking or eating foods with caffeine within 3 to 4 hours of the time you plan to go to sleep.

Get the blood moving and increase your circulation

If you have enough time during a scheduled break, consider a brief workout or a jog around your workplace. Even a small amount of exercise can provide an energy boost. Taking the stairs instead of the elevator or enjoying a quick dance routine (alone or with fellow residents) in the oncall room or another available space can be fun and invigorating. Click here for dance video.

Take a nap.

You can also snooze on your break if you’d rather sleep than exercise. A nap of 10-20 minutes is considered ideal because you won’t enter deep sleep and feel excessively groggy when it’s time to wake up. For some residents, the “coffee nap” can be effective. This strategy involves drinking a cup of coffee and then taking a nap that lasts 15-20 minutes. Your wake-up time will coincide with the caffeine in the coffee taking effect.

Exercise caution: People who experience sleep problems due to shift work are at higher risk of on-the-job errors and accidents. The same is true of first year residents who are new to shift work, or those who are working shifts that are longer than usual. It can be helpful to ask a co-resident or nurse to double check your orders and encourage everyone to notify you promptly if they notice any errors.

Consider a post-work snooze: Many residents take public transportation home post call. But it you drive home after your shift is over, then consider that drowsy driving accidents are a common hazard associated with shift work. Use public transportation on days when you are post call or a night shift if you can. If you must drive and are feeling drowsy, take a nap before driving. If your workplace does not have a room where you can nap undisturbed, you can doze for a few minutes in your car before leaving the property. If you begin to feel drowsy behind the wheel, pull over at the next available opportunity where you can park safely and nap for a few minutes.

Tips for Residents and Fellows With Rotating Shifts

Fixed shift work creates plenty of sleep challenges for residents and fellows, but rotating shifts that involve different start and times for shifts during a given week or month can make these issues even more challenging. Residents face these challenges in every year of residency and fellowship. Rotating shifts vary by residency and fellowship program.

Residents and fellows with rotating schedules should prepare for shift changes by adjusting their sleep times. Let’s say you are currently working a day shift and planning to rotate to a night shift the following week. You should gradually delay your bedtime by one or two hours each night a few days prior to starting the night shift if possible. This will help you get enough rest and avoid sudden changes.

Some rotating shifts are better for sleep than others. For example, rotating from day to afternoon to night shifts is a more natural progression that is easier on your body compared to rotating in the opposite direction or in random patterns. Rotating shifts every 2 to 3 days may also be better for residents than rotating their shifts every 5 to 7 days, and too many consecutive night shifts can be problematic.

If you work a rotating schedule and the routine is wearing you down, consider having a word with your chief residents. They may be able to adjust your shifts or rotations and provide a schedule that is better for your sleep schedule.

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