My friend texted me the other day that she was thinking of quitting her training program.
Some schedule changes earlier in the year led to her being scheduled for back-to-back month-long night float rotations. She was in the middle of her second straight month of nights and was feeling tired, depressed, and burned out.
Now, this might be a unique situation since night float rotations, on average, are only one to two weeks, but it just highlights the difficulty of working nights.
On paper, night float is the ideal scheduling solution. It adheres to ACGME duty hour guidelines. It provides 24-hour coverage. Studies have shown no decline in patient outcomes. And learners prefer it too. When compared to 24-hour call shifts, surveys of trainees across multiple specialties report increased sleep, personal time, and reduced fatigue.
In practice, as one might guess, night float is still much more challenging than working during the day.
The challenges of night float
First, the night team often runs with a skeleton staff. The night person covers the daytime responsibilities of several people. There are fewer resources available in the hospital at night. There is often little to no transition time scheduled when shifting between day and night shifts. The cafeteria closes. There may or may not be enough clean call rooms for everyone.
Despite working a similar number of weekly hours, learners report increased fatigue and decreased mood when working nights. It has been shown that learners sleep fewer hours during the night float rotation. Furthermore, sleep schedule disruption persists more than three days after the end of the night float rotation.
As we start our medical careers, we are thrust into these demanding schedules without any education or resources and are expected to be able to function at any hour of the day. As an anesthesiologist in a busy academic center, I am expected to be able to switch back and forth often.
Here are seven tips that I have learned throughout my career to improve the day-to-night transition and improve your alertness during night float:
1. Optimize sleep when you are not at work. Not all sleep is equal. A few short naps at work plus a few hours of restless daytime sleep at home will not be as effective if you are not sleeping long enough to go through REM cycles. Sleep in a quiet, dark, and warm room to trick your brain into sleeping when the sun is up. Minimize bright lights or screen time before sleeping. Meditation can help quiet your mind and help you relax after an especially busy overnight shift. Reduce caffeine intake near the end of your shift. Sleep aids, such as melatonin, can shorten the time it takes to fall asleep.
2. Nutrition at night. Stay hydrated throughout the night. Warm liquids can increase your core body temperature to help you feel less sleepy. Drink caffeine at the beginning rather than at the end of your shift to optimize its peak effectiveness. Avoid snacks high in fats and sugars, as those can make you drowsy and less productive.
3. Take activity breaks. Standing and stretching after working in a sedentary position help increase blood flow and improve brain function.
4. Use the power nap. Several studies have found improved alertness for a period following a 10 to 20-minute “power nap.”
5. Take advantage of post-call hospital resources. Using a hospital-supplied taxi or rideshare voucher to go home reduces the risk of drowsy driving. It also reduces the need to re-caffeinate at the end of your shift, making it harder to sleep once you get home.
6. Rest. Rest as much as you can as you transition between night and day. Switching is like going on a trip and managing jet lag. It is easier to travel west or transition into night float than it is to switch back. If you have a few days off after the end of your night float before returning to your day schedule, try to rest as much as possible to shift your schedule back to your normal circadian rhythm.
7. Don’t neglect your support network. Not only is night float both physically and mentally exhausting, but it is also emotionally isolating. During night float, you are in a different time zone from most of your friends, family, and colleagues. The usual resources are severely limited or simply not offered. When I am on night float, I could go for days without seeing my partner even though we lived together. Take five minutes to say hello/ goodbye to your spouse on your way out the door, text your friends and family, or reach out to someone also on a night float rotation to check in.
The biggest impact on after-hours work is the toll that it takes on us — our ability to focus and safely get home after work — changes our mood. While working long hours may be “fine” for patient care, we must prioritize learning how to keep ourselves safe and sane during after-hours work.
Alexandra Ruan is an anesthesiologist.