Night Shifts in Emergency Medicine
This study identified fatigue among physicians as one negative aspect attributed to night shifts. Thirty-six percent of respondents indicated in comments that working night shifts has negatively impacted their health because of fatigue. This finding is pervasive in night shift literature. In a study by Cydulka and Korte, fatigue has an odds ratio of 7.5 of being associated with burnout and number of night shifts had an odds ratio of 3.6 association with burnout. Burnout had the highest odds ratio by far (odds ratio = 7.5) of being associated with low career satisfaction. Nagai et al. reported that "all fatigue scores increased progressively from the beginning of the day shifts to the end of the night shifts". According to Machi et al., fatigue was related to the perceived difficulty of the shift and did not vary according to day or night shifts. Physician fatigue is inherently concerning because of its affect on safety. The negative influence of night shifts on cognitive and psychomotor performance measures has been reported. In 2006, according to the United States National Postgraduate Medical survey, percutaneous injury in interns was significantly higher during extended work duration and doubled during night shifts compared with day work. Reaction time and time for intubating a mannequin were significantly slower in EPs during night shifts when compared with day shifts. According to Dula et al., working a series of 5 night shifts results in a substantial decline in cognitive performance in physicians working in the ED.
Solutions to the problem of fatigue and decreased performance during night shifts are suggested in the literature. Modafinil has been shown to improve cognitive performance during night shifts. A mid–night shift nap significantly improved morning cognitive and psychomotor performance, as well as subjective reports of fatigue compared with no nap in EPs and emergency nurses. Studies have demonstrated controversial benefit of melatonin for improving daytime sleep and night alertness. In a small, prospective study, hydrocortisone taken before a nightshift by desynchronized EM physicians decreased subjective fatigue on the first night shift. Permanent night shifts have been shown to improve mood, fatigue, and performance.
Night shifts negatively impact sleep. Thirty-five percent of the physicians in this study indicated in comments that a poor quality of sleep is associated with working night shifts. According to the International Classification of Sleep Disorders, there is a new sleep disorder known as shift work sleep disorder (SWSD). SWSD is described as symptoms of insomnia and excessive sleepiness that occur as transient phenomena in relation to work schedule. Additionally, fatigue and sleep difficulties increase with advancing age. For a majority of retired physicians, night shifts impacted their decision to retire. This finding speaks to the reported difficulty EM physicians have with night shifts with advancing age. According to a study of EPs in preretirement years, 74% reported less ability to recover from night shifts. More research is needed to elucidate the impact of night shifts on retirement age.
Strategies to lessen the impact of night shifts on sleep include improved sleep hygiene, reducing the number of consecutive night shifts, reducing the length of night shifts, and power napping.
This study identified a significant impact on mood and social interactions among physicians attributed to working night shifts. Twenty-nine percent (n = 139) of respondents indicated that night shifts had a negative impact on their mood. Decrements in mood, including irritability and stress, are often associated with fatigue and insufficient sleep. Nine percent of respondents (n = 43) indicated in comments that family relationships were challenged because of working night shifts, including strained relationships and not enough time or energy for family. Awareness of the potential negative effects on social interactions can lead to better coping skills. The solutions described here can also mitigate the negative effects of night shifts on mood and social interactions.
Nineteen percent (n = 91) of respondents reported challenges with maintaining healthy lifestyles. Comments included poor dietary choices, weight gain, and insufficient exercise. Providing healthy snacks in hospital EDs, wellness workshops, and exercise facilities can be beneficial.
In summary, EPs report the negative impact of night shift work, including fatigue, poor quality of sleep, mood decrement, irritability, and health challenges. Night shifts have a negative influence on job satisfaction and can be a factor in the decision to retire.
This study identified numerous negative impacts of night shift work for EPs, including fatigue, poor quality of sleep, mood decrement, irritability, and health challenges. This speaks to the importance of actions to be taken by individuals, institutions, and the specialty of EM to address these issues. Potential future directions include education, programs, and research, to understand the effects of night shift work and to promote wellness and longevity among night shift workers.
There are several significant limitations to this study. The accuracy of the data was dependent on accurate and unbiased self-report of participants. There may have been nonresponse bias; it is possible that those who were more negatively or positively affected by night shift did not respond. It is also possible that those negatively affected by night shifts may have left the specialty. Although these data are 6 years old, we have no indication that satisfaction with night shift work would have increased during the interim. On the contrary, the most recent graduates are increasingly aware of and focused on lifestyle and work–life balance. The unavailability of certain demographic data created some limitations of data analysis. All participants are residency-trained practitioners and data are generalizable to this group. It is unclear if the data are generalizable to nonresidency-trained practitioners.
Discussion
Fatigue
This study identified fatigue among physicians as one negative aspect attributed to night shifts. Thirty-six percent of respondents indicated in comments that working night shifts has negatively impacted their health because of fatigue. This finding is pervasive in night shift literature. In a study by Cydulka and Korte, fatigue has an odds ratio of 7.5 of being associated with burnout and number of night shifts had an odds ratio of 3.6 association with burnout. Burnout had the highest odds ratio by far (odds ratio = 7.5) of being associated with low career satisfaction. Nagai et al. reported that "all fatigue scores increased progressively from the beginning of the day shifts to the end of the night shifts". According to Machi et al., fatigue was related to the perceived difficulty of the shift and did not vary according to day or night shifts. Physician fatigue is inherently concerning because of its affect on safety. The negative influence of night shifts on cognitive and psychomotor performance measures has been reported. In 2006, according to the United States National Postgraduate Medical survey, percutaneous injury in interns was significantly higher during extended work duration and doubled during night shifts compared with day work. Reaction time and time for intubating a mannequin were significantly slower in EPs during night shifts when compared with day shifts. According to Dula et al., working a series of 5 night shifts results in a substantial decline in cognitive performance in physicians working in the ED.
Solutions to the problem of fatigue and decreased performance during night shifts are suggested in the literature. Modafinil has been shown to improve cognitive performance during night shifts. A mid–night shift nap significantly improved morning cognitive and psychomotor performance, as well as subjective reports of fatigue compared with no nap in EPs and emergency nurses. Studies have demonstrated controversial benefit of melatonin for improving daytime sleep and night alertness. In a small, prospective study, hydrocortisone taken before a nightshift by desynchronized EM physicians decreased subjective fatigue on the first night shift. Permanent night shifts have been shown to improve mood, fatigue, and performance.
Impact on Sleep
Night shifts negatively impact sleep. Thirty-five percent of the physicians in this study indicated in comments that a poor quality of sleep is associated with working night shifts. According to the International Classification of Sleep Disorders, there is a new sleep disorder known as shift work sleep disorder (SWSD). SWSD is described as symptoms of insomnia and excessive sleepiness that occur as transient phenomena in relation to work schedule. Additionally, fatigue and sleep difficulties increase with advancing age. For a majority of retired physicians, night shifts impacted their decision to retire. This finding speaks to the reported difficulty EM physicians have with night shifts with advancing age. According to a study of EPs in preretirement years, 74% reported less ability to recover from night shifts. More research is needed to elucidate the impact of night shifts on retirement age.
Strategies to lessen the impact of night shifts on sleep include improved sleep hygiene, reducing the number of consecutive night shifts, reducing the length of night shifts, and power napping.
Impact on Mood, Health Maintenance, and Social Interactions
This study identified a significant impact on mood and social interactions among physicians attributed to working night shifts. Twenty-nine percent (n = 139) of respondents indicated that night shifts had a negative impact on their mood. Decrements in mood, including irritability and stress, are often associated with fatigue and insufficient sleep. Nine percent of respondents (n = 43) indicated in comments that family relationships were challenged because of working night shifts, including strained relationships and not enough time or energy for family. Awareness of the potential negative effects on social interactions can lead to better coping skills. The solutions described here can also mitigate the negative effects of night shifts on mood and social interactions.
Nineteen percent (n = 91) of respondents reported challenges with maintaining healthy lifestyles. Comments included poor dietary choices, weight gain, and insufficient exercise. Providing healthy snacks in hospital EDs, wellness workshops, and exercise facilities can be beneficial.
In summary, EPs report the negative impact of night shift work, including fatigue, poor quality of sleep, mood decrement, irritability, and health challenges. Night shifts have a negative influence on job satisfaction and can be a factor in the decision to retire.
Future Directions
This study identified numerous negative impacts of night shift work for EPs, including fatigue, poor quality of sleep, mood decrement, irritability, and health challenges. This speaks to the importance of actions to be taken by individuals, institutions, and the specialty of EM to address these issues. Potential future directions include education, programs, and research, to understand the effects of night shift work and to promote wellness and longevity among night shift workers.
Limitations
There are several significant limitations to this study. The accuracy of the data was dependent on accurate and unbiased self-report of participants. There may have been nonresponse bias; it is possible that those who were more negatively or positively affected by night shift did not respond. It is also possible that those negatively affected by night shifts may have left the specialty. Although these data are 6 years old, we have no indication that satisfaction with night shift work would have increased during the interim. On the contrary, the most recent graduates are increasingly aware of and focused on lifestyle and work–life balance. The unavailability of certain demographic data created some limitations of data analysis. All participants are residency-trained practitioners and data are generalizable to this group. It is unclear if the data are generalizable to nonresidency-trained practitioners.
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