Per the National Institution of Health (NIH), the average adult should receive at least seven hours of sleep per night.1
Sleep patterns that deviate from this average show increased rates of health issues compared to those who regularly maintain adequate hours of sleep.
Unfortunately for EM residents, many factors hinder our ability to keep consistent sleep schedules in our day-to-day life because of shift work. Whether frequently switching from days to nights or having difficulty sleeping after an intense shift, having a set routine is often not feasible for our specialty.
So, what are realistic ways to overcome these obstacles and prioritize good sleeping habits? This article is going to tackle this tricky subject from various angles. The first applies to scheduling chiefs or administration. The second applies to residents and their efforts to combat demanding schedules.
Shift Scheduling
The specialty of EM requires physicians to accept that variability is the name of the game with our line of shift work. We were all familiar, at some point in our career, with the uncomfortable oscillations between day and night shifts, especially with how disorienting it is to start a shift on one night and then finish it on a new day when the sun is bright and shining, yet having to forcibly convince yourself to say, “OK time for bed!” For some, this transition is easily attainable after a day or two. Switching sleep cycles is exceptionally challenging for others and can cause increased stress, fatigue, insomnia, and decreased mental agility due to a prolonged lack of adequate sleep.2 However, there are multiple ways to optimize work schedules to reduce the amount of sleep debt and desynchronosis.
Kuhn’s article on circadian rhythms in EM describes how shift schedules containing counterclockwise rotation in time are strongly associated with more adverse outcomes. Starting shifts earlier each night as the week goes on correlates with poor sleep and clinical efficacy.2 Many EM programs, for this reason, have adopted the “circadian scheduling” format in which each successive shift will start later in the day in a clockwise manner to reduce disruption to our internal sleep cycle (ie, 1-2 morning shifts, followed by 1-2 evening shifts, followed by 1–2-night shifts), with at least a full day off after the last night shift before starting back in the morning. ACEP has discussed potentially beneficial patterns for scheduling night shifts, including solitary nights, clockwise monthly rotations, and the Thomas Schedule.3
For many programs, single night shift rotations, wherein the resident does not need to flip their schedule, provide a quicker route for adjusting back to the daytime schedule. However, for many resident-run programs or programs with smaller class sizes, this poses a challenge regarding scheduling and adequate staff coverage. The clockwise monthly rotations have shown a scientific advantage, emphasizing starting shifts early during the first week and progressively pushing the shift start time further back every month. This style is related to the “Thomas Schedule,” where a resident works an entire month of nights and does not have to spend multiple times each month adjusting to a new schedule. It is important to note that per ACEP, weekly shift rotations pose a significant threat, as the body takes one week to acclimate to scheduling changes. Research also supports shorter stretches of overnight shifts over longer stretches.
While the common notion might assume that one’s body will adjust to a complete night schedule in 7 consecutive shifts versus 3, studies show that for most individuals, the build-up of sleep debt and decreased cognitive function will precede comfortably adjusting to a complete night schedule in a week. Thus, constant changes week by week cause inherent adjustment challenges unless the person commits to the cycle for longer than the time it will take to adjust to a new circadian cycle physiologically. Thus, educating the scheduling resident or staff member on evidence-based options is one step to decreasing undue consequences of poor-quality sleep commonly associated with our field.
Optimized Sleep
EM physicians are bound to have some cycling through overnight shifts in their work schedule. So, while on these shifts, how can one optimize sleep to reduce these adverse side effects and enhance mental performance?
The University of Utah compiled a list of habits that can improve your overall quality of sleep during night shift duties. Not surprisingly, the first is to take a nap just before the first night shift in a streak for about 1.5-3 hours. The purpose is to give the body more rest before changing one’s sleep cycle because napping is more beneficial to prevent sleep debt rather than to fix it.4
Another tip is to sleep as soon as your shift ends, and you are home. Unfortunately, this is not always easy. The sun naturally causes our body to believe we should be awake. Getting black-out curtains, face masks, and assuring a quiet environment all assist in setting up the success of sleep time. If these interventions are unsuccessful, melatonin supplements have been shown to help sleep.
References
- National Heart, Lung and Blood Institute. How Much Sleep Is Enough? March 2022.
- Kuhn G. Circadian rhythm, shift work, and emergency medicine. Ann Emerg Med. 2001;37(1):88-98.
- ACEP. How to Design the Optimal Schedule for Working Shifts. Undated.
- Jone J, McAuliffe B. Sleep Tips for Night Shift Workers. University of Utah Accelerate Learning Community. Oct. 2, 2023.