Guidance on Avoiding Issues on Night Duty

Introduction

This guidance has been devised following a series of agency nurses who have allegedly been asleep when on duty. Clients have provided evidence from mobile phones of pictures/video to support their allegations. In many cases the person has denied being asleep and various explanations have been given including claiming they were praying, resting their eyes, had a headache and were avoiding bright light or had not been provided with a break or fluids so were dehydrated and exhausted.

There are many reasons why some staff prefer night work, it may be due to child/family care responsibilities etc. An important recognition is that when working nights there are usually fewer people around and it is inevitable that for some individuals, they feel more tired and sleep less than on daytime shifts.

Its also recognised that working night shifts can have a physical or psychological impact on individuals so it is important that you look after yourself, your colleagues as well as your patients/client when working nights. This begins before you work your night shift.

Promoting good bedtime patterns

It is important to have good habits whether sleeping during the day or at night. Keeping to a regular sleep schedule – going to bed at the same time and waking up at the same time – is recommended as a way to promote good sleep.

The Dos and Don’ts Guidance

Dos

Develop a bedtime ritual that you follow before you go to sleep – relax with a book, listen to soft music, or take a bath. This can help as a signal that your body is ready for sleep.
Keep your bedroom as cool as possible – people sleep better in cooler environments (around 18 degrees C).
Eat a light meal before going to bed to avoid hunger.
Regular exercise during the day helps sleep patterns but try to avoid exercise about three hours before bedtime.
Keep the bedroom dark – use an eye mask, blackout blinds or heavy curtains (or even a thick blanket) on your bedroom window. Even if you don’t work nights it can get very light in the early mornings during British summertime.
Keep the bedroom quiet – use ear plugs if necessary.
Write a ‘to do’ list before you go into the bedroom so you don’t lie awake worrying that you will forget important things the next day (a pen and paper by the bed can also help).
Use a relaxation to help you sleep, you can buy items which support rest and relaxation either via sounds or aromas
Invest in a good mattress or at least some decent pillows – seek manufacturer’s advice on the best type of pillow for you and your usual sleeping position.

Don’ts

Avoid stressful or stimulating activity before you go to bed, including the use of screen devices such as tablets/iPad etc.
Avoid alcohol or nicotine in the two hours before sleep. Alcohol might make you feel sleepy, but it will wake you up too quickly after falling asleep.
Nicotine is a stimulant and may affect the time it takes you to get to sleep. Don’t drink caffeine for up to four hours before going to bed.
Avoid a heavy or fatty meal before bedtime as they are harder to digest.
Avoid watching TV, video games, studying, playing, or working on a computer in the bedroom.
If you can’t avoid this as you live in a bed sit or shared accommodation – think about
having distinct areas in your room such as a desk which you can close off and a cupboard to store study material.
Don’t try and force yourself to sleep – sleep is a passive process. If you can’t sleep, after 30 minutes in bed get up and do something to distract yourself.
Avoid clock watching – watching the clock can increase anxiety about length of sleep. Set your
alarm if necessary and turn your clock away from your sight line.
Avoid difficult conversations with loved ones or confrontational discussions before bedtime wherever possible.

It is essential for night workers to learn how to manage their daytime sleep.

Here are some tips to help:

Silence mobile phones/ landlines so you are not disturbed – agree to times when you can be called e.g., before 10am and after 4.30pm
If possible, locate your sleeping area in a quiet part of your home
Ask those you live with to respect your need to sleep and to not disturb you unless there is an emergency
Allow yourself time to unwind when returning home after a night shift
Do not panic if you cannot sleep – follow the advice in the previous section
Ask colleagues to share their tips for coping some of these may work for you

Preparing for the first night

It is advisable to get extra sleep before working the first night shift. If you do not sleep before your first shift you could be awake for 24 hours or more.

Strategies to adopt during the shift to reduce risk of falling asleep on duty

Getting through the first night is usually easy but by the second or third fatigue begins to become an issue.

Ross (2011) suggests the following strategies:

1. Eat your main meal before going on shift - and have a lunch half-way through the shift and another light meal when you get home. Eating small amounts often throughout the night will keep your energy levels up. Find out what works for you but avoid a heavy meal before going to sleep.

2.Keep moving during the shift – when you have a quiet moment walk about and stretch. You could do this while checking on patients. If you are doing a 1:1 ask for cover for 5 minutes every couple of hours so you can walk to the toilet, make a drink etc.

3. Keep hydrated - but do not drink too much caffeine. Avoid caffeine towards the end of the shift as it can make going to sleep difficult when you get home. The effects of a cup of coffee can be felt within 20 minutes and can last up to 3 or 4 hours depending on the strength of the drink and your individual tolerance. Remember it is not only coffee that contains caffeine; cola drinks, tea, and some over the counter pain killers or cold remedies can also contain caffeine.

4. Keep your mind active – through your shift by talking to colleagues. Remember while you talk to colleagues you must respect the need to keep the noise level low for the patients/clients in your care so that they can sleep/rest.

5. Power napping and rest breaks - evidence is divided on the use of power napping due to the time it takes following a power nap to regain full alertness. If napping is allowed appropriate facilities should be available with scheduled breaks being more than 40 minutes to allow employees sufficient time to have a short nap, refresh themselves and regain alertness before resuming work. In some organisations sleeping on a break is not permitted so it is important to establish if this is allowed by asking the nurse in charge/shift leader. Some organisations refer to Waking Shifts which mean you are not permitted to sleep at any time in this shift even when on breaks. You should have a minimum of 20 minutes break away from the work environment if the shift is longer than 6 hours. Most Trusts allow between 45-90 minutes unpaid break. You must ensure you know the time you are required to return to duty and do not rely on others to call you to remind you to return to duty. If you are allowed to sleep, ensure you have your own alarm on your phone set to allow time for you to freshen up and to return alert on duty. If you are unable to take your break away from the work environment during a night shift, then you should discuss this with the Nurse in Charge and report this to your agency for them to address with the Client/Organisation you were working in.

6. Circadian nadir/body clock - this is the time when the natural body clock is at its lowest between 3am and 6 am. Night workers can feel cold, shaky, nauseous, sleepy, and drowsy at this time. This is a normal reaction as the body is programmed to be less active at this time. It can be difficult to stay awake especially if work demands are low. Eat and drink something warm (avoid caffeine) during this period and try to keep busy. If possible, schedule your break during this time.

Getting home safely

The end of a night shift is recognised as a high- risk period for car accidents, particularly towards the end of a few back-to-back shifts. If you are driving to and from work be vigilant to the risks of fatigue. If you do feel yourself falling asleep at the wheel pull of the road if it is safe to do so and have a short nap.

Avoid driving for long periods or a long distance after a period of night shifts or long working hours. It is advisable to have a rest or sleep and travel later in the day. It may be better to use public transport or share a lift with a co-worker and take it in turns to drive. This would help to reduce costs and having someone else in the car can help you both remain alert.

Park in well-lit areas if you are arriving and/or finishing work when it is dark. If you have concerns about your personal safety when travelling to or from work on a night shift or any unsocial shift, speak to your agency .

Coming off nights and back onto day shifts

Adjusting back to days can be difficult and your shift pattern should allow enough time to recover from night shift work before going onto the next shift.

Limit 12-hour night shifts to two to three consecutive shifts and when changing from night shifts to day shifts or vice versa, allow a minimum of 2 nights of full sleep to ensure adjustment to the new schedule.

Have a short sleep when you get home from your last shift and try to carry out normal daytime activities when you wake up and go to bed at your regular time that night to get back into routine.

Looking after your health

Working shifts can increase demands on your health.

Psychosocial health:

Maintaining a good work life balance is important so:

Make family and friends aware of your shift schedule so that they can include you when planning social activities
Make the most of your time off – plan mealtimes, weekends, and evenings together.
Invite others who work similar shifts to join you in social activities when others are at work and there are fewer crowds.

Physical health:

Shift workers can be more at risk of gastrointestinal complaints, diabetes, and cardiovascular problems.

A healthy diet and regular exercise is important.
Lack of access to healthy foods during shift times or lack of rest breaks can make this a challenge so go prepared with your own food and drinks

Stimulants/sedatives:

Shift workers can use stimulants such as coffee, cigarettes, and high energy drinks to keep them awake and alcohol or sleeping pills to help them sleep.
The effects of both stimulants and sedatives are only short term and can lead to the risk of dependence, addiction, and physical health problems. Avoid depending on either as a long-term strategy for dealing with the shift work. If you are following the guidance above and are still having difficulties staying awake or going off to sleep seek medical advice.
Let your GP know you work shifts so that they can be vigilant to any new or existing health problems that could be caused or made worse by work.

If you find it difficult to adjust or cope with shift work, your physical or mental health is being affected or you are unable to adjust your sleeping patterns and are suffering from chronic fatigue then you should seek advice and support. You can see your GP for advice. If you have a long-term condition that is affected by shift work or need to take medication at certain times of the day you should seek advice from your GP on how to manage this. If you are pregnant and having difficulty coping with shift work, you should seek advice from your GP or midwife.

Professional Responsibilities

Registered Nurses & Midwives have a duty under the NMC Code to manage risk (NMC, 2018) you must:

Act without delay if you believe that you or your colleagues or anyone else may be putting someone at risk – this would include sleeping/dozing on duty
Inform someone in authority if you experience problems that prevent you working within the code or other nationally agreed standards – this would include rest periods on duty, not receiving breaks when doing 1:1
Report your concerns using the Datix/Risk system in the organisation or in writing to the Head of Nursing for ICG Medical Ltd if you identify problems and you feel people are being placed at risk.
As a Nurse/Midwife or Health Care Assistant/Support Worker you have a duty to keep yourself and your patient/client safe and remaining awake and able to function safely on duty is key to this.
Issues such as inability to take a scheduled rest break and pressure to stay on after the shift has ended should be raised with your agency and the Head of Nursing for ICG Medical Ltd as these are professional concerns especially and if these result in fatigue, errors, and subsequent risks to patients.
Nurses should also think about the impact of having multiple jobs and the total number of working hours on their ability to practice safely.

Conclusion

Shift work is an inevitable part of providing 24-hour care. By following the advice above night workers can protect their own health and the health and safety of the people they are providing clock care to.

References

Nursing and Midwifery Council (2018) The code: standards of conduct, performance and ethics for nurses and midwives, London: NMC

Ross B (2011) The first time: surviving the night shift, Nursing Times, 31st August 2011