Top Tips for Working Nights

Night shifts are unfortunately an inevitable (and important) part of being a foundation doctor. This article will cover general advice and tips on how to manage night shifts as well as things I have found useful that perhaps weren’t taught at medical school. These tips worked for me, but everyone copes with night shifts differently so take the advice with a pinch of salt and adapt them to whatever suits you.

Sleep
Sleep (or lack of) is one of the most difficult parts of working nights, so it is vitally important to have good sleep hygiene. There is plenty of official advice online but here are some tips I found useful:

1. Enjoy a lie-in and wake up naturally on the day before your first set of nights.
2. Try to get a 20-40 minute nap in the late afternoon the day before your nights start.
3. Get rest when you can while on shift. Set 30-40 minute timers on your phone and keep your bleep close by while resting on shift to avoid completely nodding off!
4. Get to sleep as soon as possible and for as long as possible in the day during your set of night shifts. Set an alarm for 2-3 hours before your next shift starts (e.g. 5pm).
5. Ear plugs and an eye mask are essential for getting as much as sleep as possible during the day.
6. Having a shower when you get home and having a fresh set of bedsheets and pyjamas can help make you feel sleepy when your body clock is telling you otherwise.
7. Treat yourself after your night shifts finish! Do whatever makes you happy to celebrate finishing your nights. Some colleagues of mine like to have a glass of wine to celebrate finishing and then relax during the day. Personally, I preferred going straight to sleep then waking up
   slightly earlier at 2-3pm to relax in the afternoon and have a few beers before going to bed at my usual time.
8. Avoid going on holiday straight after night shifts! I made this mistake after my first set of nights and really struggled to reset my body clock. I found being forced to wake up at normal times for the usual day job was the best way to get back to normal.
9. Get as much rest as possible in your time off before going back to work. During the night shifts you will have missed a night of sleep and
   accrued a “sleep debt” which needs paying back. Try to get a few hours more sleep each night than you normally would in your time off.

Food and Drink
As your sleep goes a bit haywire during the night shifts, food becomes an even more essential way to energise yourself. Here are some tips for getting through the nights:

1. Prep main meals at the start of the week or buy microwave meals for each night shift. Being tired and hungry at 4am when seeing a patient is not pleasant so it is really important to have a proper meal midway through the shift to keep yourself going. Some people like having a healthy, nutritious meal to keep them going. Personally I loved having a warm comforting microwave meal (but not too stodgy) to look forward to each shift.
2. Bring plenty of snacks. If the shift is particularly busy you may not have time to have a proper meal so having filling, wholesome snacks
   throughout the shift can be a lifesaver.
3. Make sure you still have breakfast, lunch and dinner every day. This is vital to keep yourself energised during the shifts. I sort of inverted this pattern by having dinner when I woke up before my shift started, “lunch” midway through my shift at around 1am, then a bowl of cereal and juice when I got home before going to bed during the day.
4. Make sure you eat well before going to sleep in the morning otherwise you’ll wake up feeling hungry in the middle of the day.
5. Be careful with caffeine. You really don’t want to get home after you finish too alert to sleep because you had a tea or coffee too late into your shift. What worked for me was having a coffee before my shift started and a cup of tea early on in the shift. Make sure to avoid drinking any caffeine in the last 6 hours of your shift.
6. Treat yourself! Do whatever will make you happy and content to get through the shifts. For me this was buying some fancy San Pellegrino cans to enjoy during my midnight lunch and a pack of beer to look forward to on the final day after I finished.

During the Shift
Here are a few general tips to work efficiently and appropriately while on shift:

1. Try to get to hand over at least 15 minutes before it starts. At my Trust we usually had to arrive for handover 15 minutes before our shift started which was frustrating, but the flip side was that we usually finished the shift 15 minutes early at morning handover. Remember the day team need to get home to rest as well so don’t be late for them to leave.
2. For each patient handed over, document their name, date of birth, hospital number, ward, problems and jobs. Make sure you get an idea of the urgency of the problem/job so you can prioritise who needs seeing first.
3. Prioritise urgent reviews first then work logically ward-to-ward. Contact your seniors early on if you feel overwhelmed or have more than one clinically urgent job. Review jobs list regularly to reprioritise throughout the shift.
4. Document in the patient notes all relevant history points, vital signs, exam findings (ABCDE), relevant tests carried out and management
   plan. Ensure you include your name, grade, bleep and signature at the end. Communicate the plan to the patient and relevant ward staff.
5. At the end of your shift, hand over any important jobs to the day team (e.g. any sick patients, bloods that need chasing, new patients
   admitted). Do not leave important clinical tasks for the day team to do.

Common Jobs
This section will focus on typical jobs you might face on a night shift and how to manage them. We won’t go over urgent/emergency clinical scenarios which are covered in other articles, just remember to follow the ABCDE approach (and contact your senior if you are unsure) and you can’t go too wrong.

1. Prescribing: this is probably the most common job you will have to do on night shifts. For any prescription always confirm allergy status, see the patient to assess the clinical need for the prescription, and check any cautions or contraindications (e.g. slower IV infusion rate in
   heart failure, avoid/reduce dose of opioids in CKD).

• IV fluids: check the patient notes first for any instructions on IV fluids. Assess the patient’s fluid status and ensure no need for fluid resuscitation (e.g. hypovolaemia/shock). Check their fluid balance chart over the past 24 hours. Review the most recent U&E to choose an
  appropriate fluid. You won’t go too far wrong giving 1L crystalloid over 8-10 hours to keep them going through the night. The BNF has some helpful advice on fluid prescribing.
• Analgesia: check the patient notes then see the patient to SOCRATES their pain and do an ABCDE assessment. Rule out any sinister causes for their pain. Follow the analgesic ladder (paracetamol/NSAIDs → codeine/tramadol → morphine). Start at the lowest dose possible and increase the dose/go up one rung on the ladder as needed.
• Antibiotics: check the patient notes for any instructions and indication for antibiotics. Follow your Trust’s intranet guidelines to choose an appropriate antibiotic. Also prescribe a STAT dose if it’s several hours prior to the morning dose. Gentamicin, vancomycin and teicoplanin need careful dosing, timing and monitoring. Your Trust should have guidelines for these so just follow them and you will be fine, the ATSP app also has a helpful guide for this.
• Warfarin: always check the patient notes to see if there was a reason it was not prescribed during the day (e.g. patient due to have a procedure). Check the patient is not bleeding! Check their most recent INR and prescribe accordingly on the warfarin prescription chart. My Trust has a helpful guide on the back of the warfarin chart to help with dosing but I must admit it still feels a bit of an inexact science. The ATSP app has a helpful guide for warfarin prescribing.

2. Patient having difficulty sleeping: a patient struggling to get to sleep requesting a sleeping tablet is another common job on nights. This task should always have low priority (unless they are distressing other patients) for a few reasons:

• it should always be done after urgent clinical matters
• sleeping tablets are potent and addictive so should be avoided where possible
• I usually find waiting a couple of hours before seeing the patient often does the trick and they fall asleep naturally. If the patient/nurse persists asking you then the safest bet is a once only zopiclone at the lowest dose possible (3.75mg) which can be increased as needed and left for the day team to review ongoing need.

3. Bloods/cannula: another common request is for you to take bloods/insert a cannula. Always ask the ward staff if they have tried first. If you are swamped the ‘hospital out of hours’ team will often have experienced clinical support workers who can help. If you are still needed
   to do it check the reason for it and whether it is necessary – can the bloods wait until morning phleb round? Do they still need IV fluids/meds?

Helpful People
You never work alone on night shifts and there is always help at hand if you need it. The ‘hospital out of hours’ (HOOH) team is very experienced and invaluable on nights. Here are some helpful people you can contact:

1. Ward staff: there is almost always a job you can ask the ward staff to do before arriving on the ward to review your patient (e.g. ECG in
   chest pain, bloods in sepsis, set up oxygen if low sats). It’s often valuable to call ahead to ask why they need this job doing overnight (e.g.
   cannula, fluids). After reviewing your patient and documenting, make sure to communicate your plan to the ward staff before leaving.
2. Clinical support workers: my Trust has experienced clinical support workers in the HOOH team who can relieve your workload massively by taking bloods, cannulae and doing ECGs.
3. Advanced nurse practitioners (ANPs): in my Trust ANPs are fantastic. They coordinate the night shift for everyone allocating jobs to you, ensuring everyone has a fair share of jobs, and even calling you up to make sure you have regular breaks! Always feel free to give them a call if you feel overwhelmed and need a hand.
4. Your SHO/registrar: your immediate medical senior is your first port of call for any clinical queries and sick patients. If you feel unsure about anything, have a chat with them. Your senior will much prefer being called a lot than potentially missing important aspects of a sick
   patient’s management. On my nights I made full use of this and, as I got more experienced and confident, called less and less but still almost always contacted them about any sick patients.

Helpful Apps
These are a few apps I used lots on my night shifts and found very useful:

1. ATSP: stands for “asked to see patient”. The most useful app on nights for me. It gives you a step-by-step overview of how to assess the
   most common clinical problems from abdominal pain to tachycardia.
2. iResus: you should not be expected to lead a cardiac arrest as an F1 doctor, but you will likely be needed to help out. The iResus app has
   all the ALS algorithms from the Resus Council in a handy app to follow when the adrenaline kicks in.
3. BNF: this is your first port of call for any queries you have with prescribing.
4. Induction: this has lots of numbers/bleeps for various departments in the hospital that you may need to contact overnight (e.g. radiology,
   specialist registrars). You can change the hospital to find contact numbers for another hospital if you need that as well. It’s user-led so if
   you notice an error you can change it for others.
5. MDCalc: does all the maths for you for any calculations you need (e.g. creatinine clearance, Wells’ score, AMT, CURB-65). Extremely helpful when your brain is frazzled at 4am.

Night shifts can feel daunting but hopefully this article has given you an idea on how to manage them and has made them feel less scary. These tips all worked for me, but everyone is different so adapt this advice to whatever works for you. Always remember you are never working alone and there are always people to contact if you need help and you will be grand.