Author: Amar Mashru / Editor: Charlotte Davies / Codes: SLO11, SLO12 / Published: 31/07/2018

You are about to embark on one of the most challenging rotas of your career. I mean, let’s be honest, for many of you, you will consider this the worst rota of your career. Let me start by reassuring you, if it stayed that bad, none of us would keep doing it. So for those of you considering EM as a career, first things first; it gets better, for lots of reasons. Honest.

The reason the rotas can be so tough is simply that we have to provide a 24h high quality service and the reality is that a large bulk of that service is dependent on SHOs. That’s not to say that there isn’t training value in the different learning available on different shifts – there certainly is. The exposure, the hands-on, the excitement of managing all sorts of patients with the much smaller, seniority-and-management stripped team of the night shift is a fantastic time to hone and develop skills that will benefit you career long. However, in return for working these rapidly cycling shifts, particularly those at night, the Trust and the Department owe you good quality rest and sleep facilities and a culture that prioritises your safety and wellbeing so that you can continue to care for patients and care for them well.

Rule number one: if you feel too tired to drive home at the end of a (night) shift, don’t. The Trust should absolutely be supporting your decision and providing alternatives. It is a safety critical necessity.

Check out the BMA Fatigue & Facilities Charter here.

The truth is that the decision to get behind the wheel of a car and drive is your own, just as it would be if you were drunk. In fact, being awake for 16-18h has similar effects in function to being exactly that. There is no judge who (no matter how sympathetic they may be) could deny that the decision to drive was yours. What is worrying, however, is that the evidence suggests that when we are fatigued our decision making is impaired. What is worse is that that our insight into our impaired decision making is reduced, i.e. our confidence in our decision making remains the same whilst our ability to make safe decisions falls. Imagine this when applying it to the decision to drive home, or a critical decision affecting patient care.

Our breaks are not a luxury, they are an absolute necessity to maintain patient safety. Our breaks are there to protect us and our patients. Please take the time to review the contract you are employed on, and make sure your break entitlements stipulated. We are painfully far away from the level of legislation that regulates other safety critical industries, but the least we must start with is recognising our own rights and the expectations of our employers if we have hope of improving from there. Know how many and how long your breaks should be and take them. Don’t miss your break and ask if you can leave early instead; no boss would want you looking after their mother after nine and a half hours of working straight. You wouldn’t either. Please, leave on time. Nearly everything can and should be handed over, and you may find you very quickly struggle to manage a rota when you’ve added an extra hour or two onto the end of each day. The Ed runs an an ongoing baton handover relay. We are used to it, and please get used to it as soon as you can. Avoid staying late on every shift; it might be a different saying ‘thank you’ on every occasion, and it’s not a healthy habit to get into.

We have a personal responsibility to recognise and prevent fatigue in ourselves, to consciously develop sleep routines and habits that reduce the negative effects of shift work on our health and our rest.

Those phones should not be going to bed with you – they shouldn’t even be in the room. Your bedroom should be cool and dark (especially important when sleeping in the day – get a decent eye mask or even blackout blinds). White noise can be valuable, not drinking caffeine towards the end of the day, getting into a good exercise routine, not eating just before bed. It’s not all the rota, the speciality and the department, some of it can be significantly improved by making a few simple changes, but they do need to be thought about and can require some discipline.

The Emergency Medicine Trainees’ Association and RCEM launched a #RestEM campaign in the Spring of 2018. The campaign looked to remind staff that they should be proud and supported to achieve some incredible things in their career, but they must not forget that, no matter how superhuman their feats of achievement may be, their physiology is mundanely human and must be respected as such. We need our breaks, we need good quality and regular sleep, and we need to accept nothing less than a speciality culture that respects these values in staff wellbeing.

The campaign posters were sent to all Emergency Departments so you should see them around. But if not they are available for download for printing here. The tips and advice boxes scattered within this chapter are reproduced courtesy of Dr Mike Farquhar of Guy’s and St Thomas’ Hospital who has been instrumental in raising awareness of our requirement to better understand sleep, breaks, rest and shift/night work. Mike’s work is absolutely worth a read and can be found here. The AAGBI Fatigue Work Group resources, particularly the checklists on how to recognise fatigue in yourself and colleagues are also a great resource.

Our culture starts with our behaviour and it takes each and every one of us to change it!

Rest and wellbeing is only one component of wellbeing. RCEM has a wellbeing app, and plenty more resources here.

Trainers: If you are looking to include Sleep and Shift Work Management in your Trust/Departmental induction I would urge you to check out this video.

Written by Dr Amar Mashru, HST Emergency Medicine: Campaign Lead #RestEM, Emergency Medicine Trainees Association with thanks, as always, to Dr Mike Farquhar (@DrMikeFarquhar) for his endless dedication to work in this field.

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