Originally published October 2014
Medicine has always been a 24/7 endeavour with physicians routinely working long hours, day and night. Fatigue and availability of resources can present challenges when working at night, but physicians can take steps to mitigate the risks to themselves and their patients.
Issues that can lead to medico-legal difficulties
In its review of closed legal actions and hospital and regulatory authority (College) complaint cases over a recent 5-year period, the CMPA found that clinical issues pertaining to nighttime care predominantly took place in emergency departments, in labour and delivery rooms, and occasionally on hospital wards.
Communication issues between physicians and nurses were the most common problems. These included physicians who provided insufficient information to others on the healthcare team, and nurses who failed to notify a physician regarding a change in a patient's clinical condition.
Diagnostic issues were the primary clinical concerns in emergency departments and wards. These included deficient assessment and lack of investigation, or failure to follow up on initial findings. On hospital wards, almost half of the cases involved a delay or failure of the physician to attend a patient, sometimes resulting in delayed diagnosis or treatment.
As in day time, clinical issues during nighttime labour and delivery were often associated with deficient assessment or delay or failure to expedite delivery.
System issues also affected nighttime care, including the availability of diagnostic imaging and hospital beds, fewer available supervisors and peer physicians, and reduced hospital staff. Just as with care delivered during daylight hours, a lack of communication tools, such as structured communication approaches, and failsafe systems, such as the use of checklists, were also found to impact nighttime care.
A large body of knowledge confirms that fatigue impairs human performance.1 While there are mixed findings about the effects of sleep deprivation and fatigue on physician performance and patient outcomes, doctors should nonetheless reflect on their approach to night shifts and how to best address the risks.
Fatigue is a risk for physicians working at night, particularly given that metabolism and alertness are lowest between 3 a.m. and 5 a.m. Transitioning from night shifts to day shifts, as well as the duration of any shift may also contribute to fatigue.2 Lack of sleep has also been shown to diminish reasoning skills and dull concentration. Even after a night shift ends, physicians may continue to experience the negative effects of fatigue, including decreased decision-making ability and shortened memory.3
While fatigue affects everyone differently, typical consequences include slower reaction time, attention lapses, less attention to detail, and compromised problem solving. Impaired psychomotor skills, reduced coordination, and more errors of omission may also result.4 Physicians should consider these potential negative effects in their practices when ordering and interpreting diagnostic tests; planning care; managing medications; performing surgery; interacting with patients, families, and other healthcare providers; and documenting care.
The Canadian Medical Association has issued a policy statement on the Management of Physician Fatigue.5 It includes a number of valuable recommendations and states that strategies must address physician fatigue at individual, organization or institution, and system levels.
Colleges have stated that physicians should recognize their capacity to provide competent clinical care and to ensure they are clinically fit to do so. Likewise, the courts have ruled physicians should know whether they are capable of providing the necessary care, placing the onus on physicians to recognize signs of fatigue or other conditions that would preclude the delivery of good care.
While physicians often put aside their own well-being to respond to a patient's urgent or emergent clinical needs, it is important to assess whether patient safety will be compromised. As independent professionals, physicians are usually responsible for their own acts and omissions. This means that physicians are responsible to meet the requisite standard of care, and this extends to night shift situations.
Physicians have an ethical duty to act in the best interests of their patients. If physicians feel that, owing to fatigue or other reasons, they are unable to perform a treatment or procedure, steps should be taken to find alternative care, or if possible, delay the treatment or procedure.
Being proactive in managing the risks
Physicians who work night shifts may want to take steps to manage fatigue and improve awareness. The specific steps or activities may be guided by a physician's work setting, location, support system, and other factors.
Managing fatigue can include resting and avoiding strenuous activity before work. During a night shift, doctors should be aware of their level of fatigue and the level of fatigue of co-workers, double-check their work as needed (e.g. calculations, medications), seek appropriate help and support when necessary, take naps when possible, eat well, and maximize exposure to light.6 Structured communication tools and read-back communication strategies may also be helpful.
Situational awareness means perceiving and understanding the dynamic information in one's environment. Successfully managing clinical issues often relies on maintaining situational awareness, which could be impacted by fatigue and other factors. The CMPA Good Practices Guide offers tips to practise situational awareness and improve mindfulness.
To avoid delays or failure to attend, physicians are also reminded of the importance of responding to calls and caring for patients promptly. As on day shifts, the importance of effective communication with all healthcare providers cannot be overstated.
Whether patient care is delivered during the day or at night, it should always be documented contemporaneously, that is, as soon as possible following the patient encounter. The medical record contributes to good patient care and is key to the continuity of care after the night shift. A good medical record is accurate and objective, and includes notes about informed consent, the patient's questions, the physician's answers, and information given to the patient about next steps and follow-up.
Nighttime responsibilities of supervising physicians
Physicians in a supervisory role during the night should ensure any tasks they delegate are appropriate to the trainee's level of experience. Increased supervision at night may be required.
When consulting with residents over the telephone at night, supervising physicians may want to consider whether they have an adequate understanding of the patient's clinical presentation and whether they have sufficiently questioned the resident to develop an appropriate care plan. The supervising physician should assess whether the patient's condition or the resident's level of experience requires in-person attention.
The bottom line
The CMPA's case files demonstrate that physicians should be aware of the risks associated with care provided during night shifts and maintain an appropriate level of situational awareness. They should prepare for night shifts and pay attention to their level of fatigue. As on day shifts, physicians working at night are reminded of the importance of responding to calls and attending to patients in a timely fashion. Effective communication and documentation is important, day or night.
Gaba, David, Howard, Steven, "Fatigue among clinicians and the safety of patients," New England Journal of Medicine (2002) Vol. 347. Accessed on March 5, 2014 from: http://www.nejm.org/doi/full/10.1056/NEJMsa020846
Rebbitt, Dave, "Night shifts: Are they safe?" Canadian Occupational Safety (March 13, 2014). Accessed on March 20, 2014 from: http://www.cos-mag.com/safety/safety-columns/3862-night-shifts-are-they-safe.html
Dubois, Nina, "Night shift safety issues," eHow. Accessed on March 5, 2014 from: http://www.ehow.com/list_7689646_night-shift-safety-issues.html
Stokowski, Laura A., "Help me make it through the night (shift)," January 24, 2012, Medscape.com
Canadian Medical Association, CMA Policy: Management of Physician Fatigue, 1998. Accessed September 12, 2014 from: http://policybase.cma.ca/dbtw-wpd%5CPolicypdf%5CPD14-09.pdf
Medical Protection Society, "Practical problems: Working nights," South Africa Junior Doctor (November 2013) Vol. 4 No.2 p.8. Accessed on July 7, 2014 from: http://www.medicalprotection.org/Default.aspx?DN=676c59c2-1821-4bc4-9306-da5a558031c1