Racing into the emergency department in the very early hours of a Sunday morning, a thought crossed my mind: Thank God for the night shift. Here I was, sick child in arms, agitated and awaiting triage, with a swelling queue of restless parents and kids all around.
When we finally reached the front of the queue, the attending nurse processed us with careful concentration, all the while her eyes reflecting pure exhaustion.
Among shift workers, exhaustion is a common experience. Routinely they suffer reduced sleep quality and quantity, and it’s this that can lead to poor performance, and compromised health and safety.
Assoc Prof Siobhan Banks says sleep deprivation is an issue for all Australians - four out of every 10 of us suffer from inadequate sleep.
“About half of these experience ongoing, high-levels of daytime sleepiness, and the rest know that their sleep is insufficient because they can’t function well,” she says.
“For shift workers, the effects are escalated. When you work at night, your circadian rhythm is disturbed and your body responds with impaired alertness, concentration and emotional control.”
In Australia, about 1.4 million people work shifts. As economic imperatives push working hours across the night, knowing how to manage the inevitable fatigue is critical — not only for worker performance, but also for the well-being and safety of all involved.
Working at the Royal Adelaide Hospital, Dr Alice O’Connell is well aware of the impact of shift work. Early in her career, she worked night shift in the Intensive Care Unit and says it was a mix of countermeasures that helped her to operate at peak performance.
“In the medical profession, staying alert is important,” Dr O’Connell says. In my experience, a sleep in the afternoon, followed by a coffee before starting, really helped boost my energy levels.
“I’d also make sure I’d have a small dinner and a few snacks to help overcome that sleepy feeling, then finish up with a cup of tea.”
Small meals and snacks are clearly the way to go when it comes to night shift, according to new UniSA research funded by the National Health and Medical Research Council. Assessing the impact of food over a night shift, the research found that the greater the food consumption at night, the greater the metabolic consequences.
“When it comes to eating on the job, it’s not about what you eat, but when you eat,” Assoc Prof Banks says.
“As the saying goes, eat breakfast like a king, lunch like a prince and dinner like a pauper, because your body is much more able to deal with food early in the day, and this means better performance and health outcomes.
“Night workers tend to eat throughout their shift, redistributing what they’d normally consume during the day; the challenge, however, is to eat small meals to maintain your energy while avoiding the negative effects.”
Snacking on shift is also observed among nurses, who regularly bring in food to share throughout the night. UniSA’s research with SafeWorkSA shows this is a bonding exercise, helping nurses cope with their high levels of reported fatigue and stress.
“Overtiredness can lead to a higher likelihood of error, but by coming together over food, nurses are building morale, helping them to feel more positive at work and that translates into better performance and health outcomes,” Assoc Prof Banks says.
Lindsay Patrick is a registered nurse at the Queen Elizabeth Hospital. Working a 24-hour rotating shift, she says the hours take a toll, both physically and mentally.
“Whether it’s healthy eating, exercising, or just staying in touch with friends and family, shift work leaves you constantly feeling like you are compromising normal life and you are always lethargic and sluggish,” Patrick says.
“That’s why we have our little parties at night. We share food and stories and that really helps with our energy and morale.”
From a nutritional stance, consuming chocolate, biscuits and chips isn’t healthy, but as Assoc Prof Dorrian explains, a singular perspective is limiting.
“Every behaviour, even if it has a negative outcome, is serving a purpose for that person, so when you change a behaviour, you need to understand the costs and benefits. At the BBB we aim to achieve a holistic approach so as to see all the flow-on implications of any change.”
It’s a view that rings true with emergency services – in particular the fire brigade, an on-call, around-the-clock service.
South Australian Metropolitan Fire Service Commander Rainer Kiessling, says big meals make up a core part of the job. A firefighter for 26 years, he says sleep is all about checks and balances.
“Just as a tired fireman is no good to anyone, neither is a hungry fireman, and when you’re called out to a fire at three in the morning the last thing you want to be is hungry.”
He says that a large meal at night is non-negotiable for firefighters – the team gets together for a big cook-up after their fire emergency training each night.
“Small meals are not accepted by the team. What we serve up is significantly larger than what you would get in a restaurant. Our meals are always filling and plentiful.”
While Kiessling acknowledges the physiological impact of a large meal later in the evening, he says it’s part of the culture, not only a bonding activity, but based on traditional advice handed down from colleague to colleague.
“It’s something we all learn on the job: have a massive meal and go to bed early, because you could be out all night.”
In the skies, long-haul Qantas pilot Luke Graham flies any time of the day or night, year-round, on flight sectors up to 17.5 hours. He says long-haul flying wreaks havoc on your body.
“On average, I lose one night’s sleep a week that I don’t get back; it’s draining, but you just get used to it,” Graham says.
“To counteract the tiredness, I always have a three-hour sleep before a night sector or aim for a sleep-in before a lunch-time sector.”
Assoc Prof Dorrian says napping is an effective fatigue management strategy, so long as it’s managed properly.
“It’s important to work on your sleep while on the ground, so that you can stay awake in the air. It’s something that pilots become very good at.”
“Accumulated sleep debts can lead to reduced alertness and performance” she says. “A well-timed nap can help alleviate this.
“The only downside to napping is that it can lead to sleep inertia – that groggy feeling that people experience immediately after waking.
“A 30-minute afternoon nap can counteract sleepiness, but this goes hand-in-hand with a five to 35-minute period of sleep inertia after waking.
“Instead, a shorter 10-minute nap might be better; it causes no sleep inertia, and provides immediate performance benefits for at least 35 minutes after waking.
“Unfortunately, the worst time to wake from a nap is in the late hours of the evening or the early hours of the morning, the time when your circadian rhythm is at its lowest point.
“If shift workers are napping at these times, they need to be really careful when they wake to ensure they are ready to take on duties or drive.”
For someone going without sleep for more than 17 hours, their performance is impaired to the same level as if they had a blood alcohol concentration of 0.05.
“Each year, 20 to 30 per cent of all fatal road crashes in Australia are the result of driver fatigue,” Assoc Prof Dorrian says.
“For people working night shift, this poses a significant risk. Not only because their circadian rhythm is telling them to sleep, but also because we know people on night shift tend to eat later, and that too can lead to reduced performance.”
Retired Flight Sergeant with both the Royal Air Force (RAF) and Royal New Zealand Air Force (RNZAF), Brian Ward, says he regularly dealt with a lack of sleep during his time with the armed forces.
“In the late 1980s I once worked 27 hours straight, and then had to drive myself and six others to a relocation point,” Ward says.
“They all quickly fell asleep…and unfortunately so did I. We were lucky. When the vehicle ran off the road I woke and I regained control. Suffice to say, none of us slept well for the rest of the journey.”
Exhaustion among defence personnel is part of the job, says Ward. And while there were opportunities provided to nap, he says he found it extremely difficult to sleep during the day.
“I was a very active athlete, but any time I tried to sleep during the day, it wasn’t effective; my body needs sleep at night. That’s my natural default.”
To help stay alert on the job, many shift workers consume caffeine, a method also deployed by the Australian and US defence forces. As the focus of a current BBB research project with the Land Division of The Defence Science Technology Group, the team is assessing the impact of caffeinated gum on defence performance.
“Caffeine is a great go-to for a well-timed, 24-hour attention fix,” Assoc Prof Dorrian says.
“For personnel in sustained operations, it’s an effective, convenient and cost-efficient solution for alertness, particularly in the first 24 hours after consumption, and partly into the second day.
“And as caffeine leaves no real long-term effects, it’s a welcome relief for those trying to recover missed sleep.
“But sleep is the only real cure for sleepiness and fatigue,” Assoc Prof Banks says.
“You can’t get rid of the fatigue that is associated with shift work because you’re working against biology. There is always going to be fatigue. All you can do is manage it, and at the BBB that’s just what we’re working on.”