NightsBMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c6342 (Published 24 November 2010) Cite this as: BMJ 2010;341:c6342
Yasmin Akram and Tarun Gupta ask whether working nights is dangerous for patients and junior doctors or essential for good training and care
Being a junior doctor and the first to review and manage very unwell patients overnight can no doubt be stressful and daunting, but most would agree it is a crucial part of skill and experience building. Maria Corretge, now a year 5 specialty trainee (ST) in general and geriatric medicine, explains: “I’ve learnt how to shout to get a test done, how to refer a patient to another specialty a bit more efficiently and better, and how to manage a group of trainees with very different knowledge and abilities, and I’ve developed my great instinct to know which specialist nurse to trust and which to be afraid of. And, of course, I’ve managed very sick and interesting patients as the most experienced of the group, which is very satisfying. If it was day time, the consultant would have been there.
“Poor for the patient? I don’t think so. I think a good registrar should be able to provide complete and good care on his or her own. Nights are the only opportunity we have to practise this.”
In recent years measures have been introduced to ensure there is a more cohesive and supported working environment during out of hours service provision. One such measure is the hospital at night project, which was piloted in 2004. A Department of Health evaluation report in 2005 claimed: “The hospital at night programme has shown that it is possible to deliver compliance with the European Working Time Directive, improve training out of hours, and increase doctors’ quality of working life, while improving patient care.”1
The old system
And it wasn’t always this way. With a heavy heart, consultant psychiatrist David Bramble recalls: “In the Jurassic era (1980s), two houseman colleagues died through falling asleep at the wheels of their cars after working 100+ hour weeks.” He continues: “The two men who died were lovely blokes and also had the makings of great doctors, what a waste.”
Clearly things have improved since then, but the European Working Time Directive has certainly not delivered all it promised. The president of the Royal College of Surgeons of England, John Black, recently opined that “to say the European Working Time Directive has failed spectacularly would be a massive understatement,” a view echoed across the United Kingdom. Has a hospital at night system been any more effective in achieving what it set out to?
Kerri Baker, an ST6, describes some of the problems with hospital workings at night. “The hospital really can malfunction overnight and the sooner we move to a 24 hour NHS the better. Last week’s night included a somewhat ridiculous argument with a biochemist about whether a repeat U&Es [urea and electrolytes] were ‘indicated overnight’ when the first demonstrated sodium 114 and potassium 7.3 (acute adrenal crisis); and whether the ABG [arterial blood gases] for the COPD-er [patient with chronic obstructive pulmonary disease] with decompensated type II respiratory failure started on NIV [non-invasive ventilation] at midnight could wait until working hours.”
The hospital at night model in its purest form consists of an integrated team covering the hospital site, ensuring efficient multidisciplinary handovers, juniors from different specialties performing generic roles and dividing tasks, and support from highly skilled nursing staff. It is slowly being implemented by trusts across the UK.
ST1 in trauma and orthopaedics Shahbaz Malik talks about the difficulties associated with multispecialty cover. “I have found that nights are generally OK, if you are covering your own specialty. Where there is cross cover—for example, when I had to cover general surgery, urology, and T&O [trauma and orthopaedics]—things get very busy and mistakes are likely to occur.
“I was on nights straight away as an FY1 [foundation year 1 doctor] and did not quite appreciate the urine output in a surgical patient with an acute abdomen who was as dry as a bone. I was on T&O rotation, it was my 5th day as a FY1 and I had no appreciation of how to manage a surgical patient. Suffice to say that the SHO [senior house officer] was called to see the patient. Despite that, I was called to the consultant surgeon on call’s office to answer to my management or rather the lack it.”
Can we say truly that this system has had a visible outcome in reality on nights for juniors? Alexander Yashchik, currently an ST2 doing an acute care common stem programme, feels that experience of nights depends strongly on the team you are working with: “As for stress levels and staff attitude towards junior doctors: abuse and contempt from everyone and no support from seniors (A&E [accident and emergency]); abuse and contempt from colleagues of other specialties and nursing staff and fictitious support from seniors (medics); abuse and contempt from nursing staff and patronising support from seniors (surgeons); abuse and contempt from nursing staff and variable support from seniors (ITU [intensive treatment unit]); respect from nursing staff and consistent support from seniors (anaesthetics).”
Despite all its promise, uptake of the hospital at night initiative has been slow and inconsistent. As noted in the Department of Health report, surgeons across the board seem to have been quite cynical about introducing the system. Nicholas Brazel, now an FY2 in general practice, states “As a surgical FY1 I enjoyed nights in my hospital (which doesn’t have HaN [hospital at night]) as there were less people around to get on my nerves.”
One theory is that the problem with nights is a lack of senior cover and support. One NHS trust report in 2007 stated: “Following the changes associated with the HaN programme the hospital has reduced the number of doctors working at night by 17.”2 The Royal College of Physicians warned in April 2010 that junior doctors were being placed under enormous pressure at night.3 Consultant anaesthetist Julian Hull agrees: “Trainees’ working lives are a mess with an impossible number of sick patients to look after out of hours.”
Nights can confer autonomy to junior doctors, allowing them to make their own clinical judgments and priorities, but is this the ideal situation? Nida Ahmed, an FY2 in general practice, recalls doing medical nights as an FY1, “having been bleeped by the night staff to ‘prescribe some sedation for a patient trying to climb out of bed,’ I arrived on the ward to find an agitated and tachypnoeic elderly gentleman. He was recovering from a fall and urinary tract infection. Examination revealed bilateral crackles, and following an abnormal ECG [electrocardiogram], portable CXR [chest radiograph], and ABG [arterial blood gases], I was relieved when the registrar agreed to review my patient and advise on management. It was my second night and as I had at least 10 other patients to see, it would have been easy to simply prescribe what had been originally asked for, much to the potential detriment of the patient.”
Andrew Goddard, director of the Royal College of Physicians medical workforce unit, states: “The very low number of doctors per patient at night raises serious concerns for patient safety. There are also worrying reports of very junior doctors being left unsupported.” A survey by the college found that, on the night the survey was carried out, 63 teams reported that the most senior medical cover was a junior doctor in his or her first two years of training.3
The Department of Health report admits that there was no change in death rate where the programme was applied, and no clear positive impact on either doctors’ training or patient care, so is hospital at night another failed policy?
Consultant paediatrician Patricia Smith points out: “No system is right, and are you looking at the historical perspective over the past 35 years and the changes that have occurred since we went on industrial action on 27 July 1976 (working to rule <80 hours/week)? Don’t get me wrong, I am not saying ‘in my day’—although I do remember falling asleep in the neonatal intensive care unit [NICU] firmly holding all the phones so no one could get them, necessitating a runner between NICU and labour ward until I woke up three hours later, when the boss gave me a whiskey coffee.” She asks us the essential questions: “So what is right now? What can we learn from past training purgatory? How can the present system be improved?”
“Everyone says nights are where you ‘cut your teeth’; this is just to take the edge off the fact that they are totally miserable.”
—Rhys Llwelyn Thomas, research fellow, general surgery
“The first time I felt like a proper registrar was on nights, as I had been doing middle grade rotas working as an SHO [senior house officer] in the ward before.”
—Maria Corretge, specialty trainee (ST) year 5, general and geriatric medicine
“I had to return and review things frequently, often because the trainees lacked the skills I had as a registrar. I managed 3.5 hours sleep on Saturday and 5.5 on Sunday.”
—Julian Hull, consultant, anaesthetics
“Being able to recognise and manage the sick patient is even more of a challenge at night! I found that having equipment to hand like ABGs [arterial blood gases], venflons, and so on reduced the time wasted looking for things on unfamiliar wards, while giving you more credibility with the nursing team. Having the confidence to call your registrar when you are struggling is not easy, but essential to ensuring patient care doesn’t suffer just because it’s night time.”
—Nida Ahmed, foundation year (FY) 1, general practice
“Nights—created by people being too busy ticking a box to stop and think about the consequences of ticking that box.”
—James Robertson, consultant, paediatrics
“I actually quite enjoyed nights as an FY1—got lots of hands on experience dealing with emergencies that I didn’t get during days, although I readily accept this probably wasn’t an ideal situation for patients.”
—Nicholas Brazel, FY2, general practice
Hospital at night
“In the majority of cases the hospital at night is not an educational experience.”
—Kerri Baker, ST6, acute medicine
Competing interests: None declared.