When I started working as a junior doctor, we had two weeks of induction before being officially ‘let loose’ on the wards, so to speak. We learnt about the common medications we would prescribe, heard the stories of the outgoing interns, did our hand hygiene training, and got a much-needed copy of our ‘Intern Handbook’, full of useful tips for the common emergencies we were likely to face, steps to take, medication interactions to be wary of, and so on. We also shadowed the outgoing interns during this time, and asked as many questions as we could scramble our terrified brains to think of.
But you know what we didn’t hear about? How to handle shift work. Nor was there a chapter of guidelines for it in the magic handbook. Of course, we all knew we had entered into a career where we would have on-call duties – that’s the nature of 24 hour emergency medical care, and part and parcel of our vocation as doctors. But with reflection and the beauty of hindsight, I’m genuinely amazed that we didn’t get any information or education on how to look after our physical and mental health during on-call shift work, especially the regular night shifts.
It seems to me that this dearth of shift work preparation for employees isn’t just neglected by the medical profession and workplace – it’s true whether you work in nursing, retail, the hospitality sector, manufacturing, airlines – name your shift work sector, and I’ll be surprised if those employed in it have received formal education and/or guidelines on how to look after themselves while working irregular hours. I’m doing my Masters thesis on the topic of shift work and it’s effect on our physical, mental and emotional health, and I am literally FASCINATED by the whole area. Having just finished researching and writing my literature review on it, I’ve been sort of overwhelmed by how frankly ridiculous it is that employers don’t give better training to employees at or prior to their beginning shift work. And if you’re reading this and you’ve found your experience (or that of your family members or friends) to be different, I’m all ears and would love to hear it (leave a comment below!). I was equally overcome by the desire to write about shift work on the blog for you guys, and share some very simple tips to help those of you who work irregular hours keep up some basic self-care in terms of healthy lifestyle advice. We’re talking nutrition, exercise, sleep hygiene (one of the biggest challenges on shift work, especially nights!), stress management and social well-being. The fundamental basics gang!
Shift work has evolved to become increasingly a part of the ‘24/7 society‘ we now live in, where the demand and supply of both goods and services is expected around the clock (Costa, 2010). Shift work has been defined by the Council of the European Union as ‘any method of organising work in shifts whereby workers success each other at the same work stations according to a certain pattern (The Council of the European Union 1993). Previously, only very small numbers of the overall workforce was employed in shift work, and only in certain sectors, such as hospital and emergency services. However, this has now expanded to include a wide range of occupations, and with that, the numbers who work these irregular hours. In 2010, 17% of the workforce in the European Union was employed in shift work (Eurofound, 2010). However, the most recent 6th European Working Conditions Survey reported this figure had increased to 21% by 2015 and was expected to continue the upward trend (Eurofound, 2015).
In 2007, the International Agency for Research on Cancer (IARC) classified ‘shift work that involves circadian disruption’ as ‘probably carcinogenic’ to humans (i.e. a Group 2A carcinogen) on the basis of ‘limited evidence in humans for the carcinogenicity of shift-work that involves night work’, and ‘sufficient evidence in experimental animals for the carcinogenicity of light during the daily dark period (biological night)’. (IARC, 2007). You guys may not have known that – I didn’t, until I started researching this area. Now, the IARC group commented on the difficulty in accurately assessing ‘shift work’ as an ‘exposure’ and also in quantifying the ‘risk’ to human health associated with it, due to wide variations in both the quantitative and qualitative aspects of shift work. So we can’t say shift work is a ’cause’ of cancers, the same way we can’t say red meat is. All we can say is that based on the evidence from studies done to date (which, bear in mind, have many limitations in how we interpret them), there seems to be some negative effects on health due to shift work, and some evidence increased risk for certain cancers. However, as I’ve said, it’s FAR from a perfect science.
Now, the science on how and why shift work can affect our physical, mental and emotional health is fascinating, far from perfect (as I’ve said above) in how deeply it’s understood even by experts, and to be honest, to go deep into is beyond the scope of this article simply because it is just too vast and I’m not an expert! And frankly, what is more beneficial for me to share with you guys is actionable tips you can take from reading this, to help you manage a shift working life better (I hope!). But I will, VERY BRIEFLY, discuss how shift work disrupts our circadian rhythm, because it’s the key point to understand from the outset.
So, what IS our circadian rhythm? Good question. You may have heard of the ‘body clock‘ that each of us has, and that’s a good start. As human beings, we have evolved to be what’s called ‘diurnal’ creatures – meaning, we live our lives following the light/dark cycle that results from Earth’s rotation on its axis approximately every 24 hours. So, as you know, we typically rest and repair as we sleep during the night, and we are active/working/feed/exercise during the solar (i.e. light-filled) day. Circadian rhythms have been defined as endogenous ‘physical, mental and behavioural changes that follow roughly a whole day or 24-hour cycle’ (HAS, 2012) and are self-sustained in the absence of external cues (Arendt, 2010). The term circadian is derived from Latin (circa = about, dies = the day). Circadian rhythms affect the regulation of many essential biological processes, such as hormone production, cognitive and cellular function, temperature and appetite regulation, sleep/wake cycles and metabolism (Arendt, 2010). In mammals, these rhythms are regulated by an internal ‘master’ biological clock, which is located in a region of the hypothalamus of the brain known as the suprachiasmatic nucleus (SCN) (Figeuiro, 2013). Circadian rhythms are synchronised (or aligned) with our external environment by specific cues, chiefly via the light/dark cycle (perceived by the retina), which is the dominant external synchroniser (known as a ‘zeitgeber’) of the SCN to the solar day (Figeuiro, 2013). We also now know that we have ‘peripheral clocks‘ in tissues and organs such as the liver, our gut, and fat tissue, which are synchronised with the central clock – usually. Melatonin, our sleep-inducing hormone, has been described as the ‘hand’ of the circadian clock (Steinlechner, 1996). Engaging in shift work can lead to what is known as ‘circadian misalignment’, whereby there is a mismatch between an individual’s behaviour cycles and their internal circadian timing system (Scheer, 2009).
Now, anecdotally, I can tell you, as can anyone who has done shift work (especially nights!) that it can mess you UP. Physically, mentally, emotionally. I generally got through my night shifts fine enough, but being honest, always felt pretty crappy during the week I was rostered on (we used to do 7 in a row). I struggled with sleeping during the day, lack of appetite at night, ‘brain fog’ at 4am even if I had slept the day previous, and all in all, I just felt I didn’t fully have my wits about me. Now, anecdotes are useful because those of us who do shift work will experience them differently, due to our unique differences as human beings and also shift-specific factors (e.g. whether you only do nights, or very early starts, very late finishes, or a mix). But anecdotes aside, shift work has, based on the studies to date, been associated with increased risks for several non-communicable chronic diseases such as obesity, high blood pressure, raised cholesterol, certain cancers (including breast, prostate and colorectal for the most part, but it’s important to say the research findings to date have been conflicting at times!), type 2 diabetes mellitus, coronary heart disease, and mental health symptoms and disorders including depression and anxiety. It has also, as you might expect, been associated with a range of sleep disturbance-related symptoms – there is even a ‘shift work sleep disorder‘ now formally recognised as it’s own clinical diagnosis. And outside of specific diagnoses, it almost goes without saying that shift work can lead to major disruptions to our social life, meaning individuals have to work hours often in total opposition to their families and friends, which can make seeing those in their social support networks very difficult. Why shift work can cause adverse health effects is thought to be down to a few different factors – circadian misalignment, sleep deprivation, and altered lifestyle behaviours in shift workers to name a few – and this ‘why‘ is the main hot question in the shift work research.
Okay. Recap time. Shift work = an increasingly prevalent part of our ’24/7′ society. Shift work also can = major disruptions to a person’s physical, mental and emotional health and well-being. Now, I didn’t write this article to scare or shock anyone. I write it to raise awareness, and more importantly, to share actionable tips with those of you working irregular shift work hours, to empower you to find a better balance in life outside of your day and night job! So, I think it’s time we flipped the switch into solution mode. Let’s look at some super simple ways you can try to keep yourself in tip top shape even when you’re flipping your body clock!
Timing Your Food to Fuel and Nourish
Shift work can wreak a little bit of havoc on your poor tummy, which makes sense when we think about the ‘body clocks’ I’ve described above that many different biological processes follow. This includes digestion, and the different aspects of it, and explains why your appetite during the night shift especially can seem totally out of whack. The emptying and motility of our stomach, glucose tolerance, insulin sensitivity and release, as well as liver and pancreatic activity are all decreased at night. Now, it’s really not as simple as saying ‘eat this’ or ‘eat that’ during shift work, because we are all very different, and more importantly, we aren’t machines that can run on empty. So, I’m going to keep this tip simple. The literature to date suggests the following, and are mostly applicable to the night shift, and cover food timing and content on a very basic level (Lowden et al, 2010) (Health and Safety Authority, 2012):
- The same guidance for dietary quality exists both on and off shift work – meeting your ‘five a day’ minimum, getting fibre in from fruits, veg, wholegrains and plant sources (e.g. nuts, seeds, beans, peas, lentils), choosing lean cuts of meat, two servings of fish per week (one of which should be oil), and up to 3 servings per day of dairy. WHAT we eat is just as important as WHEN we eat.
- As hard as it can be, especially on shift work when good nutritious foods tend to be less available (as opposed to vending machine options!), try to avoid resorting to energy-dense, nutrient-poor food choices – crisps, sweet treats, chocolate, etc. While this might seem like the ‘thing to keep you going’ (and often is what’s most available, I know that from shifts on the hospital wards!), it’s more likely to give you a quick sugar rush and a quick crash after – leaving you looking for more!
- Eat your main meal of ‘the day’ before your shift, and aim to have a meal (small-medium) before bed, avoiding large meals 1-2 hours before bed as this may disrupt sleep
- The above point essentially means you’re book-ending your shift with a meal – fuelling you up for your hours ahead and refuelling you for after
- If you’re on the night shift, try to avoid big meals during the night shift hours of midnight to 6am
- Instead, if you find you get very hungry during the night, try packing some wholefoods snacks to keep you going that are nutrient-dense, such as hummus and veggie sticks, homemade trail mix or energy bars, or yoghurt with raw nuts and dried fruit
- HYDRATE. Water, water water. As is the case for when you’re off shift, aim for 2 litres of water minimum per day – hydration is going to help you stay alert. On that point, try to stick to water (add a slice of lemon to your bottle if you find it bland!) over caffeine – I’ll touch on this in the sleep section, but remember, caffeine makes you pee (it has diuretic properties) and is likely to detrimentally affect your attempts at sleep when you get home. Herbal tea was always a lifesaver for me on nights – caffeine free options like Pukka were brilliant!
- Finally, wherever possible, have your break and snacks AWAY from your workstation, and ideally with a colleague if possible. Getting a little bit of head-space to enjoy your bite to eat and maybe having a little laugh or vent with a friend is a great way to refresh for the latter half of your shift.
Movement For Your Body And Mind
Motivation to exercise can be majorly lacking when you’re working shifts, especially nights. However, I actually think that’s more about what we perceive to count as exercise. I used to be absolutely ridiculous after night shifts – I would leave work in the morning after a 13 hour night on the go, and head straight to the gym to ‘stress bust’ by running treadmill sprints or lifting weights. Looking back with the beauty of hindsight, I was absolutely mad to do that. I used to think it helped me sleep better, and maybe it did, but the reality is that after a stress-filled busy shift, what we DON’T need is to add fuel to the fire by doing a crazy intense workout. So here’s some simple tips to get gentle exercise in around your shift schedule:
- The kind of shift you are working will likely play a big role in what you feel able to do. When I was working in the Emergency Department, my shifts ranged from 8am to 5pm, 12pm to 8pm and 4pm to midnight, or the night shift. So on the day shifts I generally found it quite helpful to hit the gym, and wake myself up for the day.
- On night shifts, I personally have found switching to yoga at home (pilates would be a lower impact option too!) short walks before and after the shift, and when I had access to a pool, swimming! Going for a short walk in the fresh air and daylight of the morning is a very simple but powerful way to fit in some physical activity and vitamin D (weather dependent!)
- Personally, I found doing anywhere from 10-30 minutes of a yoga sequence at home (all you need is Youtube and a mat!) after a night shift was really beneficial in helping me to switch off after a night on the go at the hospital.
- All in all, you have to find what works for you, so be your own experiment, and see when your energy levels are best to get some movement in. I guarantee, you WILL feel better for it, and ten minutes is better than zero!
Sleep – Quality AND Quantity
Trying to sleep during the day was definitely the part of shift work I struggled the most with. I’m an early bird, so it just never felt natural to me to try and catch some shut eye when the rest of the world was awake, and I could never sleep in when I had the late day shift! But I did build up little tricks to help me nod off during the day over the years, and that coupled with what I’ve read since starting my thesis is summarised here:
- AVOID seeking out medication to sleep. Sedative medication to help shift workers sleep has really no evidence to back it up, and actually has more harm associated with its use than good. Sedative medications can be extremely addictive, so do yourself a favour and keep well clear. You may have heard about the use of melatonin and other stimulant-type drugs (for example, modafinil) – stimulants have been looked at in trials to improve night shift performance, and melatonin has been looked at to help with sleep itself – but really, as pointed out in a really great review paper in the British Medical Journal last year (McKenna and Wilkes, 2018), the evidence to date seems to be inconclusive for melatonin use, and stimulant drugs have notable side effects including severe skin reactions.
- What CAN help is manipulating the use of caffeine (if you’re a coffee or tea fan) to your benefit. A big review (13 trials included) of the use of caffeine to prevent injuries and errors in shift workers (Ker et al, 2014) found there was evidence to say caffeine may help improve performance in shift workers. So if you’re gonna caffeinate, make sure you’re HYDRATING too (i.e. water water water), and time your cuppa at the beginning of the shift, and ideally not in the latter half of your shift when you may be planning to go home to sleep.
- Finally, in terms of your sleep pattern and environment, the BMJ review I mentioned had some awesome tips, especially for night shifts. The authors advised on the day of the first night shift, sleep in until you wake up (i.e. no alarm if possible), and try to minimise your ‘sleep debt’ by having a 90 minute nap (the length of one sleep cycle) between 2-6pm. During your shifts, make sure you’re sleeping in a quiet, cool bedroom, and ideally get yourself an eye mask and blackout blinds or curtains for daytime snoozing. Those worked wonders for me!
- When you finish your set of night shifts, it’s a good idea to head home for a 90-180 minute nap (i.e. 2 sleep cycles), but then DO force yourself to get up. Get out, get some daylight into you (maybe a gentle walk!), and aim to go to bed that night at your ‘usual’ time (i.e. if you were working day shifts). As much as possible, to hasten your reset, try to avoid napping in the days following – easier said than done I know, but it does pay off!
Don’t Skip Your Social Life
Shift work is one of the most disrupting types of work schedule in terms of your work-life balance, and ability to keep up with your social networks of family and friends. This is particularly true for night shift workers, and trust me, I know that from experience! But where possible, depending on who you live with (family, partner, roommates, friends) try to make even a little time to have a chat, catch up and maybe even let off some steam after a busy shift. When I do night shifts, I try to wake up to have dinner with my family, to hear about their day, and have that as my main meal before heading into work. It always feels super weird when I know they’re going to bed not long after we catch up, but it also takes you out of your own head a bit! Shift work can feel very isolating, especially when it feels like you’re going to work when the world is coming home. Making time to see friends and family, even just for a meal together, can make all the mental health difference.
Be The Boss Of Your Stress – At Work and At Home
I’ve written and spoken about stress QUITE a bit on the blog and Podcast at this stage, so I won’t labour the point too much here. You’ll find my blog post full of stress management tips I’ve found helpful here, and the Podcast episode here! I’ve had such awesome feedback from both so I hope you guys take value from them. Just to summarise, my stress-busting toolkit is the same no matter whether I’m working days or night shifts. Nights in particular can be some of the most stressful shifts, and equally some of the quietest! Here’s my top tools in my anti-stress kit (and do read the blog post or tune into the Podcast if you want to learn more!):
- Breathing exercises (my favourites are Box Breathing and 4-7-8 Breathing!)
- Physical Activity (walks and yoga are my favourites for stress-busting)
- Mindfulness and Meditation (I use the Calm app every night before bed for ten minutes and it’s been a game-changer)
- Talking it out (As I’ve mentioned in the previous point on social time, don’t underestimate the power of talking through a bad day – remember, a problem shared is a problem halved!)
Okay gang. I know that was a MONSTER blog post. But I really do hope you have found it helpful, whether you work day, night or a combination of shifts. It’s a unique way of work scheduling, and it’s becoming increasingly prevalent as our society grows ever more connected and the pace of life speeds up! Similarly to having a stress-busting toolkit, it’s important that, as a shift worker, you arm yourself with the education and therefore empowerment you need to take care of your health while working. I firmly believe employers in all sectors don’t give shift workers the information and tools they need to adopt and maintain healthy lifestyle habits while working irregular hours – I definitely received none before I began my on-call requirements as a doctor. BUT, this article is not written to dish out negativity – I’m just noting a serious need across our shift working populations, and one I hope to help improve this year!
I would LOVE to hear your thoughts on this post guys, and if you found it helpful! Leave a comment, drop me a DM on Instagram, Tweet, email, you know the drill! I’m @theirishbalance on Instagram/Twitter/Facebook!
Ciara 🙂 x