2008

Republic of Yemen
Sana’a University
Faculty of Medicine &Health
sciences
Department of Community
Medicine

[Impacts of Night Shift on Junior

Doctors in Sana’a Teaching
Hospitals. ]
 Impacts of Night Shift on Junior Doctors in Sana’a Teaching hospitals.
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Impacts of Night Shift on Junior

Doctors in Sana’a Teaching
Hospitals.
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Supervisors and Contributors:

Supervisors contributors
 Prof.Abdulwahed al sorrori  Mohammed Abdulhameed
 Prof.Abdallah Agunaid Alsaleh
NB: doctors photos and  Yazid Salam Jibrel
academic title  Zaher Mokhles Adi
 Mahmmoud Tariq Bisher
 Mouth Ibraheem Aiad
 Raid Yousif Alraimi
 Mohammed Majdi Alshaikh
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Contents
Introduction............................................................................................................4
Background of the study........................................................................................4
Research settings.....................................................................................................5
Significance of the study........................................................................................5
Problem statement...................................................................................................7
Research question....................................................................................................7
Objectives...............................................................................................................7
Type of the study (Research design)......................................................................14
Data analysis tools..............................................................................................15
OUTLINE OF THE STUDY.........................................................................................18
References............................................................................................................20

Introduction

Background of the study

Working at night is an essential part of providing a

comprehensive 24-hour service to patients in the medical
practice. However, night work requires doctors to remain awake
and alert when physiologically programmed to be asleep.

Working at night, regardless of the shift pattern, can have

consequences for both patient and personal safety, as it
increases the risk of making poor decisions or even mistakes.
So, night shifts need survival and management. It is therefore
important to learn how to prepare for night shifts and to
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manage your sleep, so that you minimize risk to yourself and to

your patients.

Many people are expected to work at night, and most do so

relatively successfully. However, all have to cope with the fact
that working at night inevitably causes sleep deprivation and
fatigue. This is because the human body is designed to sleep at
night.

Our bodies are controlled by an internal daily body clock,

situated in the suprachiasmatic nucleus (SCN) in the
hypothalamus. The SCN spontaneously generates the circadian
rhythms that regulate many physiological and behavioral
processes in our bodies, such as temperature control, hormone
production, alertness and sleep [5].

These circadian rhythms run over a period of approximately 24

hours and are strongly influenced by the natural cycles of light
and dark. At night, many of the processes that are active during
the day start to slow down as our bodies prepare for sleep. The
circadian pacemaker also stimulates night-time release of the
‘sleep hormone’ melatonin from the pineal gland, which has the
effect of lowering alertness and increasing the desire for sleep.
Working at night involves fighting against these rhythms, and
trying to be alert when you are programmed to be asleep [3].

Research settings

Significance of the study

The significance of the study is that it's one of a kind and the
first to be done in the republic of the Yemen on this critical
important subject. We believe that we can begin the corner
stone for future studies to be based on our mission in this study
and the application of the study in real life is done by
introducing good recommendations that we hope will help the
decision makers in the health care industry by opening a sealed
door in this specific concern.
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This study is mostly important to all the health care providers

beginning with doctors, students, consultants and managers. To
focusing on a daily basis contact with this night shifts who
knows! It may be me or you tomorrow in this night ward, so
guidance and knowledge about it is taken by us to you.
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Problem statement

Treating sick patients at night is nothing new, and some doctors

have always been asked to work at night. So why is there a
problem now?

In The Yemen there is need for reviewing the legislations about

the average hours to be worked in the weekly or monthly night
shift rotas. For the country own benefit & working regulations.
To be written and introduced by our humble job.

Research question
The research question may be stated as follows:" what are the
experiences of doctors who work the night shifts, with reference
to the physical aspects, the social aspects, the psycho-mental
and the work related aspects?”

Objectives

General objective

Revealing the impact and effects of the night shifts on junior

doctors in Sana’a teaching hospitals.

The specific objectives of this study are thus:

i. To explore the experience of doctors doing night shift, in
relation to the following aspects: (1) physical effects; (2)
psycho-mental effects; (3) social effects; (4) work related.
ii. To study the performance of doctors during and after the
night shift.
iii. To improve the preparing survival and recovery from the night
shift by designing healthier rotas.
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Literature review
The night shift research in Japan conducted questionnaire
consisting mainly of items concerning sleep disorders from the
Japanese version of the Pittsburgh Sleep Quality Index was
distributed to the subjects.

And the results were Significant associations were observed

between working on night shift and the use of alcoholic
beverages to help induce sleep, and between working on night
shift and daytime drowsiness. Significant differences were also
observed between two- and three-shift systems with regard to
subjective sleep quality. Moreover, average hours of sleep were
significantly associated with three related sleep items:
subjective sleep quality, difficulty in getting to sleep, and
daytime drowsiness.[1]

What is night work?

According to the International Labor Office (ILO) Night Work
Convention, 1990 , night work is “all work which is performed
during a period of not less than seven consecutive hours,
including the interval from midnight to 5 a.m.”.[2]

never the less a new review press statement about surviving the
night shift suggest that Junior doctors working night shifts
regularly suffer from sleep deprivation, leading to fatigue and
exhaustion, and evidence from America suggests that this
causes medical errors, incorrect diagnoses and road accidents.[3]

Workload patterns
The pattern of activity was similar across all three audits:
Workload peaked before 11pm and decreased gradually after
11pm.
The distribution of tasks by grade of staff changed over the
audits:
• An increased proportion of tasks were undertaken by the
nurse coordinator.
• There was a greater prioritisation of tasks.
• There was a decrease in the number of ‘urgent’ tasks that
had to be undertaken within the hour.
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The analysis showed that the pattern of workload remained

similar across the three audits. There was a distinct peak in
activity before 11pm across all sites and workload gradually
decreased throughout the night, with a small increase in tasks
occurring after 7am. This would be expected due to patient
sleep patterns and greater staffing during the twilight shift.
The urgency of tasks over the three audits showed a decrease in
the tasks required within the hour and an increase in the
number required during the shift. This was expected, as the
Hospital at Night model should reduce the urgency of tasks by
bleep filtering, the nightly handover and the role of the night
coordinator. This finding was confirmed by the qualitative
interviews, where it was suggested that the handover was useful
in providing feedback about patients who were acutely ill, and
therefore care could be anticipated. This could partly explain the
decrease in tasks required during the hour, as the task would be
carried out before it was urgent, therefore it would be classified
as required during the shift.[4]

Body clock adjustment is very unlikely to occur in junior doctors

working rotating shifts that last only a matter of days. Given
this, perhaps the most important thing to remember is that you
need to take an active approach to managing sleep and fatigue.
This is particularly true for the lifestyles and types of rota that
junior doctors are likely to follow. You will get tired, and you will
become sleep-deprived, especially if you work several
consecutive night shifts in a row. Inevitably, this will affect both
how you feel and how you perform.

However, by preparing yourself sufficiently in advance, mentally

and physically, you can reduce the negative impact of night shift
on your well-being. This will not only make the experience less
painful (or even enjoyable), but also safer for you, your patients
and those around you. [5]

For optimal functioning, humans require restful sleep of a

sufficient duration on a consistent basis. Historically, in the face
of patient care issues and educational goals, the need for
residents to obtain adequate sleep had not been viewed as a
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high priority. Recently, there has been a heightened awareness

that chronic sleep deprivation compromises patient
safety, as well as resident performance and safety. Increased
attention has been given to the risks related to inadequate sleep
for residents in and out of the workplace. A recent study of
2,737 interns observed that following a shift of extended
duration (greater than or equal to 24 hours), the risks of motor
vehicle accidents, near miss accidents, and “incidents involving
involuntary sleeping” are significantly increased. This report
adds to a growing literature that clearly indicates resident work
schedules must be developed with patient and resident safety
taken into account. Extended shifts, frequent overnight call, and
prolonged periods of time with patient care responsibility must
be limited to provide adequate time for sleep.[6]

What is the ideal rota?

It is beyond the scope of this research to proclaim an ideal rota
because local circumstances and needs will inevitably have a
part to play. Designing a rota is always a compromise, and must
encompass many variables – for example, there are significant
differences between how teams of anesthetists and other
doctors deliver clinical care compared with physicians.[7]

Slon is a pioneer writer on night work, refers to night-shift

workers as people who ‘live on the other side of the clock’.
Daytime is their sleep time, while the night time is their toil
time. These are the people of the night who slog at all hours to
keep a ‘twenty-four hour economy’ breathing and active. They
run factories, manage observatories, fight fires, work at
newspaper and television stations and allow supermarkets to
provide all-night services. This economy that never sleeps also
keeps hospitals in operation. Foulkard supports the thought that
there are differences between night-shift workers and daytime
workers. He views the whole aspect of sleep and wakefulness,
and night and day shift from a social order point of view,
claiming that many people are forced to
sleep and wake up at the wrong times due to the pressures of
society. Foulkard also advocates that people have to accept that
they are members of a daytime species and that there are risks
associated when humans work night shifts.
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Westfall-Lake and McBride express their concern about the shift

workers and their safety and state that working shifts can be
demanding. Crace argues that this economic demand which
requires people to be away from their families at these ‘odd’
times for night work could result in adverse effects being
experienced.[8]
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Research design and methodology

Variables

Personal data:
• Age: to the last birth day in years between 20- 50
• Gender: either male or female
• Rank: the doctors rank to meet the participant criteria
• Marital status: responsible for family or not (in form of
married, single, divorced and widow).
• Number of dependents: who share the participant salary.
• Department: the unit in a hospital where the doctor works.
• Hospital: the name of the specified health center.
Physical effects:
• Circadian rhythm: brain circuits which regulate sleep and
produce wakefulness.
• Sleep disturbances: when sleepiness interferes with daily
routines and activities, or reduces the ability to function.
• Health problems: any physical or psychological disorders
that disturb the life because of night shift.
• Sick leave: leave permission from the work due to sickness
to make rest or sleep.
• Tiredness and fatigue: sensation of fatigability and
tiredness due to night shift.
• Wight gain and or loss : increase or decrease of body built
after start work night shifts.
• Worst time of shift: the time during night shift you feel it’s
the worst.
• Injuries and traumas:
• Pills after the shift: A drug that affects emotional state.
Psychotropics include antidepressants, sedatives,
stimulants, and tranquillizers.
• Referring to drugs that affect person’s mental state.
Psychological and mental:
• Sad: unpleasure feeling during or after working the night
shift.
• Irritable: emotional disorder associated with anxiety.
• Life satisfaction: acceptance of the night life style.
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• Work satisfaction: Sense of inner fulfillment and pride

achieved when performing a particular job. Job satisfaction
occurs when an employee feels he has accomplished
something having importance and value worthy of
recognition; sense of joy.
• Mood changes: Alternation of a person's emotional state
between periods of euphoria and depression.
• Destructive habits: Specialist therapies are often not
available and many people with these problems drop out of
treatment. Overcoming Self-Destructive Habits needs good
understanding for 'emotionally unstable' or 'borderline
personality disorder' (BPD), such as anxiety, depression
and bulimia.
Social effects:
• Stress and strain: feeling of something overloading you.
• Smoking: feel better when you smoke during night shift
especially when you fall in sleep.
• Qat chewing: qat chewer during night shift improve your
performance.
• Maintenance of social relationships: when you start to work
the night shift your relationships not affected.
• Family conflicts and children's need: your duties to your
family and your children is done in perfect manner.
• Women activities at home: women working at night has
any different social impacts depending on each culture
attitude towards women (e.g. coking, child care, house
keeping)
• Social support: support from family, community and
coworkers for doctor who work night shift.
Work related:
• Rotational systems vs. permanent night duty.
• Shift time: at which time the doctors work in shift and for
how many hours per week or per month do they work.
• Tolerance of shift: to which limit the doctors are able to
work well at shift.
• Attitude towards patients: the dealing of the doctors with
the patients at shift work.
• Availability of supervision: if there is presence of
supervisors during working the night shift.
• Trouble at work: a problem during work the night shift.
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Type of the study (Research design)

Cross sectional survey. A descriptive, quantitative approach is
chosen for our study.

Data collection techniques

Our research depends on the questionnaire that we performed.
In the March to come we will be obtained by this questionnaire
in governmental hospitals in Sana'a. We will divide in three
groups each of which will investigate separate departments in
the same hospital for three nights. Investigating junior and
resident doctors who shift in these nights. The sealed
questionnaires to be fulfilled and gained back by the
participants. However, small meetings to help explain the
content of our questionnaire will be done in 5 minutes to make
the most reliable and validity of the data collected.

Sampling
We are thinking of a specific sample population to be the
residents and house officer doctors in Sana'a training
governmental hospitals for one week in a raw introducing closed
and open ended questions to the participants.

Criteria for participants

Only the residents and house officers in the governmental
hospitals in Sana'a who will be on night shift in may 2008. We
will ask the participants in the study to answer the prepared
questionnaire. And the participant should at least experienced
night shifts for one month.

Data collection and Analysis procedure

In each institution, the survey will be handled by the research
team to the doctors. Questionnaires will be handed out and
collected within one week. Each subject who was given a
questionnaire and one envelope, completed the questionnaire,
put it into the envelope. The respondent wrote his or her name
on the envelope only. Then we will collect them, returned only
the envelopes to our team. This procedure was used in order to
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ensure anonymity and to prevent anybody from recognizing the

sleep status of any participant.

Data analysis tools

For statistical analysis, SPSS 15 for windows is used, epi-info 6
(statistical calculator) is used to determine our sample size. And
Filemaker 8.5 and Microsoft Excel 2007 will be used to compile
the data.

Ethical considerations
Authorization to conduct the study Permission to conduct the
study well be obtained from:
The Ethical Committee of the Sana’a University Faculty of
:Medicine &Health sciences Department of Community Medicine
• The management of the selected hospitals.
• The Research Ethics Committee of the University of Sana’a
and the selected hospitals.
Permission to conduct the study was also sought from the
participants.
In this regard, verbal consent from the night doctors along
with the voluntary filling in of the questionnaire were
regarded as participant consent.
Right of full disclosure and the right to withdraw.
The aim, purpose, method and usefulness of the study were
explained verbally to the night doctors directly.
Printed information on the front and back pages of the
Questionnaire informed the prospective respondents of the
following:
-The aim of the study.
-The identification of the researchers.
-Proof of consent for the study obtained from the designated
Hospital’s management.
-The usefulness of research on this topic.
The researchers also asked the doctors to participate
voluntarily and explained to them what the nature of their
voluntary involvement in the study would entail. They were
informed of their right not to participate if they so wished and
that a refusal to take part in the study would not in any way
prejudice them. Information on when and where they may
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Obtain results was also given. Their right to withdraw at any

time was also emphasized.

Pre-test study

The initial questionnaire well used in a pre test study where a

sample of ten doctors tested the questions, and after this the
‘pre test’ method will be applied. Feedback will be obtained from
the pre test study participants and from experts on the
questionnaire.
The questionnaire will be also given to the researcher’s
Supervisor and co-supervisor for comments.
The researcher subsequently adjusted the original questionnaire
in preparation for the actual field work of this study, taking
recognition of the feedback from these sources and the pre test
study.
A pre-test or pilot study serves as a trial run that allows us to
identify potential problems in the proposed study. Although this
means extra effort at the beginning of a research project, the
pre-test and/or pilot study enables us, if necessary, to revise the
methods and logistics of data collection before starting the
actual fieldwork. As a result, a good deal of time, effort and
money can be saved in the long run. Pre-testing is simpler and
less time-consuming and costly than conducting an entire pilot
study. Therefore we will concentrate on pre-testing as an
essential step in the development of research projects.

Work plan

Time table for the research :

1/1/2009 Dead line for the research.
September/October 2007 literature review started.
13/11/2007 proposal draft.
January/2008 questionnaire preparing.
March/2008 final edition of the proposal.
May/2008 data collection.
May - June/2008 data analysis and discussion.
October/2008 conclusions and recommendations.
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November/2008 research writing and information gathering for

the draft edition.
December/2008 final edition of the research.
Final touches till the dead line.
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OUTLINE OF THE STUDY

Chapter 1: Orientation to the study including the ethical

Considerations, definition of variables and terms,
outline of the study and Abbreviations.
Chapter 2: A review of the relevant literature.
Chapter 3: The research methodology including design of
the
study, Study population, criteria for participation,
sampling Procedure, data collection and data
analysis
procedure.
Chapter 4: Results of the data analysis.
Chapter 5: Discussion of the findings.
Limitations of the study.
Recommendations
Conclusion
References
Appendices
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Estimated budget of research (September/2007 – December/2008)

September/October 7600 YR
Literature review started.
2007 38.2 $
November/December 4040 YR
Proposal draft.
2007 20.3 $
2000 YR
January/2008 Questionnaire preparing. 10 $
2000 YR
March/2008 Data collection. 10 $
2000 YR
April/2008 Data analysis and discussion. 10 $
Conclusions and 2000 YR
May/2008
recommendations. 10 $
Research writing and information 5000 YR
June/2008
gathering for the draft edition. 25 $
November/December 10000 YR
Final edition of the research.
2008 50 $

34640 YR
Total
174 $
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References
1. Takashi OHIDA, A. K. (Feb 15, 2001). Night-Shift Work Related Problems in Young
Female Nurses in Japan. Minato-ku, Tokyo , Japan: Department of Public Health
Administration, National Institute of Public Health.

2. Conditions of Work and Employment Programme. (May 2004). Geneva:

International Labour Office.

3. Cuthbertson, L., & Lea, R. (Novmber 2005). SURVIVING THE NIGHT SHIFT: A NEW
GUIDE. Royal Collage, London.

4. Mahon, A., Harris, C., & Tyrer, J. (August 2005). The implementation and impact of
Hospital at Night pilot projects. York, England: York Health Economics Consortium,
University of York.

5. Horocks, N., & Pounder, R. (2006). Working the night shift:preparation, survival
and recovery (Vol. Vol 6). Royal College of Physicians, London: Publications
Department,.

6. Lois E. Krahn, C. M. (2005). Identifying the Resident at Risk for Sleep Deprivation.
Mayo Clinic Arizona: Department of Psychiatry and Psychology.

7. Pounder, P. o. (September 2006). Designing safer rotas for junior doctors in the
48-hour week. Royal College of Physicians, London.

8. Swartz, B. L. (15 May 2006). Experiencing Night Shift Nursing: A Daylight View.
University of the Western Cape: University of the Western Cape.