The Proposal 25042008

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.

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

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Supervisors and Contributors: Supervisors  Prof.  Prof.

Abdulwahed al sorrori Abdallah Agunaid NB: doctors photos and academic title

contributors

 Mohammed Abdulhameed Alsaleh  Yazid Salam Jibrel  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 2007 November/December 2007

Literature review started.

7600 YR 38.2 $

Proposal draft.

4040 YR 20.3 $

January/2008

Questionnaire preparing.

March/2008

Data collection.

April/2008

Data analysis and discussion. Conclusions and recommendations. Research writing and information gathering for the draft edition.

May/2008 June/2008 November/December 2008 Total

Final edition of the research. 34640 YR 174 $

2000 YR 10 $ 2000 YR 10 $ 2000 YR 10 $ 2000 YR 10 $ 5000 YR 25 $ 10000 YR 50 $

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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.