The morning after the night before: Nightshift and the danger it poses to Irish road users - AWS
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Reiltin Tynan | School of Medicine, National University of Ireland, Galway
The morning after the night before: Nightshift and the
danger it poses to Irish road users.
Introduction
Everyone here has felt tired at some point in their lives. Many of us know what it is to nod off
in a lecture theatre, or on public transport, or watching television. Hopefully fewer of us know
the panic in the aftermath of drifting to sleep at the wheel as we drive home. Unfortunately,
many do know that feeling- and for most, the shock of it is enough to become hypervigilant
for the remainder of the journey. For others, however, it has fatal consequences- not only for
themselves but also for concurrent road users1. Night-shift is notorious for significantly
disrupting sleeping patterns2-5. Additionally, night-shift is associated with increased stress and
burnout levels, which may contribute to distracted driving and an inability to react timely to
dangerous early morning road conditions6,7. It is believed in Ireland that driver fatigue is a
contributory factor in as many as 1 in 5 driver deaths annually. Furthermore, tiredness-related
collisions are 3 times more likely to be fatal or result in a serious injury due to high impact
speed and lack of avoiding action8.
Although it is very hard to prove whether driver fatigue indisputably independently increases
crash risk- for example it may be fatigued drivers are simply driving longer distances with
resulting risk per kilometre of crashing the same regardless of driver fatigue- it is apparent
that sleep related crashes are far more likely to occur in individuals that work night-shift,
multiple jobs or have a sleep related disorder9,10. It is therefore is becoming a much more
pertinent issue as the number of night-shift workers increases globally11. Night-shift in
healthcare is almost inevitable. Few individuals avoid it completely, and it is a way of life for
many. Very few work places put in place protocols to ensure people are not too tired to drive
home after a night-shift12. The onus ultimately falls on individuals to decide whether they are
safe to work. This practice is illegal in the long-haul trucking industry or aviation13,14. Why is it
acceptable in healthcare? The life of doctors and nurses is characterised by risk assessment
and reaction. The greatest risk we take in reality is when we decide to drive home after a
particularly terrible shift, exhausted, in search of the comforts of home. For some this is the
last journey they will ever make. It is time for that to change.
Night-shift fatigue and driving
Majority of healthcare workers that rotate through night-shift perceive themselves to be less
alert on the first night in comparison to subsequent nights. This ‘first night-shift phenomenon’
possibly reflects an extended time of prior wakefulness before the start of the first night-shift,
due to difficulty converting from day to night working schedules, and possible anxiety about
the upcoming series of nights15. It was believed that a brief nap during the first night-shift
limited the deterioration in performance of healthcare workers across the night 16.
Interestingly, recent studies have found objective performance is equally impaired on
1Reiltin Tynan | School of Medicine, National University of Ireland, Galway
subsequent nights and is not just limited to that first night. It is now understood that alertness
and impaired performance during night-shift is most likely due to lack of circadian adaptation
to night work17. Misalignment of the circadian pacemaker with sleep-wake timing is common
in shift workers; it results in sleep deprivation and excessive sleepiness during work18.
The combined effect of these circadian and sleep-related factors impairs performance and
reduces alertness of healthcare workers on duty. It was also found that sleep was most
restricted between consecutive night-shifts, and healthcare workers opted for a ‘recovery’
rather than ‘preparation’ approach; willing to sleep more on completion of nights, rather than
sleep in excess prior to the commencement of night-shift19. Circadian rhythm disruption can
make for hazardous work environments, and it also contributes to the dangers not only
driving home from the shift, but also driving to the next shift20,21. This natural physiological
disturbance may prove to be very difficult to rectify, however, as even permanent night-shift
systems are unlikely to result in sufficient circadian adjustment to provide individuals with
health and safety benefits. Only a small selection of permanent night workers seem to adjust
their endogenous melatonin rhythm entirely to night work. Other environmental factors such
as lighting and stimulation also impacts on circadian rhythm, further complicating matters 22.
Stress and night-shift work
For many, night-shift is simply more stressful. It is often understaffed, mistakes are easily
made due to fatigue and lack of support for junior staff members, and hospitals are
overcrowded23,24. The first week of 2020 in Ireland had a record number of patients without
beds, with huge numbers of surgeries cancelled and a devasting knock-on effect for hospital
environments25. It is not unreasonable to infer that these working environments catalyse
human error and increase individual stress levels. Many issues can play on people’s mind as
they drive home, causing them to be distracted and increasing the risk of dangerous driving26.
Stress is also likely to be the most frequent cause of short-term insomnia, although
infrequently documented polysomnographically. Additionally, apprehension of subsequent
working days is associated with a low amount of slow wave sleep and impaired subjective
sleep quality. It is reasonable to draw the conclusion that many healthcare workers have some
degree of anxiety or apprehension when facing dire work environments. The increased stress
experienced therefore has a two-fold impact on driving- both in terms of distracted driving
and increased driver fatigue27.
In 2017, according to the National Highway Traffic Safety Administration, distracted drivers
took at least 3,166 lives throughout the U.S. Mobile phone usage was the main contributory
factor in driver distraction but other manual, visual and cognitive distractions attributed to
fatal accidents. It was found that cognitive distractions alone could cause collisions, with
individuals contemplating financial difficulties, recent fights and relationship troubles listed
as some of the causes of accidents in 2017. Driver distraction reduced the ability to safely
react to hazards28. Studies completed by Pavlidis et al. demonstrated that sensorimotor
distractions hyper-arouse the average driver and can result in significant deterioration in
driving performance. They suggest that generation of unobtrusive orthotic feedback loops
may notify the driver (and possibly other drivers) of their over aroused state and
consequential impaired driving ability, to create safer driving conditions in the future 29.
2Reiltin Tynan | School of Medicine, National University of Ireland, Galway
Car technology is advancing, with several companies focusing on developing accurate means
of detecting driver fatigue. Many are fine tuning camera-based systems that monitor head
and eye movements, blink rate, body posture, heart rate and body temperature. In some
instances, they hope to tailor artificial-intelligence software to individual drivers and
determine when they are operating outside of their norms30. This technology is especially
important as automated driving is phased into countries. Whether automated vehicles will
make roads safer driving post shift is yet to be determined as the human–machine interface
must be optimised before safe driving is possible, especially when the vehicle is under
complete automated operation31,32. Current predictions indicate that the introduction of fully
automated cars and their widespread usage will occur within the next 20-years33. Although
there is some debate around whether Irish roads will ever be suitable for automated driving
of any kind, there are currently plans to introduce legislation allowing the testing of
autonomous vehicles on Irish roads34. These cars may appeal to healthcare workers in years
to come, and the safety mechanisms integrated within vehicles may save lives in the future.
Road conditions the morning after night-shift
Although early morning driving is not considered the most dangerous time of day to be on
the road, night-shift workers often have to contend with rush hour traffic, temptations of
distracted driving (such as texting while in traffic), long commutes, with an increased risk of
episodes of microsleep. Those on night-shift are up to three times more likely to be involved
in a road traffic accident than someone not working night-shift35. Analysis of insurance claims
also suggests a concentration of problem driving across all healthcare professionals, with an
increase in ‘at-fault’ claims seen in district nurses, community nurses, health visitors, GPs and
hospital consultants36. According to a 2017 UK national survey half of trainee hospital doctors
have had an accident or near miss on their way home after a night-shift due to sleep
deprivation37. A separate survey that year found more than a third of doctors have fallen
asleep while driving38. Suboptimal driving conditions, driver fatigue and high traffic flow
certainly contribute to the increased likelihood of accident among healthcare workers.
Early morning drivers are also facing the added danger of being dazzled by bright modern LED
headlamps on their journey home, especially during winter months. According to a report by
RAC a British automotive services company, 65% of drivers of all ages are regularly dazzled by
modern headlights – regardless of whether they are full or dipped. More alarming, 15% of
drivers admitted to being in a ‘near miss’ or ‘near accident’ as a result of being dazzled by
oncoming traffic, or when checking their rear-view mirrors39. The UN Economic Commission
for Europe is considering limiting the brightness of these modern lights, and there has been
an increase in complaints to various transport bodies concerned about the new danger it
poses on the road40,41. Although this is an issue that should be considered independently to
the danger of driving after night-shift, it is possibly a factor in the rising number of road traffic
accidents on Irish roads. Perhaps we should reconsider the legal status of LED lights, given the
danger they may pose to road users42.
Deadly consequences for young healthcare workers
3Reiltin Tynan | School of Medicine, National University of Ireland, Galway
Unsurprisingly, that the most at-risk driving post night-shift are the most junior members of
staff. Not only are they more likely to suffer burnout and dwell on mistakes made during the
shift, they are less equipped to cope with the pressures of night-shift; shift work tolerance is
most often higher in more experienced members of staff43. Not only are interns often
apprehensive about admitting to medical error, but extended work hours and night-shift is
associated with an increased risk of percutaneous injuries especially at the start of their
career44,45. It is possible that these errors lead to increased driver distraction, and any ‘near
miss’ driving accidents are also unlikely to be brought to the attention of senior members of
staff who might be able to help with rota formation.
The most frightening data of all emerging is that not even medical students are spared the
repercussions of night-shift. Although there is little data on medical students driving post
night-shift, it would be reasonable to infer that a significant proportion of Irish students would
be required to drive home; the 2012 Irish census indicated that 28% of third-level students
drove to classes and these numbers were rising when compared to previous data46. Studies
do show that night-shift detrimentally impacted student selective attention and
concentration performance in a dose response manner (ie. the greater the sleep deprivation,
the worse the students’ performance)47.
Although junior members of staff are most vulnerable and have resulted in the most lives lost
on roads, senior members of staff are not completely safe. Even consultants are at risk of
burnout and fatigue, and too are at risk on our roads. A national survey of out‐of‐hours
working and fatigue in consultants in anaesthesia and paediatric intensive care in the UK and
Ireland last year found that 91% of consultants reported work-related fatigue, over 50% who
felt it has a significant impact on their health, wellbeing and home life. Moreover, 24% stated
that they did not have departmental arrangements for covering scheduled clinical duties
following a night on-call if they had been required to be in the hospital overnight 48.
Night-shift workers and their global impact
It is easy to forget that night-shift is not simply a burden for healthcare workers. With
consumer businesses striving to meet the demand for 24-hour services, the necessity for
night-shift workers is higher than ever. Currently there is in excess of 20% of EU workforce
working nights, doubled in the last decade. In the UK, the number of night-shift workers has
risen by greater than 250,000 in the past 5-years49. Not only do airport personnel, factory
workers, emergency service personal, and even fast food operators cope with long stressful
shifts, but the night-shift in particular has devastating impact on their health. Truck drivers
have the added danger of heavy loads, long distance driving and often undiagnosed sleep
apnoea to add further danger to our roads50. Mobile workers and self-employed drivers may
do a maximum of 10-hours’ work during the night-time in each 24-hour period, although
regulation of these individuals is extremely difficult51.
The question is, who does most of the responsibility lie with in terms of driver fatigue post
night-shift: the employer or the employee? How do we best protect the most vulnerable? The
tragic death of 19-year-old Bijan Melrose last October comes to mind. He fell asleep at the
wheel, travelling to Dublin in the early hours of the morning after working in Sligo. His family
4Reiltin Tynan | School of Medicine, National University of Ireland, Galway
sued Bijan’s employer Shoot Booths Ltd, for emotional trauma and alleged contributory
negligence. They settled outside of court. One might then infer that employers have
significant responsibility in managing fatigue52. That is not to say that employees are absolved
of all responsibility. On the contrary, employees must rest and recover adequately between
shifts, report hazards and recognise when they are too tired to work or drive. It does mean
that employers should be cognisant when allocating shifts and be aware of the dangers of
driving post night-shift.
With the serious dangers of driving post night-shift, I wonder should we consider limiting the
number of shift workers in Ireland. Night-shift is undeniably necessary for healthcare workers.
People need care in hospital throughout the night, accidents are not limited to daytime hours-
abolishing night-shift in hospitals is laughable. That being said, do we truly need as many late-
night factory workers? Should we be more stringent with truck drivers or self-employed
drivers making long night time journeys- with increased penalties for those who do not take
the mandatory breaks? Perhaps there will be a disruption to daytime services, or loss in
productivity if night-shift is curtailed in other fields. At the end of the day, however, our roads
would be a safer place if less people post night-shift were driving on them.
Risk reduction and improving driver safety
Ireland ranks 3rd in the world road safety from the European commission53. The RSA have had
a number of very successful campaigns directed at increasing road safety and saving lives.
However, there was a 4% rise in fatalities last year, with a 45% increase in the number of
drivers killed. We need to need to save an additional 2 lives per month to reach the
government’s eight-year road safety strategy goal by the end of 202054.
Fig.1 Fatalities per million inhabitants by country in 201853
5Reiltin Tynan | School of Medicine, National University of Ireland, Galway
Although we rank high globally, is it truly acceptable that people are still dying on our roads?
Especially those who are simply trying to make it home after a long night’s work? There are a
certain number of things we can do to ensure safer driving for those driving home post
hospital night-shift.
1. We need to provide rooms that that tired healthcare workers can sleep in if too
exhausted to drive home. If this is not possible there needs to be a protocol in place
in all hospitals to check if people are too tired to drive home after a night-shift. This
should enable others to report concerns about fatigued individuals in a considerate,
confidential manner.
2. There needs to be increased awareness of the dangers of driving post night-shift
among all healthcare workers, but especially among junior members of staff.
Healthcare workers should be encouraged to sleep well the days prior to night-shift in
preparation for the deficit in sleep they will likely suffer. After their shift ends people
should be encouraged to nap before they drive and grab a caffeinated drink if
necessary. Above all, every member of staff should know that if they are too tired to
drive, they should call someone else to bring them home.
3. Night-shift needs to be a safer environment; not a night of stress that people dread.
This will require addressing the understaffing, the extreme waiting lists, the bed
shortages and the lack of support for members of staff at night. This will improve stress
levels, reduce burnout and create safer drivers post night-shift.
At a national level we could aim to improve road conditions, reduce peak hour road
congestion and consider the impact LED headlights are having on road safety. At an individual
level, if one sees a colleague too tired to engage in alert conversation, they are also too tired
to drive and likely to be too tired to make trusted decisions on the ward. Two key points that
could make 2020 much safer for us all include recognising that fatigue is as dangerous as
driving under the influence of alcohol, and also realising that preventing someone from
driving is not only for the safety of themselves but is ultimately necessary to fulfil a duty of
care to other road users.
Conclusion
Driving after night-shift is dangerous. Lauren Connelly, Ronak Patel, Naveed Farooki, Ilene
Markwat, Jessica S. Lin, Sobby Mathew, Kerrie Browne, Keady Clifford and Maddie (Madara)
Sulaine. These doctors and nurses have one thing in common. They died when driving home
after their night-shift. Unfortunately, this is by no means a comprehensive list of the
healthcare workers who die globally due to driving fatigue after exhausting shifts. Healthcare
workers are also not alone in the dangers of driving post night-shift. Protocols should be
implemented to protect all night-shift workers- across all professions- against the dangers of
driving while fatigued and distracted. We must address road conditions and encourage safer
driving practices, especially among recurrent night-shift workers and junior members of staff.
We must not ignore the impact driving after a night-shift has on the safety of Irish roads. We
owe it to these people, and to each other, to make driving after night-shift safer.
6Reiltin Tynan | School of Medicine, National University of Ireland, Galway
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