Why are nights and on-call harder?
At night there are fewer staff, fewer seniors on site and many patients you have never met. A junior doctor may cover several wards, and a nurse may have more patients and less support. Pharmacy, physiotherapy and specialist teams are reduced or available only by phone. Meanwhile your body is working against its natural clock, so concentration, memory and mood dip, especially between about 3 am and 6 am.
None of this makes nights unsafe in themselves. Most nights go well when people prepare, prioritise sensibly, ask for help early and look after themselves. This guide is written for doctors and nurses together, because safe nights depend on a nurse who escalates clearly and a doctor who responds and listens.
How do I prepare for my first night shift?
The day before
- Have a normal night's sleep before the first night, then try to sleep for a couple of hours in the afternoon before you go in.
- Plan meals and snacks you can eat on the go. Canteens and shops are often closed after midnight.
- Pack water, a phone charger, a pen torch, your ID and access card, and anything you need for the morning.
- Know how you will get home safely the next morning, and have a back-up if you are too tired to drive.
- Tell the people you live with when you will need to sleep, and set up a dark, quiet room with blackout blinds or an eye mask and earplugs.
The first thirty minutes
Arrive in time for handover and start a written task list straight away. For each patient handed over, note where they are, the problem, what needs doing and by when, using only the identifiers your organisation allows on a handover sheet. Ask three questions: who is the sickest patient, who has a treatment escalation plan or DNACPR decision, and which results must be checked tonight.
How do I prioritise when everyone needs me at once?
Within ten minutes you may be asked about a tissued cannula, an empty fluid bag, chest pain, a relative wanting an update and a patient who has fallen. The rule is simple: the patient who could come to harm soonest comes first. When someone calls you, ask for the full set of observations and the NEWS2 score, what has changed, why they are worried and what they have already done.
| Priority | Examples | What to do |
|---|---|---|
| 1. Emergencies | Cardiac arrest or peri-arrest, airway problems, prolonged seizures, NEWS2 of 7 or more, suspected sepsis with shock | Go now and call for help on the way |
| 2. Acutely unwell | New chest pain, rising NEWS2, new low oxygen saturation, fall with possible head injury on anticoagulants, very high or low blood glucose | See within minutes, not hours |
| 3. Time-critical tasks | Insulin, Parkinson's medicines, anticoagulants, antiepileptics, overdue antibiotics, a result that changes management such as high potassium | Do before routine work |
| 4. Routine tasks | Re-siting a cannula for a non-urgent drug, rewriting a drug chart, routine fluids for a stable patient | Group by ward to save walking |
| 5. Day-team work | Non-urgent discharge letters, routine blood forms, non-urgent family updates | Explain politely and hand over |
NEWS2, from the Royal College of Physicians, is used for most adult inpatients. A total of 5 or more, or a single parameter scoring 3, calls for an urgent review, and 7 or more an emergency response. It is not used in pregnancy or for children, where maternity and paediatric early warning tools apply. Follow your trust's escalation policy for the exact response times.
How do I escalate a deteriorating patient at night?
Delayed escalation is a recurring theme in NHS incident investigations. It usually happens because someone did not want to disturb a senior, was not sure the concern was serious enough, or gave a message too vague to prompt action. SBAR (Situation, Background, Assessment, Recommendation) fixes the last problem by putting the key facts first and ending with a clear request.
Hi, sorry to bother you, it's Ward 6. I've got a lady who isn't great really, her obs are a bit off and she's sleepy. Could someone have a look at some point?
This is Grace, staff nurse on Ward 6, about the patient in bed 12. Her NEWS2 is 7 and she is newly drowsy. She is 78, admitted two days ago with pneumonia on oral antibiotics. Respiratory rate 28, saturations 89% on 2 litres, blood pressure 92 over 54, pulse 118, temperature 38.6. I am worried about sepsis. I have increased her oxygen as prescribed and am repeating observations. I need you to review her within 15 minutes. Should I also call outreach?
The strong call gives the score and the numbers, names the concern and asks for a specific action within a specific time. It is polite and confident. Naming sepsis matters because NICE guidance (NG253 for people aged 16 or over) stresses early recognition and treatment.
If the response is not good enough
If the person you called does not come, or the advice seems unsafe, escalate again. Say clearly that you are worried about patient safety, then contact the next person: the registrar, outreach or critical care team, site manager or consultant on call. Record who you contacted, when, and what they advised. Junior doctors escalate too: call your registrar or consultant when a patient is not improving, may need critical care or needs an escalation decision. Most consultants would much rather be called at night than discover a problem in the morning.
Worked example: a busy hour on call
Tomas is a foundation doctor covering four medical wards. At 1.30 am he has: a breathless patient with a NEWS2 of 6 on Ward 2; a potassium of 6.4 mmol/L on Ward 5; a warfarin dose to prescribe on Ward 5 now that the INR is back; a patient on Ward 3 who fell, is alert, has a small graze and is not anticoagulated; and a cannula to re-site for fluids on a stable patient on Ward 4.
- Spot the two urgent problems: The breathless patient and the high potassium could both be life-threatening. Tomas asks the Ward 5 nurse for an ECG now, and the Ward 2 nurse to give oxygen as prescribed and repeat observations.
- Get help with competing emergencies: He cannot be in two places, so he calls his medical registrar using SBAR. The registrar reviews the ECG and starts treatment for the potassium under the trust guideline.
- Assess the breathless patient: Tomas does an ABCDE assessment, agrees a plan with the registrar and asks for repeat observations in 30 minutes.
- Do time-critical tasks: He prescribes the warfarin dose, which should not wait until morning.
- Group the routine work: He reviews the patient who fell, documents a falls assessment, then re-sites the cannula.
- Document and hand over: He writes up each review at the time and adds both sick patients to the morning handover.
What kept this night safe was not heroics. Tomas asked nurses to start actions while he was on his way, called his registrar early, did time-critical work before routine work and handed over clearly. The nurses helped by giving him clear information when they called.
What should a good morning handover include?
The handover after a long night is one of the riskiest moments of the day, because everyone is tired and information gets dropped. Use your trust's structured handover, and cover:
- Patients who deteriorated or were reviewed overnight, what was done and what is still needed.
- Patients who are still unstable or awaiting a senior review.
- Results that are pending or need acting on.
- Any new escalation decisions, DNACPR or ReSPECT forms.
- Deaths, transfers and admissions to critical care.
- Tasks that you could not complete, stated clearly.
How do I manage fatigue and sleep after nights?
Fatigue slows reactions, weakens decisions and makes calculation errors more likely, and tired people rarely notice how impaired they are. Use the low point in the early hours to double-check drug calculations and ask a colleague to check anything high-risk.
During the shift
- Take your breaks. For resident doctors in England, the 2016 contract sets paid breaks, with a third 30-minute break on nights of 12 hours or more. Nurses should follow their employer's policy; the Working Time Regulations give a minimum 20-minute break when working more than six hours.
- Where your trust allows it, a short nap on a break can help. Agree it with the team and make sure you can be reached.
- Drink water, eat proper meals and use caffeine early in the shift rather than near the end.
- Look out for colleagues who seem exhausted, and accept help when it is offered.
After the shift
- Do not drive if you feel sleepy. For resident doctors in England, the contract expects employers to provide a rest space or pay for alternative travel if you are too tired to travel home. Ask what your trust offers before your first night.
- Go to bed soon after getting home. Keep the room dark and cool, and keep your phone away.
- After your last night, a short sleep in the morning and an early night usually helps you switch back.
- Use your rest days to rest. Resident doctors in England are entitled to at least 46 hours off after a run of nights.
If night work is affecting your sleep, mood or health for more than a short spell, talk to your GP or occupational health. Doctors and dentists in England can also contact NHS Practitioner Health confidentially. If you ever feel in crisis, Samaritans are available on 116 123, day or night.
Learning more
Contract details differ between England, Scotland, Wales and Northern Ireland and between staff groups, so check your own contract, rota and trust policies. The BMA and RCN publish guidance on rotas, breaks and fatigue for their members.
Our course Surviving On-Call and Night Shifts covers prioritisation, NEWS2, SBAR escalation, handover and fatigue in more depth, with a structured reflection you can use as CPD evidence. If you are new to the NHS, Your First NHS Job: Induction and Expectations and Your First Week on the Ward cover the basics that make your first nights easier.
Frequently asked questions
How should I sleep before my first night shift?
Sleep normally the night before, get up at your usual time, then try to nap for one to three hours in the afternoon before the shift. Even if you cannot fall asleep, resting in a dark room helps. Avoid heavy caffeine late in the afternoon so the nap is possible, and eat a proper meal before leaving for work.
What should I eat on a night shift?
Bring your own food, because hospital shops and canteens are often shut overnight. Many people find a proper meal before the shift and lighter, regular snacks overnight easier than a large meal at 3 am. Keep drinking water. Use caffeine in the first half of the shift so it does not stop you sleeping afterwards.
Is it acceptable to call my registrar or consultant at night?
Yes. Good Medical Practice expects you to recognise the limits of your competence and ask for help. Call when a patient is deteriorating or not improving, may need critical care or an escalation decision, or when you are unsure. Use SBAR so the call is quick and clear, and record the advice you were given.
What if a nurse keeps calling me about non-urgent tasks?
Thank them, check quickly that the task really is routine by asking about observations and what has changed, then say when you expect to get to it. Group routine jobs by ward. Treat every call as possibly important until you know otherwise, because the nurse at the bedside often notices deterioration before the numbers change.
What should I do if I am too tired to drive home after a night shift?
Do not drive. Use your trust's rest facility if there is one, or take a taxi or public transport. In England, the resident doctors' 2016 contract expects employers to provide somewhere to rest or to pay for alternative travel when you are too tired, under local policy. Ask about the arrangements before your first run of nights.
How many nights in a row can a junior doctor work in England?
Under the 2016 terms and conditions for resident doctors in England, you should not be rostered for more than four night shifts in a row, and you are entitled to at least 46 hours' rest after a run of nights. Other UK nations have different contracts, so check the BMA's rota guidance or your own contract.
How do I switch back to days after a set of nights?
Many people sleep for a few hours after the last night, get up around midday, spend time outdoors in daylight and go to bed at a normal time that evening. Avoid long lie-ins and late caffeine. It can take a couple of days to feel normal, so plan easy tasks for your first day off.
Related courses
Surviving On-Call and Night Shifts
This course prepares doctors, nurses and midwives to work safely through on-call and night shifts. It covers how to prioritise competing tasks, when…
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Sources and further reading
- National Early Warning Score (NEWS) 2. Royal College of Physicians.
- Suspected sepsis in people aged 16 or over: recognition, assessment and early management (NG253). National Institute for Health and Care Excellence.
- Contractual rights factsheet for resident doctors (2016 contract, England). British Medical Association.
- Fatigue and sleep deprivation. British Medical Association.
- The Working Time Regulations 1998. legislation.gov.uk.
- Good Medical Practice (2024). General Medical Council.
- The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. Nursing and Midwifery Council.
Practitioner Insight is an independent education provider. It is not affiliated with or endorsed by the GMC, MPTS, NMC, HCPC, GPhC or any NHS organisation, and this information is not legal advice. If you have been referred to a regulator, speak to your defence organisation, trade union or legal representative.
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