Pre-shift preparation: Napping with knowledge of the sleep cycle is important. A 20-minute nap (before deep sleep kicks in), or a full 90-minute sleep cycle nap before a night shift can reduce sleep inertia and improve cognitive performance.^24,25 However, napping for 30–60 minutes may cause increased fatigue because waking is generally during the phase of deep sleep. High-intensity cardiovascular exercise and caffeine ingestion 30–60 minutes prior to shift start can further enhance alertness.^26-28 Limit caffeine intake to the first half of the shift to avoid impairing post-shift sleep onset.

During shift: Use of bright blue-spectrum light (10,000 lux) in the early part of night shifts enhances alertness without impairing subsequent sleep if exposure ceases at least two hours before sleep onset.⁹

Post-shift wind-down: Wearing blue-blocking glasses or dark sunglasses on the commute home reduces light-induced melatonin suppression. Supplemental exogenous melatonin (0.3–5 mg) taken three to four hours prior to the desired sleep onset may support circadian re-entrainment and improve sleep continuity. Doses greater than 5 mg confer no added benefit and may paradoxically disrupt sleep in some individuals.²⁹

Pharmacologic Approaches

Although behavioral interventions should remain the first-line approaches, pharmacologic therapies may be necessary in select cases of shift work sleep disorder (SWSD).

Exogenous melatonin, as noted above, facilitates circadian entrainment with minimal side effects when properly timed. In more severe cases, short-acting, non-benzodiazepine hypnotics (e.g., zolpidem, zopiclone) may aid with sleep initiation, although concerns regarding tolerance, dependency, and next-day sedation limit their long-term use.²⁹

Wake-promoting agents such as modafinil and armodafinil have demonstrated efficacy in improving alertness and performance during night shifts in individuals diagnosed with SWSD.^30,31 However, these agents may pose cardiovascular and psychiatric risks and should be reserved for refractory cases under specialist supervision.³²

Cannabinoids, including THC and CBD formulations, are not recommended because of evidence of impaired sleep architecture, increased sleep fragmentation, and the potential for adverse psychiatric outcomes including psychosis.¹⁶

By implementing the outlined evidence-based strategies, emergency physicians can mitigate the adverse consequences of shift work, improve clinical performance, and protect long-term health. Sleep should not be viewed as expendable, but rather as an essential element of professional sustainability and patient safety.

Dr. Helman is an emergency physician at North York General Hospital in Toronto. He is an assistant professor at the University of Toronto, Division of Emergency Medicine, and the education innovation lead at the Schwartz/Reisman Emergency Medicine Institute. He is the founder and host of the Emergency Medicine Cases podcast and website.