Is there a difference in the prevalence of stress related health problems between night shift, day shift, and rotating shift RNs as indicated by subjective self-report survey results ?

Title: The influence of working longer shift on nurses` quality of care


During the past three years, a series of studies have demonstrated the risks to patients and providers of long work hours in health care. Compared with nurses working shorter hours, nurses working greater than 12.5–13 consecutive hours report (1): a 1.9- to 3.3- fold increased odds of making an error in patient care1,2; (2) a significantly increased risk of suffering a needlestick injury, exposing them to an increased risk of acquiring hepatitis, HIV, or other bloodborne illnesses3; and (3) significant decrease in vigilance on the job. (9)

A number of healthcare organizations and state boards of nursing have adopted strategies to address concerns related to nurses’ shift lengths and fatigue and the connection with risks to patients and care providers. In 2003 the Accreditation Council for Graduate Medical Education (ACGME) began limiting shift length and duty hours of residents and fellows (ACGME, 2010), and ACGME published additional limitations in 2011 (ACGME, 2011). The Institute of Medicine (IOM) has also published guidelines and recommendations regarding nurses’ roles in the protection of patient safety and improved patient outcomes (IOM, 2004). (7)

Shift work is an inevitable part of many jobs which require 24 hour attendance and comprise working at unusual hours, especially at length shift . Because of potential hazards of length shift work on safety and health, there was an intensive debate on the “best compromise” shift system (Folkard, 1992). Shift length and kind of shift rotation (forward/backward rotation; quick and slow rotation) have been considered at length (Smith, Folkard, Tucker & Macdonald, 1998). Up to now, no unequivocal conclusion can be drawn with respect to shift length. One reason might be that mediating factors play an important role, such as length of recovery intervals between shifts, options for sleep recovery in these intervals, options to cope with fatigue within the shift, or personal and family activities, all of which contribute to cope with work stress (Folkard, 1992; Smith et al., 1998). (32)

Extended work shifts of twelve hours or longer are common and even popular with hospital staff nurses, but little is known about how such extended hours affect the care that patients receive or the wellbeing of nurses. Survey data from nurses in four states showed that more than 80 percent of the nurses were satisfied with scheduling practices at their hospital. However, as the proportion of hospital nurses working shifts of more than thirteen hours increased, patients’ dissatisfaction with care increased. Furthermore, nurses working shifts of ten hours or longer were up to two and a half times more likely than nurses working shorter shifts to experience burnout and job dissatisfaction and to intend to leave the job. Extended shifts undermine nurses’ well-being, may result in expensive job turnover, and can negatively affect patient care.(29)


Due to social, economical, and technological changes in the past 10 years, the workforce has adapted to different forms of work schedules. Work schedules have changed in some industries to include flexible hours, irregular shifts and at times, elongated shifts (Jansen et al., 2003). Shiftwork may be defined as a job schedule other than the standard hours of 8am to 5pm (Institute for Work & Health, n.d.). Although many sources refer to shiftwork as time worked outside the standard working daytime hours, there are “shifts” that include daytime hours, specifically in healthcare and hospital settings. Shiftwork in these settings usually revolve around 24 hour coverage, and is mostly characterized as 8 to 12 hours for full time employees.(37)

nursing work hours could influence workers’ health in a variety of ways. They frequently contribute to disrupting circadian rhythms and impacting length of recovery time before a nurse returns to work. They also contribute to overall fatigue in the workplace, affecting nurses’ vigilance and critical thinking (Tabone, 2004). (37)

Job satisfaction and burnout in the nursing workforce are global concerns, both due to their potential impact on quality and safety of patient care and because low job satisfaction is a contributing factor associated with nurses leaving their job and the profession).31)

Shift patterns have been identified as an important factor in determining well-being and satisfaction among nurses. Providing in-patient nursing care inevitably involves shift work. Shifts of 12 h or longer have become increasingly common for nurses in hospitals in some countries in Europe. This change is mainly driven by managers’ perceptions of improved efficiency from reducing the number of nurse shifts a day, therefore resulting in fewer handovers between shifts,less interruptions to clinical care provision and increased productivity due to a reduction in the overlap between two shifts.10 From the nurse perspective, longer shifts offer a potential to benefit from a compressed working week, with fewer work days and more days off-work, lower commuting costs and increased flexibility. However, previous studies on shift length in Europe did not provide evidence of nurses working a compressed work week, so it is not clear if working 12 h shifts is associated with fewer days at work. These scheduling practices have not been systematically evaluated and the movement to longer shifts for nurses has not been based on research evidence of improved outcomes for nurses and an absence of harm to patients.(31)

A recent study among European nurses investigated the association between shift length and nurses’ psychological well-being. The findings show that nurses preferred 12 h shifts because more time off helped them balance work and personal commitments,although the nature of these was not examined (e.g.,having a second job, having caring responsibilities at home and other potential confounders on the impact of 12 h shifts on nurse outcomes). Paradoxically, the study also found that nurses who worked12 h shifts were more likely to experience high levels of burnout than nurses working shorter shifts .(31)

Similarly, Stimpfel16 reported that American nurses working extended shifts,particularly longer than 13 h, were more satisfied with their work schedules but were more likely to experience burnout and job dissatisfaction than nurses who worked shifts of 8 or 9 h. However, the US study did not disentangle scheduled shift length from extended shifts due to overtime worked, a common limitation in previous research on nurses’ shift lengths.Differences between work hour regulations between countries may limit the generalizability of US research.The US has regulations governing nurses’ work hours that differ from the European Working Time Directive,in terms of limiting weekly hours, including overtime,and providing extra protection for between-shift rest hours and night work.(31)

the disadvantages (reduced family time, tiredness and stress, increased health risks). While there was some evidence to support the outcomes noted, there was not always a clear link between longer shifts and changes in the outcomes. (36)

at al found insufficient evidence of effects of shift length on nurse job satisfaction and burnout, while a more recent systematic review reported evidence of adverse nurse outcomes associated with shifts of 12 or more hours, including burnout, job dissatisfaction, intention to leave and fatigue from a number of studies, mostly from the US.(31)

From the nurse perspective, longer shifts offer a potential to benefit from a compressed working week, with fewer work days and more days off-work, lower commuting costs and increased flexibility. However, previous studies on shift length in Europe did not provide evidence of nurses working a compressed work week, so it is not clear if working 12 h shifts is associated with fewer days at work. (31)

Around a third of employers did express some concern over the impact of longer working hours on the quality of care although this should be interpreted with caution as the view was split and equally there were employers who did not feel this was the case. When it came to completion of requirements, there was also a mixed picture with some employers seeing the benefits of longer working hours while others were less convinced. The same was true when it came to concerns around safety and working longer hours. While the majority did not feel there were any concerns, a quarter of employers were concerned about the impact of working longer hours on the safety of people using care and support services. (36)

Staff participants tended to reflect different views when thinking about the impact of longer working hours in general terms compared with personal experience. There was a split in responses when it came to general quality of care – almost half agreeing that longer working hours did impact on quality and the other half disagreeing. However, when it came to reporting personal experience, staff did not feel that longer working hours had an impact on their practice. Staff did feel however that productivity did drop with longer working hours in general terms and again personally there was some difference of opinion with approximately the same per cent of staff stating that it made no difference or that it was sometimes/always the case. However staff did feel that longer working shifts do impact on their fatigue levels, their irritability and demotivation,(36)

systematic national data on trends in the number of hours worked per day by nurses are lacking, anecdotal reports suggest that hospital staff nurses areworking longer hourswith few breaks and often little time for recovery between shifts.2 Scheduled shifts may be eight, twelve, or even sixteen hours long and may not follow the traditional pattern of day, evening, and night shifts. Although twelve-hour shifts usually start at 7 p.m. and end at 7 a.m., some start at 3 a.m. and end at 3 p.m. Nurses working on specialized units such as surgery, dialysis, and intensive care are often required to be available to work extra hours (on call), in addition to working their regularly scheduled shifts. Twenty four- hour shifts are becoming more common, particularly in emergency rooms and on units where nurses self-schedule.

No state or federal regulations restrict the number of hours a nurse may voluntarily work in twenty-four hours or in a seven-day period.3 Even though state legislatures in approximately nineteen states have considered bans on mandatory overtime for nurses and other health care professionals, bills prohibiting mandatory overtime for nurses have passed only in California, Maine, New Jersey, and Oregon. No measure, either proposed or enacted, addresses how long nurses may work voluntarily.4 The recent Institute of Medicine (IOM) report, Keeping Patients Safe, explicitly recommends that voluntary overtime also be limited.

The well-documented hazards associated with sleep-deprived resident physicians have influenced changes in house staff rotation policies.6 In contrast, although shift-working nurses have been the focus of numerous studies, it is not known if the long hours they work have an adverse effect on patient safety in hospitals .( 4 )

The general purpose of the study:

The aim of the research is to assess the impact of longer working hours on performance’s nurses toward the quality of care and to examine the extent to which hospital nurses’ extended shifts (12 hor more) are associated with burnout, job dissatisfaction, satisfaction with work schedule flexibility and intention to leave current job.

Objective :

To obtain basic data about long shift work facility during the health service.

To identify reasons which have a direct influence on the nurses` health.

To assessment shift timetable.

Research Questions

The specific questions being addressed in this study were:

1- Is there a difference in expressed stress between RNs working night shifts, day shifts, or rotating shifts as indicated by waist-hip-circumference ratios (WHR) ?

2- Is there a difference in the prevalence of stress related health problems between night shift, day shift, and rotating shift RNs as indicated by subjective self-report survey results ?

3- are there more stress associated behaviors apparent in a particular nursing shift as indicated by subjective self-report surveys? (38)


Long shift timetable expose nurses to burnout , sleep , psychosocial hazards and intent to leave workplace



The knowledge base of factors contributing to registered nurses leaving staff nurse positions bas grown substantially in recent years through research studies and publications. Predictors of nurse turnover have included ones’ intent to leave their position for various reasons, including burnout, job satisfaction, organizational commitment and financial status (Lynn & Redman, 2005). Shiftwork, fatigue and recovery time are stressors in their own context, and need to be examined to determine if they contribute to a nurse’s decision to leave his/her position. Neuman Systems Model In the Neuman Systems Model (NSM), dynamic relationships among an individual, stressors, and the environment are depicted. The NSM (Figure I) is utilized within this study to examine and explore relationships among shiftwork, recovery periods and nurses’ intent to leave their positions.

The NSM focuses on how stress and the reactions from stress affect development as well as health maintenance. It uses a systems approach that is focused on the human needs of protection and the relief of reactions from stress. In particular, the NSM focuses on facilitating optimal client system stability among several components including physiology, psychology, socioculturalism, development and spiritual variables. In Neuman’s words, “Ideally the five variables function harmoniously or are stable in relation to internal and external environmental stressor influences” (Neuman & Fawcett,2002, p. 17). According to Neuman, one component should not be isolated. As a single variable influences the whole, likewise, the patterns of the whole influence the single part )Neuman & Fawcett).

Figure 1. Neuman Systems Model


Flexible Line o f Defense

Normal Line o f D efense

Lines o f R esistance



The NSM includes key elements known as the central core, flexible line of defense, normal line of defense, and lines of resistance. The central core consists of basic survival factors and baseline characteristics. Unique features or baseline characteristics may include adequate rest an individual needs before returning to the workplace. When these characteristics are disrupted, system stability is in jeopardy. The individual will attempt to correct the disruption until baseline characteristics are regained (Neuman &Fawcett, 2002).

The flexible line of defense is the first protective layer that prevents stressors from invading the central core or baseline wellness condition. It is dynamic and accordion-like in function; when expanding away from the normal defense line, greater protection is provided. When drawing closer, less protection is available. The flexible line of defense can be rapidly altered in conditions entailing undemutrition, sleep loss, or dehydration (Neuman & Fawcett, 2002).

The NSM also includes the normal line of defense and lines of resistance. Each individual has normal range of responses to the environment, which is considered a wellness/stability state. The normal line of defense is the result of these environmental stressors, as well as previous behavior. It also represents change over time through coping with diverse stressful encounters. As a result, the normal line of defense defines and maintains the stability and integrity of the central core (Neuman & Fawcett, 2002). In addition, lines of resistance serve as protective mechanisms between the normal line of defense and the central core. They serve as stabilizers and protective agents of the central core, and contain information that support the client’s basic needs, ultimately protecting central core integrity. In reference to Neuman’s work, inability of the lines of resistance to guard and protect the core structure could subsequently lead to energy depletion and death (Neuman & Fawcett, 2002).

The NSM provides an explanation of stressors and the body’s reaction. Each person is constantly affected by stressors from the internal and external environment. Stressors, known as tension producing stimuli, may potentially disturb a person’s equilibrium. Neuman identifies three stressors by their source, intrapersonal (arises within the person), interpersonal (arises between persons) and extrapersonal (arises outside the person in the external environment). Neuman further explains that resistance to stressors is provided by a flexible line of defense; a “protective buffer” reflecting the person’s condition, spiritual beliefs, developmental state, cognitive skills, age, and gender

) Neuman & Fawcett, 2002). These particular variables determine the person’s overall resistance to stressors. As stressors interact with an individual and the state of equilibrium, flexible lines of defense are encountered. Stressors, such as shiftwork and recovery time, may impact a nurse’s normal line of defense. When these two variables lead to system instability and core disruption, a nurse may decide to leave his/her position, the organization or the profession. (37)

According to Neuman, if a stressor breaks through the flexible line of defense, it disturbs the individual’s equilibrium, and triggers a reaction. The reaction may lead toward restoration or a decline, depending on internal lines of resistance that attempt to restore balance. The reaction to the stressor and the prognosis are influenced by the number and strength of the stressors affecting the person, the length of time the person is affected, and the meaningfulness of the stressor to the person. Ultimately, Neuman intends for the elient to “retain, attain or maintain optimal system stability” (Neuman & Fawcett, 2002, p. 25). The NSM includes the concepts of primary, secondary and tertiary prevention.

Primary prevention encompasses directing energy to diminish stressors or reinforce the flexible lines of defense. This level of prevention focuses on providing additional protection for the individual’s baseline level of performance. Primary prevention is appropriate before the individual is in contact with a stressor. Objectives of secondary prevention strategies include intervention after the normal lines of defense have been breached. This treatment approach would target the need for additional protection and begin to repair the normal lines of defense to regain optimal system stability. After restoration and repair have occurred, tertiary prevention strategies focus on methods to prevent further stressor penetration and support restoration of one’s level of functioning.

Tertiary prevention accompanies restoration of balance as the individual recovers from stress related causal agents.

The concepts and relationships within the NSM are congruent with the variables of interest under investigation. The central core in this study is nurse retention, as the intent to leave is measured among nurses. The flexible line of defense, normal line of defense and lines of resistance prevent stressor penetration and disruption of the central core. In this research study, stressors are identified as duration of nursing shiftwork and length/adequacy of inter-shift recovery with associated fatigue and sleep deprivation. The less recovery obtained by a nurse, coupled with shiftwork, may contribute to strained lines of resistance, with potential jeopardy to the central core (nurse retention). If stressors penetrate through lines of resistance and damage the central core, nurses may subsequently intend to leave their positions. Overall, these stressors may disturb equilibrium of nurse retention, therefore, consequently increasing nurses’ desire to leave their positions.

Primary prevention is needed before the individual is in contact with such a stressor. An example of primary prevention includes diminishing overtime hours while augmenting recovery time between shifts. Secondary prevention of stressors includes several strategies. Treatment of the stressors may include promoting retention through improving work hours, shift duration, and increasing inter-shift recovery. By augmenting inter-shift recovery, sleep debt and fatigue may subsequently diminish. When treatment occurs and is maintained, the restoration of balance may be achieved through tertiary prevention. (37)

Definition of concepts

shift refer to hours of the day in which a worker or a group of workers is timetable to be in the workplace (kogi, 2001).

Shift work definition varies, from country to country. The US bureau of labor statistics defines as being on shift work if they don’t start work between 07:00 to 09:00 hrs. (konz, 1990). Kogi, (2000) defines shift work as working other than daytime hours, and night work means work performed after 18:00 and before 06:00 hrs. the next day.

Shift organization refer to the allocation and arrangement of shifts to keep the production going for 24 hours (Kroemer, 1992).

Shift schedule refer to the assignment of workers to a particular shift and time allocated to each of the shift pattern (pierce et all,1989).

Circadian rhythm the word comes from Latin ” circa dies” which means “about a day”. Circadian rhythm are partly driven by the internal body clock and partly synchronized to the external world by cues known as Zietgobers (German: ziet, time; Geber, giver (pheasant, 1986).

Biological rhythm refer to any cycle change in the level of a measure or chemical in the body. Biological ryhthem are described physiological processes that take place within the human body (Rodgers et. Al. 1986).

Fatigue is the feeling of abnormal tiredness, lethargy, loss of drive. The word “fatigue” is a term applied to a wide diversity of conditions. (35)

The knowledge base of factors contributing to registered nurses leaving staff nurse positions bas grown substantially in recent years through research studies and publications. Predictors of nurse turnover have included ones’ intent to leave their position for various reasons, including burnout, job satisfaction, organizational commitment and financial status (Lynn & Redman, 2005). Shiftwork, fatigue and recovery time are stressors in their own context, and need to be examined to determine if they contribute to a nurse’s decision to leave his/her position.

Impact on productivity, performance, and safety.

Baltes et al. (1999) concluded that for compressed schedules, regardless of experimental rigor or time since intervention, attitudinal measures were more greatly affected than behavioral outcomes, and supervisory ratings of performance but not actual performance were higher for This document is a research report submitted to the U.S. Department of Justice. This report has not been published by the Department. Opinions or points of view expressed are those of the author(s) and do not necessarily reflect the official position or policies of the U.S. Department of Justice. Police Foundation 9 Impact of Shift Length those on compressed schedules. For example, nurses working 12-hour shifts reported that they had provided better patient care (McGettrick & O‘Neill, 2006) or experienced greater continuity of care with their patients (Campolo, Pugh, Thompson, & Wallace, 1998; Richardson, Dabner, & Curtis, 2003) as compared to their prior 8-hour schedule, even though Stone et al. (2006) reported no differences in patient care among nurses. But even when relying on self-reported measures, some have found negative outcomes associated with CWWs. For example, Burke)2003) found that nurses‘ reports of errors and injuries to patients (e.g., received more complaints from patients‘ families, administered incorrect medication or dosage, etc.) increased when hours of work increased. Importantly, when considering objective data, however, researchers who conducted a recent systematic review concluded that performance deteriorates and injuries increase for those working long hours, especially for very long shifts and when 12-hour shifts are combined with more than 40 hours of work per week (Caruso et al., 2004). Negative impacts of compressed schedules have been documented by Folkard and Tucker (2003) who reported that there was an association between increased work hours and greater industrial accidents and injuries such that accident risk in the twelfth hour of work was more than double that of the first 8 hours. Additionally, Folkard and Lombardi (2004) reported that compared to 8-hour shifts, 10-hour shifts resulted in a 13% increased risk for accidents and injuries, and that rate jumped to 27.5% for 12-hour shifts. However, when considering managers‘ reports, Northrup (1991) found that the managers in a mini-steel plant reported fewer accidents in general for 12-hour shifts, although it is important to note that there were differential accident rates in some areas; for example, the favorable finding was not true in the melt shop. Hence, it appears that when gathering data on performance and productivity, self-reported measures should be interpreted with caution because they may reflect biases associated with shift length preferences for various


In the medical field, compressed workweeks (CWWs) have been associated with negative outcomes. For example, researchers have found reductions in quality of care by nurses (Bernreuter & Sullivan, 1995; Eaton & Gottselig, 1980; Fitzpatrick et al., 1999; Todd, Reid, & Robinson, 1989) and a 7% drop in direct nursing activities (Reid, Robinson, & Todd, 1993) for those working 12-hour compressed schedules. In addition, Jeanmonod and colleagues (2008) noted that more experienced nurses saw fewer patients when working 12-hour shifts than 9-hour shifts. Similarly, researchers examining emergency room physicians found that those working 8- or 9- hour shifts had greater productivity (number of patients seen per hour) compared to those on 12- hour shifts (Hart & Krall, 2007). On the other hand, McClay (2008) did not find decreases in productivity of medical residents on 10- or 12-hour shifts, perhaps due to the smaller gap in shift length. There is also evidence that CWWs are associated with lower cognitive performance (e.g., grammatical reasoning, reaction time, motor abilities) when comparing workers on 12-hour shifts to those on 8-hour shifts (e.g., Duchon, Keran, & Smith, 1994; Rosa & Bonnet, 1993; Rosa & Colligan, 1992). (41)

There is an added complexity when examining the impact of CWWs on performance, namely the point at which performance is measured and the day of the shift. For example, worsened performance has often been present at either the end of the shift (Mitchell &Williamson, 2000), the last day of the 12-hour shift (e.g., Duchon et al., 1994), or both (Rosa & Colligan, 1988). Conversely, while Ugrovics & Wright (1990) also found that those on 12-hour shifts experienced greater fatigue at the end of the shift, they reported it being worst on the first day of the workweek. It is therefore important to examine performance at the end of a shift when considering the impact of longer shifts.(41)

Impact on health.

Researchers have identified greater health problems (Sparks et al., 1997), including mental health (Spurgeon, 2003), when total hours worked weekly exceeded 48. In addition, researchers conducting a recent systematic review of 51 studies and one meta-analysis concluded that there have been increased health complaints for those working very long shifts and when 12-hour shifts are combined with more than 40 hours of work per week (Caruso et al., 2004). They also noted that in two studies start times of 6:00 a.m. for those on 12-hour shifts were associated with greater health complaints, most likely due to circadian cycle dips between 4:00 and 6:00 a.m. (41)

in the most recent systematic review of 40 studies addressing the impact of CWWs on health, researchers found just five prospective cohort studies using control groups and reported that the results of these provide inconclusive evidence on the health effects of CWWs( Petticrew, Bambra, Whitehead, Sowden, & Akers, 2007). For example, in studies comparing 8-and 12-hour shifts in the nursing field, the results have been inconsistent. Some have found that nurses working more than 8 hours per day were significantly more likely to report having a number of health-related problems, including musculoskeletal problems such as pain, numbness, tingling, aching, stiffness, and burning in the neck, shoulders, and back (Lipscomb, Trinkoff, Geiger-Brown, & Brady, 2002); emotional exhaustion and other psychosomatic symptoms such as headaches, poor appetite, lower back pain, faintness or dizziness (Burke, 2003); and greater anxiety before and after shifts (Ruegg, 1987). Others, however, have reported neutral or more positive results associated with compressed schedules. For example, self-reported physical health of nurses revealed no significant group differences based on shift length (Campolo et al., 1998)and Stone et al. (2006) reported that nurses on 12-hour shifts were less emotionally exhausted than those working 8-hour shifts. Similarly, Eaton and Gottselig (1980) found a significant decrease in subjective symptoms such as cardiovascular complaints and general health complaints,

as well as reduced anger-frustration and anxiety-fear states for those on 12- hour compressed schedules in nursing. At the same time, Bambra, Whitehead, Sowden, Akers&,Petticrew (2008) concluded that CWWs may improve work-life balance ―with a low risk of adverse health or organizational effects,‖ (p. 764), noting that better designed studies are needed.

The findings in other industries have also been inconclusive. A number of researchers have not found significant differences between 8- and 12-hour shifts for general health outcomes (e.g., Cunningham, 1989) or psychological or gastrointestinal health (Tucker, Smith, Macdonald, &Folkard, 1998), although the latter found that those on 12-hour shifts had fewer symptoms of cardiovascular disease and improved eating habits (Tucker et al., 1998). Petticrew et al. (2007)reported improvements in mental health associated with CWWs.

Yet, in an 8-year longitudinal study of health outcomes after a change from an 8- to 12- hour shift in a manufacturing setting, Johnson and Sharit (2001) reported initial positive impacts upon digestive problems (such as heartburn, acid stomach, or diarrhea) and psychological issues( such as feelings of depression or irritability, nervousness, or difficulty concentrating) in the first year; however, these effects did not persist in the 8-year follow-up, suggesting a honeymoon effect.

It is also important to note that for many studies where health benefits have been noted for the longer shifts, the findings are tempered by a number of undermining factors. For example, while Mitchell and Williamson (2000) found that workers on 8-hour shifts reported more health complaints than those on 12-hour shifts, they also had a higher proportion of smokers in the 8-hour group. And, when studying 775 workers over two 10-year periods, Lees and Laundry (1989) found that stress-related health issues declined significantly once workers switched to a 12-hour shift. However, they cautioned that these findings may have been the result of increased leisure time and specific to a manufacturing environment.(41)

Impact on quality of life.

Spurgeon (2003) contends that work-hour arrangements can be used to enhance the overall quality of people‘s lives (p. 126). However, research on shift length has not always demonstrated improvements in quality of life for compressed workweeks. Quality of personal life. A number of studies on the impact of CWWs on personal life have demonstrated improvements for those working 12-hour schedules as compared to 8-hour schedules (e.g., Johnson & Sharit, 2001), including more time for family, social life, and domestic duties (Knauth, 2007). In examining issues of work-life balance or work-family conflict, again findings have been mixed. Facer and Wadsworth (2008) reported that municipal workers on a 4-day, 10-hour schedule (4/10s) experienced lower levels of work-family conflict than those working all other shifts; however, the findings with regard to job satisfaction, while in the same direction, were not statistically significant. Whereas the authors of a recent systematic review reported that the introduction of CWWs may ―improve the work-life balance of [workers] with few adverse health or organizational effects‖ (Petticrew et al., 2007, p. 2), others have not obtained significant findings) e.g., Grosswald, 2004; Loudoun, 2008). Furthermore, some have found negative impacts on quality of life for those on CWWs. For example, in a study of pilots in the UK, Bennett (2003) found that those working longer shifts reported a reduction in social activities. Studies with nurses have also sometimes resulted in negative quality of life. For example, nurses on 12-hour shifts in one study reported unfavorable perceptions concerning the benefits of their new shift ,e.g., less time to socialize with family and friends, their inability to maintain a routine exercise schedule, and guilt experienced from feelings of needing to have time away from their patients) Wintle, Pattrin, Crutchfield, Allgeier & Gaston-Johansson, 1995). Similarly, Todd, Robinson, and Reid (1993) examined nurses on compressed schedules who also reported decreased job satisfaction and negative impacts on social and domestic arrangements. Yet, in other nursing studies examining 12-hour compressed schedules, the findings suggest either no differences) e.g., Bernreuter & Sullivan, 1995) or greater job satisfaction (e.g., Stone et al., 2006; Ugrovics & Wright, 1990) as well as improved family and/or social life (e.g., Campolo et al., 1998; Dwyer, Jamieson, Moxham, Austen, & Smith, 2007). (41)

Impact on fatigue and sleep.

Fatigue is defined as the decline in mental and/or physical

performance that results from long working hours, lack of

sleep, poor quality sleep or poorly designed shift work

causing disruption of the internal body clock. (42)

Fatigue. Numerous studies have demonstrated greater levels of fatigue associated with CWWs and some show related increases in risk. Specifically, many studies have linked 12-hour schedules to increased fatigue, especially when compared to 8-hour schedules (e.g., Bendak 2003, Garbarino et al., 2002; Macdonald & Bendak, 2000; Rosa & Colligan, 1992; Smith, Folkard, Tucker, & Macdonald, 1998; White & Beswick, 2003). In a report to the Federal Aviation Administration, researchers noted that workers on 12-hour shifts across a number of industries are considerably more fatigued than those on traditional 8- or 10-hour shifts (Battelle Memorial Institute, 1998). In 1997, Akerstedt reported on findings of a review and noted that―taken together, the results to some extent support the common sense notion of fatigue/sleepiness being a function of the time worked‖ (p. 109), noting that it may be more pronounced if the days off are used for a secondary job. Also, Rosa and Bonnet (1993) found declines in alertness when moving from an 8- to a 12-hour shift, consistent with findings by others (Daniel & Potasova,1989 Hamelin, 1987; Volle et al., 1979). Furthermore, Rogers3 noted that ―… the effects of fatigue can include: difficulty in concentrating, slowed response times, poor decision making and reduced alertness‖ (Cramer, 2007, p. 1). The more important question is whether longer shifts lead to greater fatigue. In an experimental study with train drivers and railway traffic controllers, Härmä et al. (2002) found that a 3-hour increase in shift length for the participants resulted in a 51% increase in the risk for severe sleepiness, and Sallinen et al. (2005) noted that for each additional hour at work, the odds for severe sleepiness increased by 9%. Furthermore, it appears that safety considerations exist even when the increment of time is much smaller. For example, Cruz, Rocco, and Hackworth (2000) studied air traffic controllers and found that those working 9-hour shifts as opposed to 8-hour shifts were significantly more likely to doze off at work (83% versus 60%, χ² = 11.64, p < .01). Similarly, even a slight increase in shift length has been shown to be related to increased fatigue among nurses when comparing those on 8- and 9 -hour shifts (Josten et al., 2003). Nevertheless, some researchers have not found significant differences in fatigue based on shift length (Fields & Loveridge, 1988; Tucker et al., 1996; Washburn, 1991). In fact, in a recent Dr. Naomi Rogers is a sleep expert from the Sleep and Circadian Research Group at the Woolcock Institute of Medical Research.

systematic review of 40 studies on the effects of a CWW on various factors, researchers concluded that CWWs did not seem to have an unfavorable effect on fatigue (Petticrew et al.,2007 ) However, even the authors note that the lack of negative findings could be related to the popularity of CWW among workers, which may have created a biasing effect. And it is important to reemphasize the finding that individuals underestimate their level of fatigue (Rosekind & Schwartz, 1988). (41)

At the same time, there are other issues associated with fatigue that are of particular importance. For example, Ugrovics and Wright (1990) found that those on CWWs reported greater fatigue at the end of the shift, especially on the first day of the workweek, whereas Rosa and Colligan (1988) found that work-related errors increased as the workweek progressed and as the 12-hour day progressed (later in the shift). In sum, while the findings have been mixed, Harrington‘s (1994) observation seems quite fitting: ―Most reviews contend that the 12-hour shift leads to increased fatigue and the potential (at least) for lower productivity and poorer safety records. These findings have led researchers in recent years to caution practitioners about compressed schedules in situations where public safety could be threatened) Armstrong-Stassen, 1998; Knauth, 2007; Macdonald & Bendak, 2000; Rosa, 1995; Scott & Kittaning, 2001). Certainly, policing is one of these public safety domains in which critical incident exposure and risk for potentially devastating consequences are higher than for many other occupations. Sleep quantity and quality. With regard to sleep quantity, many studies across fields have demonstrated that shift work can adversely affect the sleep quality of workers (Bendak, 2003 Scott & Kittaning, 2001; Garbarino et al., 2002). Hence, it is important to examine CWWs across all shifts. While there have been mixed findings in the area of sleep associated with CWWs, Duchon et al. (1997) found that those working 12-hour shifts as compared to 8 -hour shifts had increased levels of sleep and better sleep quality.

Mental health

There is some evidence of increased anxiety and depression in shift workers linked to sleep deprivation, long working hours, chronic fatigue and disruption to family life and/or social support. Having a choice of shift patterns is also an important factor; an RCN study of nurse wellbeing found that working shifts when this is not the preferred pattern of work is associated with poorer psychological wellbeing (RCN, 2005). (42)

Cardiovascular system

Cardiovascular problems such as hypertension and coronary heart disease have been linked to shift work.

Gastrointestinal system

Shift work has been linked with an increased risk of constipation, stomach ulcers and stomach upsets. These are most likely due to disruption of circadian rhythms and digestive patterns as shift workers eat at irregular hours. Increased use of cigarettes, caffeine and other stimulants in night shift workers may also affect the digestive system. Diabetes and obesity have also been linked to shift work. Lack of access to hot, good quality healthy foods during shifts may exacerbate these conditions.

Reproductive health

Shift work, particularly night shift work, may present risks to women of child bearing age. This is thought to be linked to the disruption of the menstrual cycle. Night shift work has also been linked to an increased risk of spontaneous abortion, low birth weight and prematurity (Harrington, 2001). (42)


There has been considerably less research on the impact of shift schedules on overtime and off-duty work. According to Spurgeon (2003), ―There are very few safety studies which are concerned specifically with long hours worked as overtime, as opposed to those which are part of long (e.g., 12-hour) shifts‖ (p. 69). Some, however, have noted decreases in paid overtime (Facer & Wadsworth, 2010), which is consistent with an earlier finding by Foster et al.(1979) who found a 33% reduction in overtime for those on CWWs. While not the primary focus of our study, it is important to note that some researchers have identified other organizational outcomes associated with compressed schedules, such as reduced costs for commuting (e.g., Price, 1981). For example, State of Utah employees surveyed by Facer and Wadsworth (2010) also reported reduced commuting costs for those on 4/10 schedules, a logical finding given fewer days at work and one that is consistent with assertions made by many who promote such schedules. Sundo and Fujii (2005) reported that commute times may be further reduced on CWWs due to non-peak hour commutes. Facer and Wadsworth) 2010) also noted that when the State of Utah examined energy consumption associated with a 10/4 compressed schedule, they noted over a 10% decrease in energy use or an overall statewide reduction of $502,000. Others have reported that the use of CWWs results in decreased leave and absenteeism (Facer & Wadsworth, 2010; Foster et al., 1979). Hung (2006) suggests a potential cost savings with CWWs but it appears to be based on minimizing staff levels. Although this is not based on 24/7 operations and is hypothetical rather than actual, the author has previously documented savings in commuting costs (Hung, 1996). On a more negative note, Sundo and Fujii (2005) examined university employees on CWWs and found that a work-day increase of 2 hours led to a reduction in household activities by 1 hour, sleeping by about 20 minutes, and pre-work preparation time by 30 minutes, suggesting some additional impacts on activity patterns. (41)

Burnout is associated with negative health outcomes for human services workers such as psychologic distress, somatic complaints, and alcohol and drug abuse.40–42 For organizations ,burnout can be costly leading to increased employee tardiness, absenteeism, turnover, decreased performance, and difficulty in recruiting and retaining staff.6,41–45 It seems unlikely that healthcare organizations with high levels of burnout among health professionals could achieve the performance characteristics such as patient-centeredness set forth by the Institute of Medicine as a strategy to improve quality of care, if for no other reason than their difficulty retaining staff. However, only 2 studies exploring the relationship between nurse burnout and patient satisfaction were found in an extensive review of published research. Gravlin46 measured burnout using the MBI and found that depersonalization was negatively related to patient satisfaction with nursing care, but emotional exhaustion and personal accomplishment were not. Leiter et al.45 found negative correlations between nurses’ emotional exhaustion and patient satisfaction with 4 dimensions of hospital care (nurses, doctors, information, and outcomes of care). (100)

.Nursing day shift. 12 hour workdays which consistently occur within 7a.m. to 7 p.m.

• Nursing night shift. 12 hour workdays which consistently occur within 7 p.m. to 7 a.m.

• Nursing rotating shift. Any other work schedule with shifts that fall within 7 a.m. to 7 p.m., and 7 p.m. to 7a.m. (38)

Shift Work Stress

According to the Center for Disease Control (CDC), 25% of American employees view their job as the number one stressor in their life (National Institute for Occupational Safety and Health [NIOSH], 1999). Job stress has been defined by the CDC as “harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the worker.” Job stress “can lead to poor health and even injury” (NIOSH, 1999, p.6). (38)

According to researchers, three main sources of stress are affiliated with shift work: disruption of circadian rhythms, disruption of sleep resulting in fatigue, and disruption of social/family life (Chung & Chung, 2009; ). (38)

circadian rhythm desynchronization (Skipper, Jung, & Coffey, 1990). Alteration of the circadian rhythm is recognized as one of the most certain physiological consequences of shift work (Parikh, Taukari, & Bhattacharya, 2010). The circadian rhythm is a 24 hour cycle regulated by the hypothalamus in response to light and daily routines (Apostolopoulos, Sonmez, Shattell, & Belzer, 2010; Furlan et al., 2000). As a result, researchers have concluded that no shift other than the normal day shift can produce a synchronized circadian rhythm (Clancy & McVicar, 1994). (38)

below is a list of circadian bodily functions that increase by day and decrease by night.

1. Body temperature

2. Heart rate

3. Blood pressure

4. Respiratory rate

5. Adrenaline production

6. Excretion of 17keto-steroids

7. Mental abilities flickers- fusion frequency of eyes

8. Physical capacity (35)

Occupational stress in nursing can have profound consequences not only on the worker themselves, but also on patients (Golubic, Milosevic, Knezevic, & Mustajbegovic, 2009).

Physical, mental, and social health are listed among the resources which can contribute to work ability; all of which can be affected by occupational stress (Golubic et al., 2009). Nurses working night shifts or rotating shifts are noted to have higher stress than their daytime co-workers, ultimately placing them at increased risk for compromised health and work ability (Fuller, 2010). (38)

Personal Safety of the Nurse

Previous research on the stress of nursing shift work has identified a variety of factors which may impede nurses’ personal safety. For example, the American Nurses Association’s (ANA) 2001 Health and Safety Survey found that in a sample of 4,826 nurses, more than one in ten had been in a motor vehicle accident as a result of fatigue from shift work (Slavin, 2008). Abnormal eating behaviors have also been associated with nursing shift work. Nurses’ report eating more to cope with stress, and eating more high sugar foods in order to stay awake (Wong et al., 2010). Conversely, Inoue, Kakehashi, Oomori, and Koizumi (2004) found that in a sample of 538 shift working nurses, more than 10% were working under the stress of hypoglycemia. Chan (2008) discovered that nurses involved in shift work take more sick days. He also reported that in a sample of 163 nurses in shift work, 72% reported insufficient sleep (Chan, 200). Similarly, Fuller (2010) found that rotating and night shift nurses get less hours of sleep than those working day or evening shifts. West, Ahern, Nyrnes, and Kwanten (2007) discovered that shift nurses coping with poor sleep quality are more prone to depression.

In addition, Twarong (2005) found that nurses working specifically rotating shifts have an increased risk of breast cancer after 30 or more years, an increased risk of coronary heart disease after only six years, and an increased occurrence of low birth weight deliveries and miscarriages. (38)

Patient Safety

In addition to the decrease in nursing safety, decreased patient safety has also been related to shift work. A survey of nursing supervisors reported that shift working nurses demonstrated lower job performance (Parikh et al., 2010; Laydak, 1996). Inoue et al. (2004) and Clancy and McVicar (1994) discovered that the majority of nursing errors are made by nurses in the early morning hours, (i.e. during their shift). In fact, Fuller (2010) found that nurses involved in shift work are about twice as likely to make errors or incur job related injuries. (38)

Impact on individual workers and quality of care.

There was some research evidence available which considered the impact of working longer hours on individual workers both in terms of advantages and drawbacks.

From the literature, staff claim the following advantages to working longer shifts include: reductions in costs of childcare, less travel and associated costs, an increased non-working days, increased recovery time each week, improved job satisfaction.

Sources for this evidence include: Estryn-Behar et al. (2012, large-scale European study), Bendak ( 2003review) Bloodworth (2001 primary study), Richardson et al. (2007 primary study), McGettrick and O’Neill (2006 primary study). It would appear that there is some support from a workers perspective for utilising longer working hours and shifts. However, the evidence isn’t just in one direction as Estabrooks et al. (2012) discovered. In terms of job satisfaction they reviewed selected literature and found evidence to both support and reject the hypothesis that working 12 hour shifts increases job satisfaction.

As well as focusing on the advantages, there is evidence from the literature that working longer hours has some disadvantages for a proportion of workers. These include: reduced family contact during working days, difficulty with child care cover, tiredness and stress, extended exposure to workplace hazards, increased health risks.

Sources for this evidence include: Bannai and Tamakoshi 2014 (review), Rodriguez-Jareno et al). 2004 review) Cordova et al. (2012 review), Bendak 2003 (review), McGettrick and O’Neill (2003) primary study Bendak (2003) did find some evidence to link high workload levels to excessive fatigue and decrements in performance and alertness when combined with a 12 hour shift. However, the 12 hour shift in isolation was not the cause of performance changes as other individual factors also play a role.

It is worth noting in more detail findings from the recent review across sectors by Bannai and Tamakoshi (2014). They reviewed the link between longer working hours, defined as more than 40 hours a week or roughly 8 per day, and health outcomes. They did conclude that longer working hours were associated with a depressive state, anxiety, sleep conditions and coronary heart disease. This was supported by data from a large scale European study of nurses (Estryn-Behar et al. 2012) who concluded that staff were taking 12 hour shifts in order to reduce conflicts between home and work. However, this was often at the expense of their own health, with staff burnout highlighted as a concern in their study.

It is worth noting that Ala-Mursula et al. (2006 large scale European study) found that in their study of over 20,000 public sector employees that when workers had control over their daily working hours, the impact of longer hours was reduced and could help protect health and combine the demands of home life with work. However the study also found that long days combined with home domestic work were associated with more sickness absences. Once again, longer working hours cannot be viewed in isolation.

Two studies were identified which focused on feedback from people using care and support services. The first was a small-scale study carried out in the UK, which found that residents in care homes were spending longer in bed than they wanted at night. This was thought to be linked in part to 12 hour shifts, which can limit flexibility in the choice that residents might have. The argument being that there are not enough staff available at the start or end of a night shift.

The second study looked at patient satisfaction in hospital and found some evidence that longer shifts (>13 hours) negatively impacted on patient satisfaction compared to those working shorter shifts (Stimpfel 2012a large scale study). However, this was a study based in the US and may have limited transferability. (105)

Shift Work and the Older Worker

Extended work hours and shift work more profoundly affect older shift workers. In the author’s experience, older workers are less capable of working longer shifts because of the normal physiological changes that occur naturally with aging. They tend to have less stamina, are more prone to chronic illnesses, and may have a complicated home environment that interferes with rest between shifts (i.e., care of older parents, grandchildren, or ill spouses). Aging decreases the speed of circadian adaptation to night work, increases the risk of sleep disorders and negative health effects, and threatens safety in work environments designed for younger employees (Letvak, 2005).

One study suggested that older workers working 12- hour shifts had a higher incidence of absence, sickness, and intoxication (Smith et al., 1998). Younger workers are naturally fatigued at the end of a long workday. However, they are more capable of rebounding after the shift and tend to enjoy this work schedule because it rewards them with more days for social activities.

One study found that satisfaction with working hours and free time increased ) Josten et al., 2003) when working 12-hour shifts. Although older workers may enjoy more days away from work, they tend to prefer shorter shifts when given the choice of the two shifts. (107)

Negative Aspects of Extended Shift Work

Many negative aspects are associated with working extended shifts and shift work, including an increase in accidents while on the job, reduced duration and quality of sleep, and sleepiness, fatigue, and less alertness while performing duties (Smith et al., 1998; van der Hulst, 2003). The worker may experience decreased reaction times and poorer work performance (Scott, Rogers, Hwang, & Zhang, 2006). The worker will have more days off but may feel ill many of those days and experience long-term adverse health effects. Night shift workers may have fewer opportunities to communicate with upper management. Managers often cannot find coverage for extended shifts when a worker is ill or injured ) Knauth, 2007). If workers are in an environment with toxic exposures, they experience more time exposed during extended shifts (Knauth). Workers may also experience difficulties at home with spouses and children because they are away for long periods. Also, these workers are more prone to automobile accidents after extended shifts. Nurses working extended shifts experience the following: the need to reorient after returning from several days away, short time between shifts, lack of continuity of patient care, reduction in quality of patient care, and stress associated with caring for demanding patients and families for more than 8 hours (Richardson et al., 2007(.

Positive Aspects of Extended Shift Work

The positive effects of working extended shifts include the ability to work a second job, more days away from work, and more free time with family and friends. Nurses have more time for leisure and social activities, more time for domestic duties, fewer shift “hangovers,” and less travel time to and from work. Organizations favor extended shifts because managers have to provide staffing for only two shifts instead of three, experience less staff turnover, and have less overtime. Nurses have less pressure to complete assignments in an 8-hour day and better continuity of care (Knauth, 2007; Richardson et al., 2007). (107)


Hospital administration should be concerned for their employees’ and patients’ safety. Changes need to be made by both nurses and hospital organizations (Parikh et al., 2010).(38)

Research indicates that more than 16 hours between shifts is necessary for nurses to obtain at least seven hours of sleep, therefore shorter eight hour shifts are healthier than the popular 12 hour shifts (Parikh et al., 2010; Kuhn,1997). If 12 hour shifts are unavoidable, research indicates that 3:00 a.m. to 3:00 p.m. shifts are less detrimental than 7:00 p.m. to 7:00 a.m. shifts (Parikh et al., 2010(. Moreover, shift working nurses who perceive control over the days and hours they worked report lower stress at work and home. Therefore, self- scheduling is another option that hospitals could afford their workers (Fuller, 2010; Parikh et al., 2010(. Organizations could also provide healthy snack options at night to encourage proper nutrition, whether via cafeterias with extended hours of operation or refrigerated vending machines (Wong et al., 2010). Hospitals could also provide nap time facilities for employees. (38)

Implications for Occupational Health Nurses

The implications of extended duration work shifts for the occupational health nurse are many. When interacting with employees who work extended shifts, occupational health nurses should focus their practice on the health and safety needs of workers under their care. The occupational health nurse should be aware of employees who are no longer able to function effectively during extended duration shifts and assist them in finding alternative working arrangements in the organization. The occupational health nurse should assist with workplace changes that can help the worker succeed (e.g., improving workplace lighting and providing canteen and recreation facilities) (Workers Health Centre, 2005(. Occupational health nurses should be aware that extended shift durations and shift work place employers at increased risk of liability if an accident or adverse event occurs; and they need to be aware of the needs of the employer as well as the needs of the workers. The occupational health nurse should be aware that shift workers are at high risk for disability retirement due to injuries sustained at work and should educate workers about the risks associated with prolonged wakefulness, their susceptibility to sustaining injuries due to fatigue, and ways to prevent these injuries.

Occupational health nurses must possess extensive knowledge of the effects of extended duration shifts and shift work on workers’ physical, mental, and emotional well-being. The occupational health nurse must not only have knowledge of the signs and symptoms of adverse health effects associated with shift work, but also be able to assist workers to change their lives to eliminate risk factors. (107)

Method and procedures


The participants of this study consisted of 100 permanent nurses who were respondents to a questionnaire, all working in general hospital. This group comprised of 50 male nurses and other 50 female nurses. …..nurses worked on night shift and …..nurses worked on day shift. Night shift nurses formed part of the subjects since they rotate to work in both shift, from time to time or when their turn comes to work on night shift. The subject work in all unite of hospital, which are ……., ……., belong to the main unites. Only day nurses working in …. Participant in the study, since theatre …… during the day and closed at night.


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