Public Health Briefs
Rotating Shift Work, Sleep, and
Accidents Related to Sleepiness in
Hospital Nurses
Diane R. Gold, MD, MPH, Suzanne Rogacz, MD, Naomi Bock, MD, MS,
Tor D. Tosteson, DSc, Timothy M. Baum, MS, Frank E. Speizer, MD, and
Charles A. Czeisler, PhD, MD
Introduction
Concem for iatrogenic risks to pa-
tients caused by hospital staff experienc-
ing sleep disruption has led to a reexami-
nation of the work schedules and sleep
pattems of physicians."> This cross-sec-
tional study was designed to examine the
impact of work schedule on the sleep
schedule, sleepiness, and accident rates of
female nurses in a Massachusetts hospital.
Methods
A self-administered questionnaire
was distributed June through September
1986 to 878 registered nurses, licensed
practical nurses, and other ancillary staff
in the hospital. The nurse was asked to
record, for the current week, the previous
2 weeks, and the following week, the num-
ber of shifts worked for each work-shift
category (i.e., day, evening, night) at the
hospital and at any other job. The nurse
was also asked, "Does your job involve a
variable work shift? That is, do you work
the day shift sometimes and the night shift
at other times?," which is a National Cen-
ter for Health Statistics (NCHS) question
previously used to identify shift workers
in the US population.5'6 In addition, the
nurse recorded her sleep and wake times
when she worked the day shift, the
evening shift, the night shift, and on days
off.
Information was collected regarding:
quality of sleep; the use of alcohol (per
month), prescription or nonprescription
medication, sleeping aids, or other kinds
of drugs to get to sleep; nodding off at
work (per week); nodding offwhile driving
to or from work in the past year; and ac-
cidents, errors, and "near-miss" acci-
dents in the past year. The variable "any
accident or error" included automobile
accidents, medication errors, on-the-job
procedural errors, and on-the-job per-
sonal injuries that the nurse reported had
occurred because of sleepiness.
We used prior hypotheses based on
physiologic and epidemiologic data re-
garding shift work and circadian disrup-
tion7-17 in the definition of shift categories
(Table 1), which were created from shift
schedules for the current month. Day/
evening shift work was grouped as a single
category because shifting from days to
evenings has not been demonstrated to
disrupt circadian rhythms.
Sleep and wake times were used to
determine whether a nurse obtained "an-
chor sleep'- t least 4 hours of sleep ob-
tained regularly during the same clock
hours every night, both during work days
and days off. Studies by Minors and Wa-
terhouse18 suggest that loss of anchor
sleep may be a surrogate for circadian
rhythm disruption.
The relationship between shift and
outcomes such as sleepiness and acci-
dents was explored first through univari-
ate and then through multivariate analy-
Diane R. Gold, Naomi Bock, Tor D. Tosteson,
Timothy M. Baum, and Frank E. Speizer are
with the Channing Laboratory, and Suzanne
Rogacz and Charles A. Czeisler are with the
Center for Circadian and Sleep Disorders Med-
icine, Department of Medicine, Harvard Med-
ical School, Brigham and Women's Hospital,
Boston.
Requests for reprints should be sent to
Diane R. Gold, MD, MPH, Channing Labora-
tory, Brigham and Women's Hospital, Harvard
Medical School, 180 Longwood Avenue, Bos-
ton, MA 02115.
This paper was submitted to the Journal
March 6, 1991, and accepted with revisions No-
vember 12, 1991.
American Journal of Public Health 1011
 Public Health Briefs

ses, using EPISTAT and SAS (proc pared to day/evening nurses, more rota-
logistic). We attempted to validate the re- tors were 35 years old or younger (77.8%
porting of medication errors, but this was versus 64.5%). By contract, the option of
not possible because written accident re- not rotating and not working the night shift
ports submitted to the hospital's risk man- was dependent on seniority. Conse-
agement office usually documented the quently, whereas 23.7% of rotators and
nursing supervisor rather than the nurse 22.1% of night nurses had worked at the
associated with the error. hospital for 1 year or less, only 9.3% of
day/evening nurses had done so.
Resudt During their work days, rotators and
night nurses reported fewer hours of sleep
Of 878 hospital employees contacted than day/evening nurses (Figure 1). Of the
by the research assistants, 687 (78.3%) re- day/evening nurses, 92.2% obtained an-
turned the questionnaire, 36 (4.1%) re- chor sleep regularly throughout the
fused to participate, and 155 (17.7%) failed month. In contrast, only 6.3% of night
to return the questionnaire. The study co- nurses, none of the rotators, and none of
hort included 593 female registered nurses the nurses in work categories 4 through 6
and 42 female licensed practical nurses. (Table 1) obtained anchor sleep regularly
The mean age of the nurses was 33.9 throughout the month.
years (range 21 to 65 years). When com- Of the nurses from all work categories
who responded "yes" to the NCHS ques-
tion on variable work schedules, only
IIORXDAYS 53.6% experienced anchor sleep disrup-
tion. The group responding "yes" included
49.4% of the day/evening nurses, 94.1% of
as 1 rotators, and 2.9% of night nurses.
In comparison to day/evening nurses,
~~~
70 ~ ~ ~~~~~~~
_ _(= night workers had 1.8 times the odds and
~~~~~~~~~~~~~slsep/24 h rotators had 2.8 times the odds of report-
R
~~~*>5-7 hi ing poor quality sleep (Table 2). Night
E ~
~~ ~ ~ ~ ~ ~ ~ ~
nurses and rotators had twice the odds of
T U >L h using medications to get to sleep.
Nodding off on the night shift oc-
curred at least once per week in 35.3% of
20-
is rotators, 32.4% of night nurses, and 20.7%
a
of day/evening nurses who worked occa-
Day/ might Rotator Occasional sional nights. On the other hand, neither
Evening Nights day/evening nurses nor rotating nurses re-
DAYS OFF ported significant problems with nodding
off on the day or evening shift (rates for
lee nodding off: 2.8% and 2.7%). When com-
pared to day/evening nurses, rotators had
79- 3.9 times the odds and night nurses had
3.6 times the odds of nodding off while
driving to or from work in the preceding
~~~~ fie. year (Table 2).
n Ngt
In univariate analyses two confound-
. Onl .% of dyeni n. e s 5 _o ers of the relationship between shift and
accidents were identified: working at the
Ca Nigt Roao O-casina hospital 1 year or less was associated with
medication errors, and an age of 35 years
or younger predicted automobile near-
miss accidents. The use ofalcohol to get to
Day-o might Rtotator -Occeasional sleep was an independent predictor of all
EvPen ing N1ights categories of accidents.
Ak. Only 396 of day/evo nurse sbM :r 5 hors2 hours on wordays, as ooxnparSed Adjusting for these factors, the odds
to 8% of rotars and 20% of rnght nurses. s tan 50% of nurses fom each of the work of reporting any accident or error were
scedusspt >7 hour*24 how onworkdays. On daysofgreaterthan75% ofnumsesfrcrf twice as high for rotators as for day/
each of Fe work sd e slpt >7 hours/24 hours.
evening nurses (Table 3). Rotators had 2.5
FIGURE 1 -Hours of sleep per 24 hours on workdays and on days off by catory of times the odds of reporting near-miss ac-
work schedule. cidents. After adjustment the effect of ro-
i

1012 American Joumal of Public Health July 1992, Vol. 82, No. 7
 Pubik Health Briefs

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tating on medication errors was reduced sectional study. The hypotheses gener- grants NICHHD 5-RO1-HD20174 and NHLBI
from 2.2 (95% CI: 1.0, 4.9) to 1.8 (Table 3). ated might be best tested through a case- 5-T32-HL07427 (Gold and Tosteson) and
5-MOI-RRO2635 (Rogacz).
control study design, with validation of We would like to acknowledge the enthu-
Disussion reported accidents. siastic participation ofthe hospital nurses, nurs-
The data present a potential di- ing administrators, and Department of Risk
The results of this study are consistent lemma for hospital policymakers. Even if Management and Loss Control personnel in
rotating leads to circadian rhythm disrup- this research project. We are grateful to Mr.
with laboratory investigations that have Joseph Ronda for assistance in data manage-
demonstrated that sleep deprivation and tion and accidents, nurses and hospital ment and to Ms. Darlene Bramble for secre-
misalignment of circadian phase as experi- administrators will have to determine tarial assistance.
enced during rotating shift work are each their priorities: the family responsibilities
associated with frequent lapses of attention of nurses and the staffing requirements of References
hospitals may limit the potential for al- 1. Friedman RC, Bigger JT, Komfield DS.
and increased reaction time, leading to in- The intern and sleep loss. N EngliJ Med
creased error rates on performance tering hospital schedules to improve the 1971;285:201-203.
tasks.7-9 These data also suggest that a health of nurses and the safety of pa- 2. Lurie N, Rank B, Parenti C, Woolley T,
record of a representative work schedule tients.1920 El Snoke W. How do house officers spend
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Reporting bias and selection bias may This research was supported in part by Na- in mood and cognitive performance of
have influenced the findings in this cross- tional Institutes of Health research and training house officers after night duty. Br Med J.

July 1992, Vol. 82, No. 7 American Journal of Public Health 1013
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Psychological Monogr. 1959;73:1-26.
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MC, Zimmerman JC, Knauer RS. Human
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11. Bjerner B, Swensson A. Schichtarbeit and
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Birthweight Distributions in Mexico
City and among US Southwest
Mexican Americans: The Effect
of Altitude
Francis C. Notzon, PhD, Jose Luis Bobadjila, MD, PhD, and
Irma Cona, MPH
Inftdudion
Low birthweight rates (birthweight
<2500 g) vary widely with racial or ethnic
origin.1-3 However, these differences are
attributed primarily to socioeconomic
conditions strongly associated with these
groups,4- leading to the assumption that
the more socioeconomically disadvan-
taged groups are the most likely to have
low birthweight babies. Low socioeco-
nomic status often is associated with fac-
tors known to impair the rate of fetal
growth, such as inadequate nutrition and
smoking.7 Insufficient prenatal care and
other factors also may mediate between
low socioeconomic status and low birth-
weight.4 While the association between
socioeconomic status and ethnicity ap-
pears to hold for US Blacks and Puerto
Ricans, this is not so for Mexican Amer-
icans.
The low birthweight rate for Mexican
Americans is similar to that ofUS Whites,
despite low socioeconomic status and
poor access to prenatal care, and is far
work in full and part-time night nurses. J
PhysioL 1977;267:23P.
16. Adams J, Folkard S, Young M. Coping
strategies used by nurses on night duty.
Ergonomics. 1986;29:185-196.
17. Gadbois C. Women on night shift: interde-
pendence of sleep and off-the-job activities.
In: Reinberg A, Vieux N, Andauer P, eds.
NightandShift Wor*Biological and Social
Aspects. New York, NY: Pergamon Press;
1981:223-227.
18. Minors DS, Waterhouse JM. Anchor sleep
as a synchronizer of rhythms on abnormal
routines. IntJ Chronobiology. 1981;7:165-
188.
19. Czeisler CA, Moore-Ede MC, Coleman
RM. Rotating shift work schedules that dis-
rupt sleep are improved by applying circa-
dian principles. Science. 1982;217:460-463.
20. Knauth P, Rutenfranz J. Development of
criteria for the design ofshiftwork systems.
JHwn ErgoL 1982;11:337-367.
lower than the rate for US Blacks or Pu-
erto Ricans (Table 1). This phenomenon,
descnbed as a "public health enigma," is
not readily explainable.8 Nevertheless,
the low birthweight rate of Mexican
Americans is so dramatically different
from other US minority groups that a ver-
ification of the accuracy of the Mexican-
American rate is warranted.
One approach to verifying these data
is to compare Mexican-American birth-
weights with those found in Mexico. If
Francis C. Notzon is with the National Center
for Health Statistics, Centers for Disease Con-
trol, US Department of Health and Human
Services, Hyattsville, Md. Jose Luis Bobadilla
is with the Population, Health and Nutrition
Division, The World Bank, Washington, DC.
Irma Coria is with the Department of Analysis
and Statistics, National Institute of Perinatol-
ogy, Mexico City, DF, Mexico.
Requests for reprints should be sent to
Francis C. Notzon, PhD, National Center for
Health Statistics, 6525 Belcrest Road, Hyatts-
ville, MD 20782.
This paper was submitted to the Journal
December 4, 1990, and accepted with revisions
November 27, 1991.
July 1992, Vol. 82, No. 7
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