Occupational Medicine 2003;53:83–88

DOI: 10.1093/occmed/kqg045

IN-DEPTH REVIEWS

Shift work and occupational medicine:

an overview
Giovanni Costa

Abstract In modern society, more and more people work during ‘non-standard’ working

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hours, including shift and night work, which are recognized risk factors for health,
safety and social well-being. Suitable preventive and protective measures are
required to mitigate the adverse effects and ensure that the worker can cope
satisfactorily. These are based mainly on the organization of shift schedules
according to ergonomic criteria and on specific medical surveillance. Occupational
medicine has to consider very carefully the several factors (psycho-physiological,
pathological and social) that can influence tolerance and/or maladaptation.
Key words Health; medical surveillance; nightwork; occupational medicine; shift work; work
hygiene; work tolerance.
Received 1 December 2002
Revised 1 January 2002
Accepted 1 February 2003

Introduction rigidly determined by the normal diurnal working day:

Modern society is changing quite rapidly, both in terms
of economic and productive strategies (e.g. new tech-
nologies, market globalization, information processes),
and in terms of the social organization and individual
behaviours.
The ‘24-hour society’ that we have been approaching in
recent years requires a social organization where time
constraints no longer limit human activities: both virtually
(electronically) and practically (industrial and services
organization), people want, and are able, to do everything
at any hour of the day or night, both at a work and at a
social level (leisure activities, transport, communications,
shops, etc.) [1–3].
Consequently, the arrangement of working hours has
become a crucial factor in work organization, and
acquires different values according to the economic and
social consequences that can arise at different periods of
the company and worker’s life.
Not only has the link between work place and working
times been broken (e.g. telework), but also the borders
between working and leisure times are no longer fixed and
Department of Medicine and Public Health, University of Verona, Italy.
Correspondence to: Professor Giovanni Costa, Department of Medicine and
Public Health, University of Verona, Servizio di Sorveglianza Sanitaria,
Strada Le Grazie 8, 37134 Verona, Italy. Tel: +39 045 8027 634; fax: +39 045
8027 633; e-mail: giovanni.costa@univr.it
working hours are extended to evening and night hours,
as well as to the weekend, and hours of duty have become
more and more variable.
According to the most recent European Union (EU)
Survey on Working Conditions [4], carried out in 2000 in
the 15 EU countries, only 24% of the working population
(27% of employed and 8% of self-employed workers) are
now engaged in the so-called ‘normal’ or ‘standard’
daywork, that is between 07.30–8.00 and 17.00–18.00 h
from Monday to Friday.
This means that the vast majority of workers are
engaged on ‘non-standard’ working hours, including shift
and night work, part-time work, weekend work, com-
pressed work week, varying working hours, split shifts,
seasonal work, on-call work, etc.
The increasing diversification of working time patterns
reflects the societal reasons mentioned above, as well as
economic demands and individual preferences. On the
one hand, companies look for a prompt adaptation of
production and service systems to increasing market
demands and technological innovations; while on the
other hand, employees ask for a more balanced pattern
between working and leisure times to improve their
working and social life.
This ‘temporal flexibility’ is one of the milestones of
the present ‘labour flexibility’, and interacts with the

Occupational Medicine, Vol. 53 No. 2

© Society of Occupational Medicine; all rights reserved 83
84 OCCUPATIONAL MEDICINE
other components, such as ‘numerical flexibility’ (dealing
with different types of work contracts and number of
workers involved), ‘productive/geographical flexibility’
(dealing with different ways and sites where work is
performed) and ‘functional flexibility’ (dealing with job
characteristics and organization, e.g. job enrichment, job
rotation, teamwork, autonomous work) [5].
In this context, shift work is the most widely used tool
of working time organization, as it enables round-the-
clock activities not only in relation to rigid technological
conditioning (e.g. chemical and steel industry, power
plants) and necessary social services (e.g. hospitals,
transport, electricity, telecommunications), but also to
support productive and economic choices (e.g. textile,
paper, food, mechanical industry, banking), as well as a
wider use of leisure time (entertainments).
Obviously, one should aim at improving the quality of
human life (more goods, more services, higher salaries,
more leisure activities, etc.) in a society that never stops,
and requires continuous adjustments to its ‘evolution’
and organization.
The primary aim is to find the best possible com-
promise to deal with all the expectations; the main
problem is whether the workers are able to cope with
these changes, and with the new forms of social and work
organization, and to benefit from them and avoid the
drawbacks. If they are unable to do so, then serious
interference with health may well arise.
Shift work: its extension and health
implications
We use the term ‘shift work’ to refer in general to a way of
organizing daily working hours in which different persons
or teams work in succession to cover more than the usual
8 h day, up to and including the whole 24 h.
There are thousands of shift systems that differ widely
with respect to their structure, and in particular: the
presence/absence of night work; the duration of the duty
period (e.g. from 6 to 12 h); the number of workers/crews
who cover the whole working time (two, three, four or
more teams); the interruption of the weekend or on
Sunday (continuous/discontinuous); if workers stay on a
given shift, or alternate between the different shifts
(permanent /rotating); the speed (fast/slow) and the
direction (clockwise/counter-clockwise) of the shift rota-
tion; the start and finish times of the duty periods; and the
regularity/irregularity and length of the shift cycle.
The most recent European statistics [4] show that,
among the various possible shift systems, alternating day
(morning and afternoon) shifts are the most frequently
used, but 18.8% of the workforce are engaged in shift-
work that includes night work, with rather more men
(24%) than women (12%) involved. There are also 7% of
shift workers who work permanently at night.
It is evident that the different shift systems in operation
may have a very different impact on the workers’ health
and well-being.
Most studies and reports refer to shift work that
includes night work, since this is recognized to be a
serious risk factor for workers’ health and interferes with
at least the following four main spheres of human life.
Basic biological functions
Night work causes a mismatch between the endogenous
circadian timing system and the environmental syn-
chronizers (the light/dark cycle in particular), with
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consequent disturbances of the normal circadian rhythms
of psycho-physiological functions, beginning with the
sleep/wake rhythm [6,7].
The change from day to late evening and night work
compels the worker to modify his normal ‘activity–rest’
cycle, forcing him/her to adjust his body functions to the
duty periods. This involves a progressive phase shift of
circadian rhythms across the successive night shifts, but a
complete inversion is never reached, except in the very
rare cases of permanent night workers who maintain an
inverted sleep/wake cycle on their days off. In most cases,
the human body is exposed to continuous stress from
attempts to adjust as quickly as possible to the varying
working hours, while at the same time being invariably
frustrated by the continuous shift rotation.
Consequently people suffer from so-called ‘jet lag’ or,
more precisely, ‘shift-lag’ syndrome, which is character-
ized by feelings of fatigue, sleepiness, insomnia, disorien-
tation, digestive troubles, irritability, poorer mental agility
and reduced performance efficiency.
Sleep is the main complaint of shift workers, as sleep
length and quality can change considerably according
to the variable retiring and rising times. The review by
Åkerstedt [8] in this issue highlights the main practical
aspects of this fundamental point, showing how sleep and
sleepiness vary across the different shifts and in relation to
duty hours, shift schedules, individual strategies (e.g.
napping) and behaviours; and the consequences for the
shift workers’ psycho-physical homeostatic and perform-
ance efficiency.
Work ability
Sleepiness, sleep disturbances, chronic fatigue and
oscillatory fluctuations of alertness and vigilance can be
important contributing factors to ‘human error’, and
consequent work accidents and injuries.
This is documented in many groups of shift workers,
not only those on night shifts but also those on day shifts,
as well as in relation to duty hours, successive shifts and
prolonged duty periods [9].
The sometimes contrasting findings of the epi-
demiological enquiries on work accidents have to be

considered in the light of the interaction between
chronobiological and organizational factors, such as
environmental conditions (e.g. lighting), job content,
fluctuations in workload, time pressure, working hours
scheduling, the number of workers and supervision levels
[10].
The review by Folkard and Tucker [11] in this issue
points to the temporal interference and interactions
between human capabilities, job demands and working
hours, and the potential consequences for both safety and
productivity. From their review, it is evident that a clear
understanding of the underlying mechanisms and factors
involved can help us to cope properly with these crucial
aspects, and to minimize the possible risks and maximize
the benefits for both the workers and their employers.
Social relationships
People engaged in shift- and night work are frequently
out of phase with society, and can face greater difficulties
in their social lives because most family and social activ-
ities are arranged according to the day-oriented rhythms
of the general population. Consequently, shift work can
lead to social marginalization due to the mismatch
between the shift workers’ time budgets (working hours,
commuting and leisure times) and the complex organ-
ization of social activities [12–14].
Shift work may also interfere with the co-ordination of
family timetables, depending on the family composition
(i.e. number and age of children, cohabiting persons),
personal duties (i.e. school, housework) and the avail-
ability of community services (i.e. shop hours and
transportation). ‘Time pressure’ is a constant problem for
those who have high family burdens or complementary
duties, and this can have a negative influence on marital
relationships, parental roles and the children’s education.
Such work/non-work complaints are often more fre-
quent than those related to the biological problems, are
also often the main cause of maladaptation to shift work
and may have a clear influence on the development of
psychosomatic disorders.
Psycho-physical health conditions
In the short term, a deterioration in health is mainly
manifested in sleeping troubles, digestive disturbances
and psychological symptoms (anxiety, irritability). In the
longer term, it may be reflected in more severe disorders
that can lead to an increased morbidity and absenteeism,
with a consequent high economic and social cost both for
the individual and for society.
The review in this issue by Knutsson [15] focuses on
the epidemiological evidence for the association between
shift work and health disorders, in particular gastro-
intestinal and cardiovascular diseases, as well as the
effects on pregnancy.
G. COSTA: SHIFT WORK AND OCCUPATIONAL MEDICINE 85
It should also be taken into account that shift work
can influence the risk of intoxication by chemical sub-
stances due both to the circadian fluctuation in biological
susceptibility to xenobiotics, and to the desynchronization
of the mechanisms of detoxification [16], as was shown
dramatically by the Bhopal disaster [17]. This needs to
be considered in the process of risk assessment with
reference both to environmental threshold limit values
and to biological exposure indices, as has been suggested
for prolonged 12 h shifts [18].
Trends and considerations of the
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outcomes
Reports on the impact of shift work on health and
well-being have shown a progressive increase and
evolution over the years [19–21]. Until the mid-1970s,
most studies pointed to the occurrence of health
disorders, mainly relating to sleep, digestive and mental
problems. In more recent years, most studies have
reported troubles in psychological and social well-being,
performance efficiency and increased stress levels. This
may be related to many intervening factors, in particular:
(i) working conditions have improved (particularly in
the industrialized countries); (ii) shift workers are either
more ‘resistant’ (better living conditions in general) or
more ‘self-selected’ (healthy worker effect); and (iii) the
more severe health disorders masked the minor ones in
the past, and now health disorders are identified at earlier
stages. This latter point may also reflect on the higher
attention paid to shift work by occupational health
physicians.
However, it should be taken into account that many
confounding factors can influence the outcomes, which
sometimes show conflicting results. First, incidence or
prevalence data can differ widely depending on the size,
work sector, time period, and composition of the groups,
and in particular in relation to the proportion of more
vulnerable people, e.g. older workers and women. It is
also worth noting that most studies are cross-sectional,
and that their results may reflect a relevant ‘healthy
worker effect’.
Secondly, the methods used may differ significantly
depending on the aims of the investigators (e.g.
physicians, ergonomists, psychologists, sociologists,
epidemiologists) and the type of data recorded (e.g.
questionnaires, medical examinations, instrumental tests,
insurance data). Furthermore, in many studies, the
definition of ‘shift work’ is quite generic, often without
any distinction concerning either the amount of night
work or the type of shift schedule.
Thirdly, health perceptions can vary across cultural,
historical, social and individual conditions. Some authors
have emphasized differences between shift and day
workers in reporting complaints and troubles (and related
86 OCCUPATIONAL MEDICINE
absenteeism); shift workers, may often accept them as
part of the job, while day workers are more likely to
consider them worthy of medical control. On the other
hand, sometimes shift workers do not report their health
troubles completely, or even deny them, because they are
more afraid of losing the economic benefits associated
with shift and night work.
Finally, as medical surveillance extends and improves,
so also does the possibility of identifying shift work-
related disorders, and hence their prevalence, which can
also be significantly influenced by their epidemiological
trend in the general population (e.g. peptic ulcer and
cardiovascular diseases).
Tolerance to shift work: a complex and
open question
It should be recognized that there is a high inter-
individual variability in tolerance to shift work. Many
factors concerning both the individual characteristics and
the social conditions can interact with working
conditions, and influence both short-term adjustment
and long-term adaptation [22–24].
Ageing may be associated with a progressive intol-
erance to shift work due to reduced psycho-physical
fitness, the decreased restorative properties of sleep, and a
higher proneness to the internal desynchronization of
circadian rhythms. On the other hand, younger people
can find it difficult to adapt to night work either because
they are more sensitive to acute sleep loss, or because
it hampers their possibility of participating in, and
integrating with, social groups.
In addition, some personality traits and behaviours
(e.g. morningness, neuroticism, rigid sleeping habits and
difficulty in overcoming drowsiness, proneness to internal
desynchronization) have been reported to be associated
with more difficulties in coping with irregular work
schedules.
In contrast, good physical fitness and proper sleep
hygiene can favour tolerance to shift work, as they can
increase performance efficiency, lessen fatigue and
improve recovery mechanisms [25]. In addition, ‘com-
mitment’ to shift work, as in the case of workers willing
and able to adapt their daily habits and activities to their
irregular working hours, seems to be an important
determinant of tolerance [26].
As Knutsson reports in this issue [15], it is also well
documented that shift work may have some specific
adverse effects on women’s health and reproductive func-
tions. Further, women shift workers (and in particular
those married with small children) can have more
difficulties in combining their irregular working schedules
with their additional domestic duties, and thus suffer
more from sleep problems and chronic fatigue than their
male colleagues [27–29]. This supports the view that
women shift workers, without being discriminated against
in terms of parity, should have more protection in the
form of exemption from night work when pregnant and
the possibility of transferring to day work when their
children are young. This has been stated in many inter-
national directives, national legislations and collective
agreements.
However, it is not yet completely clear to what extent
personal characteristics influence long-term tolerance to
night work and hence whether they can be used as
possible predictors of such tolerance. Severe troubles
related to the perturbation of circadian rhythms and sleep
are usually the main cause of intolerance during the first
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years of shift work, whereas long-term intolerance is more
related to other work and social conditions. Both factors
influence the process of self-selection that occurs among
these workers and may sometimes mask the results of
epidemiological inquiries.
On the other hand, shift work may be well accepted
(or even chosen) by those people who are more able or
willing to use daytime hours or off-duty periods to comply
with their personal needs and preferences, such as study-
ing, ‘moonlighting’ or solitary hobbies. For this reason,
even some of the most demanding shift systems (e.g. fast
backward rotation with a double shift in a single day) are
often preferred by some groups of shift workers, despite
their clear negative impact on circadian rhythms and
sleep.
Moreover, proper support from an individual’s family
and friends at home, as well as from their co-workers and
supervisors at work, has been proved to enhance both
adaptability and tolerance [14,30]. Further, a shift work
tradition within a community may significantly favour
tolerance since it assists in the combining of the organ-
ization of social life with work timetables [31,32].
In contrast, many surveys in developing countries have
shown that less favourable living and social conditions,
which are often connected with both poor working con-
ditions and long working hours, may aggravate the impact
of shift and night work on health [33–36].
Some practical implications for the
health surveillance of shift workers
Some international directives have recently stressed the
need for the careful organization of shift and night work
and the protection of shift workers’ health: in particular,
the ILO Code of Practice on Working Time [37] and
Convention No. 171 on night work [38], and European
Directive No. 93/104/EC concerning certain aspects of
the organization of working time [39], which has been
implemented by national legislation.
Occupational health physicians therefore have a duty
to protect the workers’ health from this occupational risk
factor, and the responsibility to evaluate their fitness for

shift or night work, with obvious implications for both
individual life and work organization.
Consequently, medical evaluation, both at an indi-
vidual and at a group level, must be linked to a careful job
analysis, paying particular attention to the organization
of the shift schedules, in order to take into account the
psycho-social constraints. In fact, it would appear to be
unreasonable and uneconomic to define a plan for the
medical surveillance of people obliged to work on an
unfavourable shift system, or to declare a person ‘unfit’
for a ‘bad’ shift system.
Knauth and Hornberger [40] in this issue skilfully
illustrate the ergonomic criteria that should be followed
for the better design of shift schedules, and what other
compensatory measures may be adopted in order to avoid
or limit the adverse effects on health and well-being. It has
to be emphasized that ‘there is no one best shift system’
suitable for all workplaces, but each shift system should
be tailored to the specific job demands and personal and
social conditions of the workers involved. This implies a
careful strategy for the arrangement of shift systems that
requires the participation of the workers in the whole
process of designing and implementing their shift
schedules. This is of paramount importance, not only
to take account of their direct experience of the problems,
but also to promote the right motivation to accept the
choices and, consequently, to put into action the correct
counter-measures.
Thus, occupational health physicians can give valuable
help and support both to employers in planning the best
possible shift schedule, and to employees in adopting the
most appropriate personal coping strategies [8,40–44]. In
this way, almost any worker can cope with shift and night
work without significant perturbations of their health and
social life.
However, according to the epidemiological evidence
reported by Knutsson [15], there are some health
disorders that may represent, at least in principle, an
absolute or relative contraindication to night and shift
work, and thus require a temporary or permanent assign-
ment or transfer to day work [45–48]. They deal in
particular with: (i) chronic sleep disturbances; (ii) severe
gastrointestinal diseases; (iii) ischaemic heart disease and
severe hypertension; (iv) insulin-dependent diabetes;
(v) thyroid and suprarenal pathologies; (vi) epilepsy;
(vii) chronic anxiety and depression; (viii) chronic renal
impairment; (ix) malignant tumours; and (x) pregnancy.
The complexity of the problem requires careful
attention from occupational health physicians in order
to avoid a risky attitude towards an acritical selection
of many workers that sometimes can lead to some
discrimination. In fact, it cannot be simply assumed that
the removal of such risk factors will, by itself, be
automatically and totally beneficial to the worker’s health.
It must be recognized that most troubles and disorders
G. COSTA: SHIFT WORK AND OCCUPATIONAL MEDICINE 87
complained of by shift workers pertain to the psycho-
somatic domain and reflect a multifactorial origin, related
to family heritage, lifestyles, general social conditions and
other occupational risks, as well as intervening illnesses.
Consequently, maladaptation and intolerance to shift-
and night work are the result of complex interactions,
which can act differently on each worker both in terms of
severity and timing of manifestation during the working
life [49].
Furthermore, advances in clinical diagnosis, pharma-
cology and rehabilitation now offer better possibilities
for the treatment of some diseases (e.g. peptic ulcer,
hypertension, ischaemic heart diseases, metabolic and
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hormonal disorders), and may therefore permit some
workers to remain on shift work permanently if their
transfer to day work would be problematic due to other
risk factors or to personal resistance to changing their job.
Periodic checks are important tools aimed at detect-
ing early signs of difficulty in adjustment or intolerance
that may require prompt intervention both at the organ-
izational and the individual level. The periodicity of the
health checks should be set in relation to the various
factors related to both working conditions (e.g. shift
rotas, combined risk factors) and individual character-
istics (e.g. age, health). As a general guideline, it appears
advisable to plan a second health check during the first
year of shift or night work (which is crucial for adaptation
and coping), and successive health checks at least every
3 years for those under 45 years of age and every 2 years
for those over 45.
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