You are on page 1of 8

Occupational Medicine 2009;59:159–166

Published online 6 March 2009 doi:10.1093/occmed/kqp015

Shiftwork impacts and adaptation among health
care workers
James B. Burch1,2, Jasmine Tom3, Yusheng Zhai1, Lela Criswell3, Edward Leo3 and Kisito Ogoussan1

Background Shiftwork among health care workers impacts upon the safety and health of both employees and

Aims To characterize shiftwork-related attitudes, behaviours, symptoms and coping strategies among health
care workers, two validated questionnaires (the Standard Shiftwork Index and the Pressure Manage-
ment Indicator) were used to identify factors predicting shiftwork adaptation.

Methods Participants (n 5 376, response rate 25%) were grouped according to their work schedule (days,
permanent evenings, rotating days plus evenings, permanent nights or relief and combined shifts).

Downloaded from by guest on March 2, 2011
Indicators of lifestyle, work organization, sleep disruption, health and pressure management among
workers on irregular shifts were compared with participants on day shifts, after adjustment for gender,
age and marital status. Principal components analysis and ordinal logistic regression were used among
irregular shiftworkers to identify factors predicting schedule adaptation.

Results Night and relief/combined shiftworkers reported a greater ability to accommodate irregular schedules
and disrupted sleep, but were also more likely to report work-related impacts than day workers.
Permanent night workers generally reported poorer health, more absenteeism and less job satisfaction
than day workers. Factors associated with optimal work performance or schedule contentment among
shiftworkers included adequate sleep, evening circadian preference, increased age and organizational
satisfaction. Reduced work performance or schedule discontent was associated with sleep/wake
difficulties and poor health.

Conclusions This study confirmed previous research and identified factors that can be targeted for the development
of more effective shiftwork adaptation programmes in a health care setting (sleep timing and duration,
exercise and optimal health and organizational satisfaction).

Key words Circadian rhythm; medical care; nursing; shiftwork.

Introduction a.m. to 5.00 p.m., Monday to Friday working week. Night
workers tend to sleep more poorly and for shorter dura-
The modern world depends on employees who work ir- tions than their counterparts on day shifts [1], which can
regular, round-the-clock schedules in critical work sectors lead to fatigue, daytime sleepiness, reduced alertness and
where the consequences of errors can be severe, such as in impaired job performance [1,2]. In addition to reduced
the public transportation, utility, safety and health care mental and physical well-being, irregular work schedules
occupations. Working irregular shifts (shiftwork) has been can lead to social disruption and familial discord [2,3].
defined as a work schedule outside the customary 8.00 Irregular shifts are an integral feature of the health care
sector since many patients require continuous medical
Department of Epidemiology and Biostatistics, Cancer Prevention and Control
Program, Center for Colon Cancer Research, University of South Carolina,
care and monitoring, and because of personnel shortages,
Columbia, SC 29208, USA. increasing numbers of health care professionals are re-
Dorn Department of Veteran’s Affairs Medical Center, Columbia, SC 29208, quired to work irregular hours. Almost 75% of nurses
USA. in the USA participate in some form of shiftwork and
Department of Environmental and Radiological Health Sciences, Colorado State 18% of nurses work night shifts consistently [4]. Occu-
University, Fort Collins, CO 80523, USA. pational stress due to shiftwork among health care pro-
Correspondence to: James B. Burch, Department of Epidemiology and viders contributes to burnout, reduced work efficiency,
Biostatistics, Cancer Prevention and Control Program, Center for Colon Cancer poor performance, decreased job satisfaction, increased
Research, University of South Carolina, 915 Green Street, Room 228, Columbia,
SC 29208, USA. Tel: 11 803 576 5659; fax: 11 803 576 5624; e-mail: rates of absenteeism and turnover, decreased quality and quantity of care and ultimately to higher health care 

The Author 2009. Published by Oxford University Press on behalf of the Society of Occupational Medicine.
All rights reserved. For Permissions, please email:

Participants were adaptation. in addition to tinuous variables) or the Mantel–Haenszel chi-squared demographic parameters [e. occupational stress [14] was used to acquire information on schedule char. USA). 24-h on. 2011 and on how health care workers adapt to irregular work a question or to quantify personal or work-related factors schedules [3. health and stress. sleep. education and income]. . lower www. per- Methods manent evening shifts (shift started mid to late afternoon and ended by midnight). (pressure from workload. Cary. imaging centre (ultrasound.resourcesystems. re. The impact of working irregular shifts can instrument uses Likert scale responses that are summa- contribute to a range of adverse health outcomes includ. coping strategies. worry. Circadian preference responses were calculated and responses among workers on day (‘definitely a .00 a. relief/combined) were compared to those on day shifts. and pressure management were compared similarly [16]. health be.6]. sleep For continuous variables and Likert scale scores. campus in a department with both day and irregular nights. days. . grouped in one of five work schedule categories as follows: permanent day shifts (work started between 4. shifts using the generalized linear models procedure (con- mation on work. The Pressure Management Indicator (PMI. medical residents) or worked relief positions (on ing).00 p. No personal characterize work organization and attitudes. gender.g. outpatient surgery centre and call) with unpredictable hours that included nights.). . there is a recog. in the relief/combined category had long. age and marital status and lifestyle (47 items). The bles). evenings and days (e. body mass in. alterations in physiological homeostasis. organizational commitment.g. anx- health outcomes are primarily due to unhealthy coping iety/depression. job strain and stress can be either detrimental or beneficial to worker health indicators (job satisfaction. Subjects were asked ei- characteristics that have an adverse impact on health ther to rate their level of preference or agreement with Downloaded from occmed.30 and 5. The objectives of this study were to (e.13].’ and ‘more a . [3. disruption and control. Night work among health care workers is as. an out. shifts using the least significant differences statistic. hours of overtime work. problem focus. .12]. Self-administered questionnaires solicited infor. physical symptoms and strategies (e. rized into 24 subscales characterizing stress inducers ing gastric ulcers. an inpatient mental health facility and a neurodiagnostic Initially. life work bal- desynchronization of circadian rhythms or to intrinsic ance and social support).g. pleted either during work hours or on days off. (e. demographic or lifestyle characteristics among laboratory. race/ethnicity. perma- comprising four campuses: a main hospital campus with nent nights (shift started mid to late afternoon and ended a Level II trauma centre.9–11]. satellite laboratory. age.30 and 9. Consequently.oxfordjournals. cardiovascular disease. least and fatigue (33 items) and general health. health-related symptoms. associated family medicine residency programme. which included those with variable schedules including patient facility that included a walk-in urgent care clinic. sleep amount).’) were combined to form shifts were compared to those on each of the irregular two groups: morning or evening types. days plus evenings (rotating Participants were employed at a regional medical facility schedule that included both previous categories). statistic with Fisher’s exact P-value (categorical varia- dex (BMI). decision latitude. organizational satisfaction.m. Average scores concerning work organization. questionnaires long-term shiftworkers.m.8] computed tomography. variable shifts X-ray. health-related symptoms. Eligible employees were those working on any workers on irregular shifts (evenings. acteristics and attitudes towards work (41 items). NC. The questionnaire was com- haviours. and ended between by guest on March 2. Strategies for coping with irregular work schedules home demands and daily hassles).org) disruption. resilience. . a family practice clinic with an the following morning) and relief or combined shifts. 48-h off). were delivered to individual workplace mail compart- nized need for more research on specific shift-related ments with an introductory letter. magnetic resonance imag. It is still unclear whether shiftwork-related adverse organizational security. and a min- sleep characteristics and social and lifestyle factors imum of 60 min was typically required for completion. impatience. career develop- productive disorders and cancer [7. ment. sleep Standard Shiftwork Index (http://www.160 OCCUPATIONAL MEDICINE costs [5. personal responsibility. days plus evenings. depression.workingtime. long-term alcohol or tobacco use). managerial responsibility. Par- cardiac catheterization facility and a fourth campus with ticipants on day shifts served as the comparison group. chronic exhaustion) and stress moderators (drive. Others breast diagnostic centre. http:// sociated with difficulties performing routine tasks. well-being squares means adjusted for gender. Exploratory factor analysis and logistic regression Data were analysed using the SAS computer program were then used to identify factors predicting shiftwork (SAS Institute. Completed questionnaires were returned anonymously uate how these factors differ among those with irregular in sealed envelopes via drop boxes in several locations schedules compared to those working permanent at each facility. Following university and hospi- susceptibility factors that are more prevalent among tal Institutional Review Board approvals. identifiers were requested. This 120-item rates [7. among health care workers on different shifts and to eval. nights. was used to assess ma- performance ratings or increased accident and injury jor dimensions of occupational stress [15].

BURCH ET AL. and 12% worked relief or combined shifts. transcriptionists (document 0. Type III sums of squares). laboratory technicians. group predictor variables into factors [17]. BMI. respectively). widowed 42 (24) 21 (38) 7 (25) 27 (38) 13 (28) Work status n (%) Full time 130 (75) 39 (71) 16 (57) 51 (70) 31 (67) Part time 31 (18) 14 (25) 9 (32) 20 (27) 9 (20) Other 13 (7) 2 (4) 3 (11) 2 (3) 4 (10) a Mean 6 SEM.05 and **P .$39 999 53 (32) 21 (40) 8 (28) 19 (26) 10 (22) $40 000–$59 999 44 (26) 17 (32) 5 (18) 32 (45)** 15 (33) $$60 000 70 (42) 15 (28) 15 (54) 21 (29) 20 (45) Marital status n (%) Married/live-in partner 132 (76) 34 (62)* 21 (75) 45 (62)* 33 (72) Single. Percentages totalling . 7% worked evenings. secretaries. *P . and ordinal logistic regression was used (to ac. 19% worked permanent nights scores (n 5 24). radiology technologists. Responses to tolerance questions were grouped into preparation from dictated recordings). medical technologists. Posi- with varimax rotation.100% are due to refusals or missing data. in ascending keepers. receptionists. race. commodate three levels of each response) to identify ad. unit assistants. envi- aptation predictors. house- three categories (disagree. B. after ad- ated with schedule adaptation among the irregular justment for other factors in the model (Proc Logistic in shiftworkers (day workers excluded. non-Hispanic 129 (74) 37 (67) 21 (75) 52 (71) 39 (85) Non-Caucasian and Hispanic 45 (26) 18 (33) 7 (25) 21 (29) 7 (15) Education n (%) High school 13 (7) 6 (11) 2 (7) 5 (7) 5 (11) Undergraduate 134 (77) 37 (67) 23 (82) 63 (86) 32 (69) Graduate school 27 (16) 12 (22) 3 (11) 5 (7) 9 (20) Annual income n (%) .01 compared with day shift. Polychoric data trans. gender. 0. Characteristics of study population (n 5 376) Characteristic Permanent days Permanent evenings Rotating days and Permanent nights Relief or combined shifts (n 5 174) (n 5 55) evenings (n 5 28) (n 5 73) with nights (n 5 46) Gender n (%) Female 160 (94) 45 (87) 24 (92) 65 (89) 35 (76)** Male 11 (6) 7 (13) 2 (8) 8 (11) 11 (24) Age (years)a 41 6 1 36 6 2 33 6 2** 38 6 2 39 6 2 Ethnicity Caucasian. patient service representatives. workers. gression was then used to determine factors associated with adaptation. age (39 years) and proportion of females (90%) and formations were performed on non-continuous or by guest on March 2. non-Hispanic Caucasians (90%) among participants Downloaded from occmed. Items with initial eigenvalues . 2011 Likert scale data. n 5 202).oxfordjournals. Tests of proportional odds assumptions were satisfied. Associations between tolerance ronmental service technicians and operating room Table 1. married and worked full time (Table 1). which was defined by responses to three questions: ‘Do you consider your work performance op- Results timal on your current work schedule?’ (optimal perfor- mance). social order). ratios (OR) with 95% confidence intervals (CIs). neutral or agree. Explor. 15% rotated be- to three groups of predictor variables: PMI subscale tween days and evenings. Variables were incorporated into tions held by permanent day or evening workers included a given factor if the absolute value of the loading exceeded nurses. work characteristics (n 5 13) and sleep.5. divorced. 0. The average fatigue or coping items (n 5 17). Most participants were college subjected to a secondary principal components analysis educated. Age. Complete data you adapt to changes in your work schedule?’ (schedule were available for 376 employees: 46% of respondents adaptation).1 that were similar to the entire workforce (40 years and 82% contributed up to 70% of the total model variance were and 91%. clerks. Logistic re. answers and factors were determined by computing odds dividual and work-related factors to identify those associ.: SHIFTWORK ADAPTATION AMONG HEALTH CARE WORKERS 161 A primary objective was to screen a wide variety of in. SAS. J. nursing assistants. Principal components analysis was applied worked day shifts. ‘Are you content with your current work Approximately 1600 anonymous questionnaires were dis- schedule?’ (content with schedule) and ‘How well do tributed and 401 (25%) were returned. atory principal components analysis was first used to education and income were also included in each analysis. .

2 2.0 6 0.01 compared with day shift.9 6 0. Participants of age. shopping).1 6 0. alcoholic or circadian preference for evenings compared to day work- caffeinated beverages.2 3.9* 5.0 6 0.7 6 0.1 4.2** Days. unit assistants.2 3.2 6 0.2 3. The primary motivation for work- and family practice residents and faculty.8 6 0.4 6 0.8 6 0.1 2. Work characteristics and attitudes among health care workers (n 5 376)a Characteristic Permanent Permanent Rotating days and Permanent Relief or combined shifts days (n 5 174) evenings (n 5 55) evenings (n 5 28) nights (n 5 73) with nights (n 5 46) Overtime hours worked per week 2.2* Rotating shifts (nights and days) 1.2** Job requirement 3.7 4.2** 2.2 6 0. Workers in the relief or combined shift category these groups also tended to prefer working nights or un- also included emergency medical technicians.2** 3. BMI or access to different types of ers (Table 3). The distribution ing irregular shifts was higher pay (Table 2). There were more likely to report impacts on sleep and had a greater Downloaded from occmed.5 6 0.1 6 0.0 6 0. workers on eating establishments among irregular shiftworkers com- rotating days plus evenings included: phlebotomists. house cleaning).1 6 0. days.1 4.2 3. responses among workers on days gists. laboratory mestic or work activities.1 6 0.2 3.8 6 0.1 1.1 2.5 6 0.2 3.2 3. do- cardiovascular technicians.0 6 0. (available at Occupational Medicine Online).2 Night shift only 1.1 2.2** Fits sleep schedule 2.05 and **P .7 6 0.9 6 0.2 3.2 3. pared with day workers (data not shown). transcriptionists.2 6 0.2 2.7 6 0.7 6 0.2 3.1 6 0.7 6 0.7 6 0.2 6 0.6 1. However.5 6 0.1 6 0.1 2.2 2.3 6 0.2 2.162 OCCUPATIONAL MEDICINE technicians.7 6 1.5 6 0.2** 3.6 6 0. no night shifts 4.1 1.8 6 0.3 2. ultrasound techni.1 2. . Tables incor- nurse managers and administrative coordinators.4 6 0.1 3.1 3. pared with those on day shifts and that their schedule cians.2** Domestic activitiesb 3.1 2.1 6 0.4 6 0.3 4.1 Reason for current schedule More convenient domestically 3. medical technologists.3 6 0.0 6 0. case managers. 0.5 6 1.3 6 0.1 2.2 Work activities 3. sports 3.g.1 3. schedule-related disruption of social.2** 2.2 6 0.2 6 0. Those working other irregular shifts tended to re- cilities maintenance workers.3 6 1.2 6 0.1 4.2 6 0. Relief shifts were staffed by fa.1 6 0. nurses.2 6 0.6 6 0.3 6 0.2 2. Night workers exhibited the greatest Table 2.3 6 0.1 2.6 6 0.0 6 0.6 6 0.2 1. working evenings.7 6 0.1 6 0.8 4.1** 3.4 6 0. more nators.2 1.0 6 0.2 1.1 current schedule Work schedule does not affect Exercise. clinical technicians.1 1.5 6 0.2 2.5 6 0.7 6 0.7 4.1 1.3 3.6 6 0.1 1. In general. porating all results are provided as supplementary data nent night workers included transcriptionists.5 6 0.3 6 1.0 6 0. nights or relief/combined shifts were fered from those on irregular shifts (Table 1).5 6 0. In addition to those listed above.1 6 0.6 6 0.1 3.2 Non-domestic activitiesc 3.1 6 0.2 Only job available 1.1** 2.2 2.3 6 0.2** 3.1* Social life 3. gender and marital status among day workers dif.1 3. radiological technolo.1** 2.9 6 0.1** outweigh disadvantages Performance is optimal on 4. laboratory technicians.2 3.1 2.2* Advantages of work schedule 4. patient registration clerks.2 Higher pay 2. *P .5 6 0.5 6 0.2 3.9 6 0.8 6 0.2 2. therapists.2 2. Table 2.2** 4.4 6 0. nurse specialists.1 3.5 6 0.4 6 0.8 6 0.oxfordjournals.3 6 0.4 5.5 6 0. port less contentment with their work schedule. sistants.1 3.1 6 0.8 6 0.1 6 0.7 6 0.6 6 0. nurses.1 3. nicians.1 3.8 6 0.8* Years working at present job 8. and shorter job durations com- processors.9 6 0.0 6 0.4 6 0.2 2.1 1.6 6 0. occasional night shifts 1.7 6 0. medical technologists and labour or delivery tech.1** 3.2* Required to switch shifts 2.2 2. nursing as.2 Education/career development 3.2 2. b Activities at home (e.1 3.2 2.9 6 0.2** 3.1 3.2 3.1** 1.6 6 0.1 1.9 6 0.2** 2.1 2.1* 2.1 4.1** with co-workers Can handle night work easily 3.3 6 0. plus evenings tended to be similar to those on permanent clerks and case managers.2** 3. by guest on March 2.2 2.1 2.3 Prefer to work Days.2 6 0.8 6 0. 0.6 6 0.3 6 0. disadvantages outweighed the advantages.2 6 0.0 6 0. Higher scores indicate more agreement with the statement or a stronger preference. paramedics usual times (Table 2). c Non-work activities away from home (e.3 6 0.0* Content with current work schedule 4. nurse shift coordi.7 6 0.0 6 0.3 6 0.0** 5.g.0 6 0.6 6 0.1* a Least squares mean 6 SEM of quantity or score after adjustment for gender. Perma. operating room Work characteristics and attitudes are summarized in technicians. 2011 no differences in consumption of cigarettes.0 6 0. age and marital status.8 6 0.

rela.2 3. age and marital status. organizational satisfaction (job and organi. cohol use).2 6 0.7 0. 2011 Characteristic Permanent Permanent Rotating days Permanent Relief or combined days (n 5 174) evenings (n 5 55) and evenings nights shifts with nights (n 5 28) (n 5 73) (n 5 46) In good health n (%) 166 (95) 50 (91) 28 (100) 66 (90) 41 (89) Number of sick leave days 0.2 Often experience chest pain or tightness 1.6 6 0.01 compared with day shift.2 2.1 3.8 6 0. feel tired all day 2.9 0.8 6 0. perceived stress (ongoing negative pressures). tendencies towards poor health (Table 4).1 6 0.1 6 0. Table 4.9 6 0.2* When waking early. tiredness and circadian .1 1.1 3. family and working days (data not shown).3 6 0.4 6 0.1 3. workload.2 6 1.2 NSAIDs.6 6 0. tors that were subsequently evaluated as potential deter.9 6 1.oxfordjournals.2 1.2 tasks without feeling tired Normally sleep well 3.2* 3.1 Often have heart palpitations by guest on March 2.2 Can miss sleep without much difficulty 2.2 2.0 6 0.2 1.1** 2. B.1 6 0.1* 3.3 2.0 6 0.1 6 0.2 3.1 3.4 6 0.0 6 0.3 6 0. personal re.1 1.2 6 0. Sleep characteristics among health care workers (n 5 376)a Characteristic Permanent Permanent Rotating days Permanent Relief or combined days (n 5 174) evenings and evenings nights (n 5 73) shifts with nights (n 5 55) (n 5 28) (n 5 46) Evening circadian preference n (%) 55 (32) 41 (75)** 8 (29) 49 (68)** 23 (53)** Work schedule does not affect sleep 3.2** Can stay up late to finish 3. *P .7 0.2 2.1 1.9 0. home/work balance and average hours moderate physical activity at work and daily hassles).2 Often have gastrointestinal symptoms 3.2 6 0. job statistically significant differences in mean subscale PMI duration (years at current job and smoking status). achieving the recommended amount).2 3.8 6 0.1** 2. rest (napping. age and marital status. com- scores for workers on irregular shifts compared to those muting (hours spent driving to/from work).7 6 0. partner support and al- The principal components analysis identified 16 fac. health status (number of sick days within 3 months).1 6 1.1 1.6 6 0.5 6 0. diet and perceived work perceptions (organizational security. *P .1 6 0.0 to personal (not family) illness Non-prescription medications n (%) Acetaminophen (paracetamol) 33 (19) 12 (22) 5 (18) 19 (26)* 6 (13) NSAIDs 78 (45) 14 (25)* 7 (25) 28 (38) 20 (43) Caffeine tablets 2 (1) 0 (0) 0 (0) 0 (0) 1 (2) Antacids 28 (16) 8 (15) 6 (21) 21 (29)* 8 (17) Melatonin 4 (2) 0 (0) 1 (4) 4 (5) 1 (2) Sleep aids 16 (9) 3 (5) 1 (4) 9 (12) 2 (4) Physically fit compared to others 3. coping (number of dependents.3 6 0.1 3.1 3. 0. Higher scores indicate more agreement with the statement or a stronger preference. Higher scores indicate more agreement with the statement or a stronger preference. exercise (amount per week and (overtime hours and schedule changes on short notice).6 6 0.0 6 0.0 6 0.2 a Least squares mean 6 SEM of quantity or score after adjustment for gender.0 past 3 months Number of sick days taken due 0.8 6 1. diet and fitness).05 and **P .0 0 6 1. recognition.4 6 0. 0. a Least squares mean 6 SEM of quantity or score after adjustment for gender.1 3.5 6 0.2 2.: SHIFTWORK ADAPTATION AMONG HEALTH CARE WORKERS 163 Table 3.2** 3. 0. 0. BURCH ET AL.0 6 0.01 compared with day shift. J.1 3. tionships. organization climate. minants of schedule adaptation.2* 1.2 6 0. home).4 6 0.2 3.9 6 0.1** 2.4 6 0.5 6 0.2 6 0.3 6 0.1 2.5 6 0.0 0 6 1.1** 3.1 3.2 6 0.5 6 0.1 6 0.2 2. health (self-rated calorie and fat intake. Health status and symptoms among health care workers (n 5 376)a Downloaded from occmed. The factors (and the medications (number of prescriptions and non-steroidal questionnaire items they included) were: work schedule anti-inflammatory use).4 6 0.2* 3.3 3.3 6 0.3 2.05 and **P . managerial role.6 6 0.5 6 0. lifestyle and coping (daily caffeinated beverage intake and sponsibility.8 6 0.2 6 0. There were no zational satisfaction and organizational commitment).2 3.3 6 0. non-steroidal anti-inflammatory drugs.

None of the evaluated factors were associated a Number of sick days within 3 months.9–2. difficulty Health statusa 0. evening chronotype. Content with work schedule related factor were evaluated separately.8) greater organizational satisfaction and commitment (Table 5). Factors previously linked schedule. physical symptoms. mismatches between endogenous circa- with greater impacts on sleep. Strategies that can help achieve this include and attitudes. use sleep medication. Forced sleep at inappropriate times dur- though they were less likely to consider their current ing the circadian cycle may result in shorter sleep duration schedule as advantageous. Discussion d More sleep needed.5 (1. night and relief/combined shiftworkers schedule on their days off. [1. use of sleep aids. which is consistent with previous strategies. good health. fitness and health.0–1. sleep timing (difficulty falling asleep and workers on irregular shifts (n 5 202) waking up early) and mental well-being (state of mind. f non-prescription medication use (antacids and acetamin. an acknowl. To adapt to a new sched- performing night or relief/combined shiftwork were in. 2011 0. c Difficulty falling asleep. shiftwork adaptation. even activity patterns.3) CI: 1. exercise and Organizational satisfactione 1. sleep figured prominently in our results and were consis- ule has fewer impacts and allows for better schedule tent with previous studies among health care workers tolerance.6) edged need for more sleep and a rest-related factor that Organizational satisfactione 1. OR 95% CI mance included increased age. Reduced Age 1. an internal may help optimize performance. Sleep timingc 0.2) Exercisef 1. sleep amount (hours sleep needed and sleep Table 5. Get more weekly exercise. The results also suggest that exercise phase resetting. particularly among night and relief/combined shift.3–0.26. Night workers commonly revert to a daytime In general. gastrointestinal complaints and poorer self-rated fitness. evening circadian preference. which may suggest that this sched. night workers typically realign their endogenous cir- creased pay and work availability. positive mood. paired performance and reduced safety.6 (0. coping napping.8) was associated with sleep aid consumption.4–0. Results among workers on rotating days tics. fewer sick days and con- structs related to sleep and rest (Table 5). tolerate irregular shifts coincided somewhat paradoxically During this time. achieving the recommended amount. When items in the rest. not often tired. Factors that predicted ‘schedule content- Sleep timingc Downloaded from occmed. energy work schedule level and life/work balance). whereas optimal performance was associated with shiftwork tolerance include sleep quality and flexibil.7 (0.6 (0. minimizing domestic noise . lack of tiredness and evening circadian preference (Table 5). b Takes naps. More job or organizational satisfaction. or tended to wake up early were less likely to report op- There is considerable variation in the ability of workers timal performance and were less content with their work to adapt to irregular schedules. The primary motivators for and greater fragmentation [1].1) performance was associated with poor health. consistent with studies locus of control.00–5.3. Factors that were associated with optimal work perfor. demonstrating a beneficial effect of exercise on sleep ruption. ule. social suggests that schedule-related impacts were still occur. im- ring. A perceived ability to cadian phase to coincide with their rest/activity rhythm.5 (0.164 OCCUPATIONAL MEDICINE preference).oxfordjournals. which can disrupt diurnal rest/ reported a greater tolerance to irregular schedules. 95% BMI 1. confidence level. greater circadian rhythm amplitude or more rapid for more sleep.10.6 (0.4–1. with ‘schedule adaptation’ (data not shown). Characteristic or factor Performance optimal on current resilience.9) Sleep amountd 1. more organizational commitment. less domestic dis. Irregular shift- workers. despite a tendency towards greater self-reported workers in our study who had difficulties falling asleep schedule tolerance. interactions) can lead to disturbed sleep/wake timing. more organizational support and the ability to [26]. Factors predicting schedule adaptation among health care medication use).1 (1. ophen or paracetamol).0–2. The results indicate a need to prioritize sleep timing choose one’s schedule [2. with the use of sleep aids and an acknowledged need ity.7 (1.0–2.0) ment’ included a slightly elevated BMI.0–1.9) falling asleep or early wakening and better performance Rest-related itemsb 1.7 (1.14). our analysis identified several factors associated with and evenings were generally similar to those among per. evening circadian OR 95% CI preference was the only item associated with a statistically significant positive performance rating (OR: 2. wake up early. as well as behavioural and lifestyle characteris- research [10]. Factors associated with adequate manent day workers. After screening and and duration in order to optimize job satisfaction and per- consolidating 145 items addressing work organization formance.9) incorporated napping.1 (1. This dian timing and environmental cues (ambient light. e This study found that night workers had more sick days.1– by guest on March 2.18–25].9–2.23]. psychological and social factors.

Uni- issues. • Identification of factors predicting shiftwork toler- Circadian preference (chronotype) is associated with the ance can lead to the development of more effective diurnal timing of numerous psychological and physiolog. Several ules that induce frequent circadian rhythm phase shifts factors related to shiftwork adaptation identified in this facilitate better schedule tolerance [20. or more seniority and greater de. particularly Yvonne Chudd and potential for confounding due to different job or worksite Margo Karsten. tions from the Standard Shiftwork Index and Resource Systems. In this study. This study characterized shiftwork-related attitudes. workers. cor. Department of Veterans participants were similar to those of the entire workforce.23]. no differences were observed between day and Conflicts of interest irregular shifts for the proportion of full. tent with studies indicating that older workers have more job satisfaction [29] and less fatigue. Career response rate. Others (sleep timing and duration. Simon Folkard. strategies for schedule adaptation. by restricting these analyses to that reset circadian phase. tion identified in this study included: sleep timing perature. Winefield AH. domestic . • Modifiable targets for improving shiftwork adapta- subjective arousal and alertness. research. CO. body tem. Lancet analysis was effective for this purpose since it allowed for 2001. UK. Harrogate.358:999–1005. possibly due to a survivor effect [2]. Evening circadian preference was another Downloaded from occmed. Interpretation of this study’s results is limited by the Funding cross-sectional.or part-time None declared. screening and consolidation of many variables into con. By understanding what fac. organizational satisfaction and commit- strategies can be developed to foster optimal health ment) represent modifiable targets for the development and performance. characteristics. 2011 characteristic that was more common among irregular • Shiftwork has been associated with health and shiftworkers in this study. more effective optimal health. Study strengths in. coping strategies and symptoms and explored impacts of their schedule. for allowing use of ques- identification of tolerance predictors. tween day and irregular shifts were eliminated. Health in a 24-h society.: SHIFTWORK ADAPTATION AMONG HEALTH CARE WORKERS 165 and lighting and appropriately timed exposure to factors ysis [17]. demographic characteristics of Development Award from the U. consistent with previous by guest on March 2.30].B. Key points cision latitude. Wales. The long-term health and well-being of workers on ir. melatonin shiftworkers only. job demand or satisfaction. facilitating a parsimonious anal. Acknowledgements respondents. 2. The authors express their gratitude to management and staff of Poudre Valley Hospital justment for potential confounding. potential biases due to differences be- ingestion or exercise. adequate sleep.oxfordjournals. differential response rates among workers on different shifts or other unmeasured factors cannot be excluded.B. Anonymous data collection avoided biased responses to sensitive questions but precluded assessment of non. Rajaratnam SM. Affairs VISN-7 to Dr J. dimensions of self-reported shiftwork tolerance. Arendt J. fatigue and recovery: the contribution of age. Also. Lushington K. Potential reasons for non-response range from simple inconvenience to schedule. blood pressure and secretion of melatonin. of more effective schedule adaptation strategies among creased age with optimal work performance was consis.27] or lead to study (organizational satisfaction. and duration. B. meal timing. Although the (Fort Collins. USA). However. It is unknown whether this may have impacted the versity of Wales Swansea. self-administered design. the association of in. circadian preference and age) were consistent with previous verse health effects [19. organizational secu- rity or satisfaction and personal or managerial responsi- bility. schedule intolerance and ad. Work-related ceptual groups (factors). BURCH ET AL. that intrinsic. It is still unclear whether sched. J. cluded the use of validated instruments and statistical ad. a selection College Research Council of the Colorado State University Col- bias may have been introduced due to the relatively low lege of Veterinary Medicine and Biomedical Sciences.28]. such as bright light. exercise and optimal health and orga- tisol and catecholamines [18. Our results suggest nizational satisfaction and commitment. and was linked with better performance. ical processes including sleep patterns and preferences. environmental and lifestyle factors contrib- uting to circadian preference may be further explored to facilitate better shiftwork tolerance. A primary study objective was to screen a wide References range of individual and work characteristics to identify predictors of shiftwork adaptation. evening rhythm desynchronization.or health-related The authors gratefully acknowledge Prof. regular shifts hinges on their ability to adapt to the behaviours. Also. Principal components 1.23. UK. Winwood PC. for use of the PMI. safety impacts among health care workers. exercise and tors predict shiftwork adaptation. vations [18. health care workers on irregular shifts.

Work Stress 2001. Kuehnle T.42:169–200. J Biol J Occup Environ Med 2004.50:1485–1502. A systematic review of stress and 2008. Chronobiol Int 6. Kaneita Y. among hospital nurses. Gander PH. Does 25. among nurses. gender. Paivi K. Epidemiology of the number of scale points used—an experiment using 5-point.15: 26. job performance. Youngstedt SD. Downloaded from occmed. Elovainio M. Epidemiology of exercise and 3–13. 2007. 17. Parkes K. 5. performance in short shift work schedule. Cooper CL. 3. The Standard Shiftwork Index: a battery of ques. Age. Smith L. How long and how much are nurses now shift in peak melatonin secretion associated with improved working? Am J Nurs 2006. Barton J. Ashkenazi I. Kline CE. 13. Clin J Oncol Nurs Sleep 2004. Reinberg A. Internal desynchronization of cir- 2004. Dawes J. Pisarski A. 12. Rapid Muntaner C.21:68–76. 1145–1150. Extending a model of shift-work tolerance.oxfordjournals.46:1278–1281.36:73–78. 23.23:1363–1377. Edwards D.166 OCCUPATIONAL MEDICINE responsibilities and shiftwork. Rhythms 2006. Fogg LF. Ohida T. Barton J. 2008. Sleep 1997. Crowley by guest on March 2. and socioeconomic factors in adults (30–49 years). 20. Berger AM. 24.56: 7-point and 10-point scales. Kupper LL. Sleep Med Rev 2007.27:1077–1087. ity. Ergonomics standard work schedules: a study of Canadian workers.20:113–119.3:306–321. and job satisfaction Health Psychol 1998. Lobb B.38:635–642. Totterdell P. J Appl Psychol between women who had always done shift work with 1994. Tolerance of shift work. Euchronism. Com- J Adv Nurs 2003. 18. The epidemiology of 10. tion of human circadian rhythms a sign of illness? Chronobiol 15. 28.27:18. Asche SE. Haus E. Folkard S. Job stress. AbuAlRub RF. Roenneberg T. Chro- Causes Control 2006. Trinkoff A. Paine SJ. Jamal M. Impact of shift work on the health mance. J Occup 29. and social sup. and safety of nurses and patients. Burnard P. PWS-Kent Publishing Co. Health. 11.24:553–588. Bøggild H. morningness/eveningness: influence of age.17:489–500. Watson B. Measuring occupational stress: de. velopment of the pressure management indicator. Costa G. Jeppesen HJ. Lipscomb J. cadian dysregulation and potential long-term effects. Analysis and Other Multivariable Methods. 21. those who had never done shift work. Ashkenazi I. Himali U. Travier N. 27. McGrail MJ. plete or partial circadian re-entrainment improves perfor- 7.79:449–454. Yokoyama E. tionnaires for assessing shiftwork-related problems. 2011 Stress Health 2004.25:625–643. Smith L. Boston. J Occup Health Psychol 2002. Spelten E. Ruggiero JS. and mood during night-shift work. J Nurs Scholarsh 19. Williams S. J Adv Nurs 2006.106:60–71. Int 2007. Guilleminault C. Quera-Salva MA. Juda M et al. Crain AL.4:263–288. Factors influencing health of workers and toler. Am Nurse 1995. port among hospital nurses. Int J Mark Res 438–449. Brady B. Kivimaki M. Biological clocks and shift work: cir. Claustrat B et al. Smolensky M.9:4–30. Haus E. Eastman CI. Geiger-Brown J. Work allochronism.7:156–173. Applied Regression ance to shift work. and choice in health service shift workers. cadian rhythms and tolerance to shift work.4:215–221. Lee C. human circadian clock. stress and health of employees on non. J Adv Nurs 2005. Reinberg AE. Suzuki K. and dyschronism: is internal desynchroniza- Stress 1995.11:429–438. stress management interventions for mental health nurses. Theor Issues Ergon Sci 2003. Costa G. Tseng CY.35:254–263. work variables. Booth R. smoking. ethnic- Health and performance factors in health care shift workers. Appl Ergon 2007. Burnout. sleep habits and occupational accidents ments. Do data characteristics change according to the 30. 16. Bohle P. 2006. 22. Gallois C. 1988. Brook C. Hobbs BB. Virtanen M. Uchiyama M. . sleep. turing. Smolensky MH. Cancer Winch S. Muller KE.52:445–453. Sleep Biol Rhythms 2006. Choosing to work at night: a moderating influence shift work lead to poorer health habits? A comparison on individual tolerance to shift work. nobiol Int 2006. Internal locus of control 9. Tamagawa R. alertness.50:61–104. and negative affectivity as predic- 8. RN burnout: the hidden cost of hospital restruc. tor of sleep patterns among shiftworkers in two environ- Daytime sleepiness. MA: 4. Kleinbaum DG. DeMoss C.20: 14. J Nurs Adm 2005.10:465–471.