Title The influence of working longer shift on nurses` quality of.docx

Title: The influence of working longer shift on nurses` quality
of care
Introduction:
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)
Background:
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)
Hypothesis:
Long shift timetable expose nurses to burnout , sleep ,
psychosocial hazards and intent to leave workplace
Literature:
CONCEPTUAL FRAMEWORK AND LITERATURE REVIEW
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
Stressor
Flexible Line o f Defense
Normal Line o f D efense
Lines o f R esistance
Central
Core
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
workers.
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)
Overtime.
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)
Implications
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
Subjects
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.
Questionnaire
Weekly Summary: Week ( )
YourName:
Is English your second language? (Yes or No):

You will be expected to write a one-page summary on the
readings and videos for the week. This can be primarily based
on assigned readings and videos, but you should extend it by
discussing what you have learned from the readings and videos.

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