Shift work and its impact upon nurse performance: current knowledge and research issues

Shift work and its impact upon nurseperformance: current knowledge andresearch issues

Joanne M. Fitzpatrick BSc PhD RGN

Lecturer

Alison E. While BSc MSc PhD RGN RHV Cert. Ed.

Professor of Community Nursing

and Julia D. Roberts BA MA Cert. Ed. RGN RNT

Lecturer, Research in Nursing Studies Section, Florence Nightingale Division

of Nursing and Midwifery, King's College London,

London, England

Accepted for publication 8 December 1997

FITZPATRICK J.M., WHILE A.E. & ROBERTS J.D. (1999) Journal of Advanced Nursing

29(1), 18±27

Shift work and its impact upon nurse performance: current knowledge and

research issues

Previous research investigating shift work and its impact upon the quality of

registered nurse performance and outcomes (including biological, psychosocial

and organizational) is reviewed. The present study, which involved non-

participant observation of staff nurses (n � 34) within their ®rst year of practice

(Part 1 or Part 12 of the United Kingdom Professional Register), is described.

The ®ndings demonstrated support for earlier research which suggested that

1212 hour shifts are associated with less effective performance. This study,

together with previous research, highlights important indicators for the design

and management of future empirical work which is required to investigate the

in¯uence of shift work upon process as well as outcomes for nurses, service

users and the employing organization. This is particularly pertinent in the light

of recent changes in work patterns. The well-being and effectiveness of the

nursing workforce requires enhancement, and the effective management of

shift-work is a key strategy in achieving this.

Key words: shift work, process, outcomes, nursing

INTRODUCTION

Within health care provision, the need for 24-hour nursing

care requires nurses to work shift systems. Health care

management must address the needs of the nursing

workforce in order to maximize the ef®ciency and

effectiveness of care-delivery. Research in the ®eld of

shift work and its in¯uence upon nurses is limited, with

researchers having tended to focus upon different aspects

of shift work, and with con¯icting ®ndings emerging.

Further, the research has been conducted in different

countries, so that differences in the nature of nursing work

within the various health care systems further limits the

generalizability of the ®ndings. It is also likely that

Correspondence: Joanne M. Fitzpatrick, Research in Nursing Studies

Section, Florence Nightingale Division of Nursing and Midwifery, King's

College London, Cornwall House, Waterloo Road, London SE1 8WA,

England.

Journal of Advanced Nursing, 1999, 29(1), 18±27 Experience before and throughout the nursing career

18 Ó 1999 Blackwell Science Ltd

nursing work has changed over time, with greater use of

technology and increased patient turnover requiring

cautious interpretation of earlier research ®ndings.

LITERATURE REVIEW

Variables in¯uencing performance

It is well established that human performance is in¯u-

enced by a variety of extrinsic and intrinsic variables

(McCloskey 1983, Feldt & Brennan 1989). Encompassed

within the former category is the individual's working

environment, which includes factors such as: shift work

(Todd et al. 1989, Skipper et al. 1990); expectations of the

health care institution, reference groups, and own

expectations (Benne & Bennis 1959); the attitudes and

expectations of superiors; the system of work organiza-

tion; quality and amount of work-related communications

(Harrington & Theis 1968); and the nurturing of innova-

tion, expression of individuality and morale (While 1994).

In view of the current interest in working patterns and the

recent European Community Directive on working time

(Institute of Personal Development 1993), it is the impact

of shift work upon nurse performance which is the focus

of this paper.

Previous research investigating shift work

A review of the literature has revealed that shift work has

been examined from a variety of perspectives, including

its in¯uence upon the biological and psychosocial systems

(i.e. outcomes) as well as its impact upon the quality of

performance (i.e. process).

Biological and psychosocial outcomes of shift work

Several studies have investigated biological and psycho-

social outcomes of shift work in general, while other

research has focused upon particular features of shift work

such as rostering and duration of shift.

Biological and psychosocial issues associated withshift work in generalSkipper et al.'s (1990) US questionnaire survey sought to

examine the effect of shift work on the physical and

mental health of a census sample of female nurses

(n � 482, 54á6% response rate) in ®ve hospitals (which

included general and psychiatric settings). The question-

naire consisted of seven scales which focused upon:

physical health; mental depression; family relations;

informal social participation; voluntary organization

participation; job performance; and job-related stress.

Internal consistency testing using Cronbach's alpha coef-

®cient revealed that ®ve of the seven scales reached

Nunally's (1978) criterion of 0á80: mental depression scale

(r � 0á903); family relations scale (r � 0á909); voluntary

organization participation scale (r � 0á828); job

performance scale (r � 0á909); and job-related stress scale

(r � 0á893). The coef®cient alphas for the physical health

scale (r � 0á671) and informal social participation scale

(r � 0á447) were more modest and should be borne in

mind when considering the study ®ndings, as should be

the absence of reported validity testing. While there was

no signi®cant association between shift work and nurses'

physical and mental health, signi®cant associations

emerged between shift work and voluntary organization

participation (P < 0á001) and hours spent in solitary

(P < 0á009), with afternoon nurses participating least in

voluntary organizations and spending the greatest

proportion of time in solitary activities. Similarly, social

isolation was identi®ed as a key problem for nurses

(n � 1087) in a questionnaire survey conducted in the

Netherlands (Bosch & Lange 1987), particularly for those

working weekend and night shifts. The nurse sample

worked in a variety of settings (including general hospi-

tals, psychiatric hospitals and nursing homes for older

adults), but selection of setting and subjects are not

detailed in the published paper.

Details of the impact of shift on job-related stress were

presented in a separate paper by the North American

researchers (Coffey et al. 1988). Using Swiercz's (1983)

tool to measure participants' job-related stress, ®ndings

indicated that the instrument's ®ve sub-scales were

signi®cantly related to shift: inadequate knowledge and

technical skills (P < 0á0046); nature of direct patient care

(P < 0á0012); interpersonal con¯icts (P < 0á0001); physical

working conditions (P < 0á0006); and management of the

unit (P < 0á0001), with nurses working the rotating shift

experiencing greater stress by comparison with those

working ®xed shifts. Further, nurses working rotating

shifts experienced signi®cantly more job-related stress

overall than those working ®xed afternoon, day and night

shifts (P < 0á001) which may in part re¯ect the experience

of working with a variety of different personnel and caring

for different patients at different times of the day. The

authors also suggested that this stress was related in part

to the disruption of circadian rhythms due to irregular

working hours. Lanuza (1976 p. 583) has suggested that

circadian rhythm disturbance due to factors such as shift

rotation may result in: `subjective feelings of fatigue,

imbalances of homeostatic mechanisms and decrements

in performance'. Further, Bosch and Lange (1987) found

that mental stress was not conducive to mental well-being

and contributed to sleeping problems and fatigue. In this

regard, it is interesting that Skipper et al. (1990) found no

signi®cant association between shift work and physical

and mental health.

By contrast with these ®ndings, Barton and Folkard's

(1991) questionnaire study involving a census sample of

psychiatric night nurses (n � 280) in one United King-

Experience before and throughout the nursing career Shift work

Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(1), 18±27 19

dom (UK) hospital reported signi®cantly higher stress

levels (P < 0á05) than the day shift nurses (n � 98). In

particular, temporary night nurses (i.e. permanent day

staff who had to undertake a 12-week period of night duty

every 12±18 months) reported the highest stress levels

(P < 0á05). Healy's (1997) more recent UK study of second

year student nurses (n � 100) undertaking their ®rst

allocation of night work found that the majority of the

sample (73%) were depressed on completion. Night work

also resulted in disturbances to sleep, appetite, energy,

concentration and an increase in psychosomatic com-

plaints such as irritability and feelings of helplessness.

Such ®ndings highlight the issue of self-selection which is

explored later in the paper. Healy's sample was drawn

from ®ve teaching hospitals. No further details of the

sample design are provided in the published paper.

RosteringThe impact of particular features of shift work, for

example rostering, has been investigated to a limited

extent. Contrary to the ®ndings of Skipper and colleagues

(1990), nurses and midwives in Barton's (1995) larger

study (n � 1082), who worked internal rotation and

irregular systems of duty rostering, experienced poorer

psychological health (P < 0á05), chronic fatigue (P < 0á05),

more social and domestic disruption (P < 0á01), more

disrupted sleep (P < 0á01), and more job dissatisfaction,

than those nurses working ¯exible systems (P < 0á01).

These ®ndings concur with the earlier Belgian work of

Verhaegen et al. (1987) which found that rotating nurses

(n � 44) (i.e. nurses who worked morning and afternoon

shifts in a weekly rotating scheme as well as periodic

night shifts) reported more health complaints than both

full time (n � 29) and part-time (n � 94) permanent

night nurses, although only the difference between the

rotating and part-time permanent night nurses was statis-

tically signi®cant (P < 0á01). Similarly, Jamal (1981) found

that nurses (n � 180) working on rotating shifts in two

Quebec hospitals obtained lower scores for mental health,

job satisfaction, social involvement and organization

commitment than nurses (n � 245) working ®xed shifts,

and scored higher on anticipated turnover, absenteeism

and lack of punctuality. In Niedhammer et al.'s (1994)

longitudinal study of the effects of shift work on sleep

among French nurses (n � 469), those who worked

alternating schedules and particularly those who

alternated with night shifts, were more likely to experi-

ence sleep disorders (de®ned by the authors as premature

awakening and dif®culties in getting to sleep) than those

on permanent schedules (P < 0á05). Sleep disorders

predicted nurses' transfer to permanent days, and a

signi®cant decrease in sleep disturbance was subsequent-

ly reported. Similarly, in Gold et al.'s (1992) cross-

sectional study, in the United States of America (USA),

nurses (n � 119) working rotating shifts were 2á8 times as

likely to report poor quality sleep, as were nurses working

day/evening shifts (n � 61).

Such ®ndings suggest that rostering constitutes an

important variable when examining the in¯uence of shift

work on employees. Empirical evidence in this ®eld,

however, is not unequivocal. Barton (1995) found that

regular rostering (a ®xed roster which is repeated when

the cycle of shifts ®nishes) and ¯exible rostering (the duty

roster is drawn up in consulation with individuals) had no

in¯uence upon permanent night nurses. However, Barton

has suggested that this may be due to the fact that many

permanent night nurses have chosen to work the night

shift and are less concerned with the details of their shifts.

In an earlier study (Barton 1994) 81% (n � 194) of

permanent night shift nurses, by comparison with 20%

(n � 69) of rotating shift nurses, had chosen to work their

present shift system. Those who had not chosen to work

their shift system displayed more symptoms of cardiovas-

cular disease and more non- domestic disruption (e.g.

dealing with dental, doctor or banking matters).

Duration of shiftTodd et al.'s (1993) two-phase survey which focused upon

duration of shift, investigated British nurses' satisfaction

with the introduction of a 12-hour shift (n � 234, 73%

response rate for phase 1; and n � 205, 64% response rate

for phase 2). All quali®ed and unquali®ed grades from 10

wards in two hospitals were recruited to the study. The

®ndings revealed overwhelming dissatisfaction among

quali®ed and unquali®ed nursing staff, with the majority

of nurses (83%) indicating a preference for returning to the

8-hour shift system. The 12-hour shift was regarded as

impacting negatively upon nurses' personal lives

(P £ 0á0001) and family commitments (P £ 0á0001), and

participants reported feeling more mentally (P £ 0á0001)

and physically (P £ 0á004) tired. However, the rostering

system was not examined by Todd et al. Similarly, in

Mills et al.'s (1983) earlier US pilot study involving a

census sample of nurses (n � 30) in one surgical inten-

sive care unit working 1212 hour shifts, a signi®cant

association emerged between drowsiness (P < 0á05) and

physical impairment (P < 0á05), and length of shift. A

methodological strength of Mills et al.'s study was that the

majority of the sample (n � 24) had not previously

worked a 1212 hour schedule (Bohle & Tilley 1989). Fatigue

was measured using: the Subjective Symptoms of Fatigue

Checklist (Yoshitake 1978); a reasoning test; and a vital

signs form test. Although not statistically signi®cant,

participants' mental reasoning increased over time, while

performance on a paper and pencil exercise at the ®rst,

sixth and twelfth hours revealed signi®cantly more errors

over time (P < 0á001), with the greatest increase occurring

between the ®rst and sixth hours.

Less effective performance over time may re¯ect the fact

that optimum mental and physical performance coincides

J.M. Fitzpatrick et al.

20 Ó 1999 Blackwell Science Ltd, Journal of Advanced Nursing, 29(1), 18±27

with peak temperature, the latter corresponding with the

time of day when individuals feel most alert; so, for

example, `day-active' people tend to feel at their best

during the middle of their waking period (Lanuza 1976

p. 584). Interestingly, the majority of Mills et al.'s (1983)

nurse sample (96%) preferred not to return to an 8-hour

shift. This may be attributed partly to having more leisure

time away from work, which the nurses regarded as

advantageous. In addition, they reported that their own

performance (P < 0á001) as well as communication within

the practice unit (P < 0á05) had improved signi®cantly

since working the 1212 hour shift.

Self-selection and adaptation

The above studies have identi®ed some of the biological

and psychosocial issues associated with shift work. These

factors impinge upon ef®ciency and effectiveness of

performance, which in turn has implications for the

individual worker, service users and the employing

organization. Similarly, affective, motivational and atten-

tional variables may in¯uence an individual's response to

shift work (Messick 1984, Vries-Griever & Meijman 1987,

Feldt & Brennan 1989). Thus attitude towards and com-

mitment to a particular shift system constitute potentially

confounding variables. Bauer (1993 p. 933) noted that:

Ònly when nurses had the choice of different work

patterns that matched their family responsibilities did

these physiological stress symptoms occur less frequently'.

Further, the results of Alward and Monk's (1990) US

study of nurses who worked 812 hours rotating shifts

(n � 30) (i.e. worked day and night shifts on an irregular

basis) or a ®xed shift schedule (permanent nights)

(n � 30) indicated that the latter perceived the ®rst shift

as requiring less overall effort than did the rotating shift

nurses (P < 0á01). The authors suggested that lifestyle

differences between the two groups rather than biological

factors alone may have accounted for the ®xed shift

group's more favourable response. Thus nurses' self-

selection for permanent night work may have positively

in¯uenced the study ®ndings. Indeed, this is a plausible

explanation for the ®ndings of other empirical work

(e.g. Verhaegen et al. 1987, Todd et al. 1989). In Verhaegen

et al.'s (1987) study investigating Belgian night nurses'

(n � 29) adaptation to different work schedules, the

sample was found to comprise people who were more

evening-oriented, and who demonstrated less rigidity of

sleep pattern and evaluated night work more positively

than nurses working a rotating system. Barton (1994)

reported that tolerance to night work increased when

individuals made the decision to work at night, for

whatever reason.

From an organizational perspective, Findlay's (1994)

pilot system of self-scheduling in a British continuing care

psychiatric ward resulted in: increased morale and job

satisfaction; greater continuity of client care; more effec-

tive use of nursing resources; and ®nancial savings.

Research in other employment spheres has yielded

interesting ®ndings. Reduced absenteeism was also a

reported advantage in Krausz and Freibach's (1983)

comparative study of ¯exible versus non-¯exible working

time for women (n � 277) in an Israeli insurance com-

pany, although comparability of ®ndings is limited due to

the different nature of the work. Work context variables,

which include hours and shifts worked (Redfern 1978),

may also be associated with unplanned absence which has

disruptive effects upon organizational productivity and

continuity of care (Beil-Hildebrand 1996). In this regard, a

proactive management approach is essential. Indeed,

Bosch and Lange (1987), as a result of their large study

of shift work for nurses in the Netherlands, recommended

that adjustment of work patterns to meet workers' needs

was an important measure in enhancing their well-being

as well as improving care delivery.

The Royal College of Nursing (RCN) (1997 p. 2) has

clearly indicated its position regarding shift working,

starting that: àll nurses should have the opportunity and

ability to review their own work patterns and to secure the

working arrangements which best suit their professional

and personal interests and their commitment to patients

care'. This is made more emphatic by the recent European

ruling requiring a 48-hour working week for non-ex-

empted staff (Institute of Personal Development 1993),

which will provide greater need for negotiation between

employers and nurses regarding shift work.

As well as the notation of self-selection, individual

coping strategies may in¯uence adaptability to working

different shift systems. A small British questionnaire

study to examine the effects of shift rotation on nurses'

stress, coping and strain (n � 18), conducted by Milne

and Watkins (1986), revealed that despite the introduction

of internal rotation, stress was perceived as being fairly

constant during the study and was managed by the use of

coping strategies such as: active cognition (drawing upon

past experience); active behaviour (adopting positive

action); and, less positively, àvoidance' (in this study,

trying to reduce tension by an increase in smoking). The

overall result was a signi®cant reduction in reported

strain.

Support for the positive effect of self-selection, how-

ever, is not conclusive. In addition, the issue of adaptation

and coping strategies of nurses working shifts warrants

further in-depth study.

The impact of shift work on quality of performance

The paucity of research investigating the in¯uence of shift

work upon the quality of performance (i.e. process) is

noteworthy. American nurses (n � 463) in Coffey et al.'s

(1988) study self-rated their clinical performance on items



drawn from Schwirian's (1988) instrument. The number of

items selected was not indicated in Coffey et al.'s pub-

lished paper. The items focused upon ®ve practice areas

which achieved acceptable levels of internal consistency:

leadership (r � 0á748); teaching/collaboration (r �0á818); planning/evaluation (r � 0á882); interpersonal

relations/communication (r � 0á795); and professional

development (r � 0á858). Coffey et al. (1988) found a

signi®cant relationship between overall performance and

shift, with self-rated quality of performance being highest

for nurses working the day shift, followed by night,

afternoon and rotating shifts (P < 0á0001). Further, within

the subscales of performance, professional development

was signi®cantly related to the type of shift worked

(P < 0á004), with those working nights rating themselves

signi®cantly higher than their counterparts. Coffey et al.

did not, however, examine actual performance in the

practice setting.

Using a repeated measure design, Todd et al. (1989)

explored the in¯uence of 8- and 12-hour nursing shifts

upon quality of care on wards (n � 10) within two

hospitals in Northern Ireland. Quality of care was mea-

sured using Monitor (Goldstone et al. 1983), 1 month prior

to the introduction of the 12-hour shift and 6 months after

it had been in operation. However, the homogeneity of the

Monitor instrument was found to be low in Redfern et al.'s

(1994) study examining the validity of three popular

generic quality assessment instruments in use in the UK,

and this should be borne in mind when considering Todd

et al.'s (1989) ®ndings. The Wilcoxon matched pairs

signed rank test yielded a signi®cant difference between

total Monitor scores for the wards (P < 0á01), with those

wards operating 8-hour shifts obtaining higher scores.

Eight-hour shift wards also obtained signi®cantly higher

scores for: planning of nursing care (P < 0á05); attending to

patient's psychosocial needs (P < 0á02); and evaluation of

nursing care objectives (P < 0á01).

Todd et al. concluded that the 12-hour shift appeared to

be associated with less effective care. The researchers also

found that with under 12-hour shifts, there was a signi®cant

decrease in the percentage of time spent by students

working with trained nursing staff (P < 0á001), with 46%

of their time being spent working alone (Reid et al. 1991).

This has implications for pre-registration nurse education,

particularly in the UK in view of the establishment of the

diploma registered nurse (RN) programme and the ensuing

demands of large student cohorts upon clinical placement

areas (Jowett et al. 1994, White et al. 1994). Reid et al. (1991)

also found that in contrast to the 8-hour shift, when

approximately 50% of observations of students working

with quali®ed staff possessed an educational content, only

16á3% were coded under the 12-hour shift system

(P < 0á05).

Reduced performance capacity owing to the in¯uence

of extraneous variables such as duration and pattern of

shift may be compensated for by the investment of greater

effort on the part of the individual (Vries-Griever &

Meijman 1987), although impaired performance may still

occur. British transplant co-ordinators (n � 61) in Smi-

ther's (1995) study which examined the pattern and effect

of on-call work, reported sub-optimal performance owing

to tiredness, lack of concentration, stress, intolerance and

irritability. Similar ®ndings have been reported in other

areas of work. For example, Budnick et al.'s (1994) US

study of sleep and alertness among industrial workers

(n � 25) working a 12-hour rotating shift revealed ad-

verse behaviours for individuals on both day and night

shifts. On the day shift, the third and fourth days of the 4-

day rotation were perceived to be less safe, less produc-

tive and demanded more effort. The number of consecu-

tive shifts worked therefore represents an important

variable. (Northcott & Facey 1995). Workers in Budnick

et al.'s (1994) study also reported a variety of adverse

effects including: dif®culty in staying awake; falling

asleep on the job; and being more accident prone on their

journeys home from work. The authors suggested that

reduced alertness and/or fatigue as a consequence of

circadian rhythm desynchronization and sleep loss con-

tributed to these ®ndings.

Within the health service, such ®ndings have poten-

tially serious implications, for example, ineffective in-

formation processing (Vries-Griever & Meijman 1987) and

ineffective psychomotor skills performance (e.g. drug

administration errors). Similarly, Gold et al.'s (1992)

survey of all nurses in one Massachusetts hospital found

that nurses working rotating shifts (n � 119) were twice

as likely to report any accident (including car accidents,

medication errors, on-the-job procedural errors and on-

the-job personal injuries owing to tiredness) or error by

comparison with those working day/evening shifts

(n � 61). In the UK, such ®ndings raise concerns in view

of recent changes to the scope of professional practice

(United Kingdom Central Council for Nursing, Midwifery

and Health Visiting, UKCC 1992), with many registered

nurses now required to take on an extended role as a

means of reducing junior doctors' hours (Bradshaw 1995,

Dowling et al. 1995).

Contrary to more recent work (Todd et al. 1989), Mills

et al.'s (1983) North American study found no signi®cant

differences between the quality of patient care delivered

on wards operating 8 and 1212 hour shift systems. Quality

of patient care was measured using a tool which drew

upon a previously developed instrument (Jelinek et al.

1974) and focused upon: documentation of patient care;

observation of patient care; protection from infection;

special treatments; emotional needs; and special needs.

The authors tested the content validity of the instrument

and also reported high inter-item correlations with

Jelinek et al.'s criteria, although no further details are

presented in the published paper.



Gillespie and Curzio's (1996) small British question-

naire study of all nurses (n � 47) from two medical wards

located in one hospital revealed that 70% (n � 23) of the

nurses working a 12-hour shift system reported increased

opportunity for patient contact and a greater proportion of

time being spent in direct patient care. Having more time

off was also regarded positively by 61% (n � 14), which

contrasted starkly with nurses working the 8-hour shift

who identi®ed less time off between shifts as a major

disadvantage. A majority of those working the 12-hour

shift (64%), however, reported that communication be-

tween colleagues could be further improved. Only 40%

(n � 7) of those working the 8-hour shift identi®ed the

opportunity for increased patient contact to be an advan-

tage. Despite this ®nding, 76% of the nurses (n � 14)

indicated that they had adequate time for direct patient

care. The authors also reported that, regardless of shift

duration, nursing documentation was adequate and that

patients (n � 10) were generally satis®ed with the nur-

sing staff. The ®ndings of Gillespie and Curzio's (1996)

study, however, must be considered with caution in view

of the small sample sizes and poor response rate (48á5%).

THE PRESENT STUDY

The principal aim of the study was to re®ne and validate

the King's Nurse Performance Scale (Fitzpatrick et al.

1997), an empirically derived generic instrument which

permits detailed examination of nurses' practice within

the institutional setting. Contextual information included

data regarding the duration of participants' working shift.

Method

The performance of 34 purposively selected staff nurses

(all were within the ®rst year of practice, Part 1 or Part 12

of the UKCC Professional Register) was observed continu-

ously for 212 hours on three separate occasions (preferably

during a morning, afternoon and evening shift) using the

King's Nurse Performance Scale. Observation was not

conducted during the night shift, since the purpose of the

study was to test the reliability and validity of the

instrument and not to examine which nursing activities

occurred during the periods of day and night. The sample

was recruited from two hospitals within one London

Trust. Ethical approval was obtained from both

participating institutions and informed consent was

gained from all participants. Participants were observed

within the hospital setting on a variety of wards within the

medical, surgical, gynaecology, oncology and cardiology

directorates. For just over half of the observation sessions

(52á5%), participants worked shifts of 8 hours duration or

less, and for the remainder participants worked 12±1212

hour shifts.

Data analysis was conducted on completion of the data

collection process. A total mean performance score and

mean scores for the scale's ®ve practice domains (physical

domain; psychosocial domain; professional domain; com-

munication domain; and care management domain) were

derived for each participating nurse using the formula: the

sum of the weighted totals divided by the total number of

ratings. The Kruskal-Wallis test was used to explore the

relationship between duration of shift and clinical perfor-

mance as well as time of shift (that is, morning, afternoon,

or evening observations) and nurse performance.

Findings

Table 1 indicates that the median total performance score

was 3á6. The median values for each of the practice

domain scores were: `physical domain' 3á4; `psychosocial

domain' 3á7; `professional domain' 3á5; `communication

domain' 3á6; and `care management domain' 3á7. The

minimum scores for the different domains of practice

ranged from 3á2 (care management domain) to 2á6 (psy-

chosocial domain) and the maximum scores for the

domains ranged from 4á0 (psychosocial domain) to 3á9(physical, professional, communication and care manage-

ment domains).

A signi®cant relationship was found between duration

of shift and total performance score (P � 0á04), with those

working a shift of 8 hours or less achieving a higher total

performance score than those working 12±1212 hour shifts

(Table 2). Signi®cant differences were also found between

the two categories of shift in the physical (P � 0á03) and

professional (P � 0á01) domains of practice, with those

Table 1 Total median score and sub-section median scores

Median Minimum Maximum Q1 Q3

Total score 3á6 3á0 3á9 3á4 3á7Physical domain score 3á4 2á7 3á9 3á1 3á6Psychosocial domain score 3á7 2á6 4á0 3á5 3á8Professional domain score 3á5 2á9 3á9 3á2 3á7Communication domain score 3á6 3á0 3á9 3á5 3á8Care management domain score 3á7 3á2 3á9 3á5 3á8



working for 8 hours or less achieving a higher score than

those working 12±1212 hour shifts (Table 2). No signi®cant

differences emerged between the two shift categories in

the psychosocial (P � 0á65), communication (P � 0á09)

and care management (P � 0á40) domains of practice. The

performance data were also explored with time of shift. No

statistically signi®cant relationship emerged between time

of shift and overall nurse performance (H � 4á06, 2 d.f.,

P � 0á132). Further, there were no signi®cant differences

between time of shift and performance in the ®ve practice

domains: physical domain (H � 1á86, 2 d.f., P � 0á394);

psychosocial domain (H � 4á49, 2 d.f., P � 0á106);

professional domain (H � 2á56, 2 d.f., P � 0á279);

communication domain (H � 1á91, 2 d.f., P � 0á385);

and care management domain (H � 5á33, 2 d.f.,

P � 0á070).

Discussion of ®ndings

Concurring with the earlier work of Todd et al. (1989), the

®ndings revealed that the overall clinical performance

score of nurses working an 8-hour shift was signi®cantly

higher than those working 12±1212 hour shifts (P � 0.04).

It is possible that factors associated with longer working

hours, for example mental and physical tiredness, exerted

an inhibitory effect upon nurses' overall performance.

Nurses in earlier studies conducted by Mills et al. (1983)

and Todd et al. (1993) reported greater mental and

physical fatigue when working 12-hour shifts in compar-

ison to the traditional 8-hour shifts. Such problems may be

further compounded by the cumulative effect of working

several 12±1212 hour shifts consecutively. Nurses working

8±812 hour shifts in this study also obtained signi®cantly

higher scores in the physical and professional domains of

practice, which suggests that less effective performance is

associated with 12±1212 hour shifts.

As previously highlighted, the focus of the study was

re®nement and validation of an observation instrument to

measure clinical performance, and not shift work per se.

In this regard, it was not within the remit of the study to

examine important elements of shift work, for example

rostering and number of consecutive days worked. The

small sample size further limits the generalizability of the

study ®ndings. A strength of this small study, however,

was that all participants were within their ®rst year of

practice and therefore at the same level of clinical

experience.

CONCLUSIONS

Shift work has been demonstrated as in¯uencing nurses in

a number of different ways. However, the ®ndings of

empirical studies to date remain equivocal. The impact of

shift pattern upon social functioning has been demon-

strated, with nurses reporting interference with their

social activities as a signi®cant problem (Bosch & Lange

1987, Skipper et al. 1990). Further, in terms of nurse

performance, Coffey et al. (1988) found that overall self-

rated clinical performance was highest for nurses on the

day shift, and that night nurses rated themselves signi®-

cantly higher on professional development.

The in¯uence of rostering has been investigated to a

limited extent. Rotating nurses in Coffey et al.'s (1988)

study experienced greater job-related stress by comparison

Table 2 Total median score and sub-section median scores by duration of shift

Median Minimum Maximum Q1 Q3

Total Score

Shift A (8 hours or <) 3á5 2á6 4á0 3á3 3á7Shift B (12±12� hours) 3á6 2á6 3á9 3á4 3á8

Physical domain score


Psychosocial domain score


Professional domain score


Communication domain score


Care management domain score




with their counterparts. Further, nurses working internal

rotation and irregular systems of duty rostering in Barton's

(1995) study experienced poorer psychological health,

chronic fatigue, more social and domestic disruption,

more disrupted sleep, and more job dissatisfaction than

those working ¯exible systems. Rotating nurses in Ver-

haegen et al.'s (1987) study reported more health com-

plaints than full- and part-time night nurses and nurses

who worked alternating schedules. In particular, those

who alternated with nights were more likely to experience

sleep disorders, according to Niedhammer et al.'s (1994)

study. Such ®ndings underline the potentially negative

impact of rotation and irregular systems of rostering for

nurses' well being, with Seccombe and Smith (1996)

noting an increasing number of nurses working internal

rotation within the health service.

Con¯icting ®ndings have emerged for those studies

which have examined the in¯uence of duration of shift.

The 12-hour shift system has been demonstrated as having

a negative impact upon nurses' personal lives (Todd et al.

1989) and mental and physical ability (Mills et al. 1983,

Todd et al. 1989). Nurses in Todd et al.'s (1989) study

indicated a preference for returning to the 8-hour shift

system. In contrast, the nurse cohort in Mills et al.'s (1983)

and Gillespie and Curzio's (1996) studies preferred to work

the 12-hour shift.

Limited empirical investigation of the impact of shift

duration upon quality of care has been conducted,

and disparity between ®ndings is evident. The work of

Todd et al. (1989) and the present study ®ndings revealed

that quality of care decreased with the 12-hour shift.

Further, Reid et al. (1991) reported that educational

activity also decreased under the 12-hour shift. By

contrast, Mills et al.'s (1983) earlier US study reported

no signi®cant differences between the quality of care

delivered during 8- and 12-hour shifts. Interpretation of

such ®ndings demands caution in view of noted

methodological limitations. Moreover, it is dif®cult to

compare the ®ndings of such studies since different

measures of quality have been utilized and researchers

have focused upon different aspects of shift work. Of

further signi®cance, as Bohle and Tilley (1989) have

identi®ed, many studies examining shift work have

adopted a cross-sectional design, with inadequate use of

control groups. Such issues provide an important focus for

the design and management of future research. A

prospective longitudinal study is required, to examine

the impact of 8- and 12-hour shift systems upon nurses.

Sample design should be considered carefully, with

adequate control for the effects of extraneous variables.

Taking into consideration previous work (Todd et al.

1989, Barton et al. 1993), pattern, rostering, duration of

shift and number of consecutive shifts worked should be

incorporated into the research design. The impact of shift

work upon process (i.e. examination of the quality of care)

as well as outcomes for nurses (e.g. personal and

professional), consumers (e.g. satisfaction, length of stay)

and the organization (e.g. unplanned absenteeism, cost-

effectiveness and productivity) should also be investi-

gated.

In conclusion, every attempt should be made to

enhance the well-being and effectiveness of the nursing

workforce, and it is argued that effective management of

nurses' shift work represents a key strategy for achieving

this. The latter also has the potential to generate positive

outcomes for consumers and for employing organizations.

Research evidence, however, regarding the strengths and

limitations of different systems of shift work remains

ambiguous. In the meantime, Seccombe and Smith's

(1996) large survey of Royal College of Nursing members

(n � 4347; 73% response rate) has revealed the increas-

ing workload stress being experienced by nurses, with

almost three-®fths of the sample claiming to have worked

in excess of their contracted hours in their latest working

week. This survey also noted an increased proportion of

nurses working internal rotation although it was not their

desired working pattern (Seccombe et al. 1993). Twelve-

hour shifts were only worked by a minority of the

respondents, but Seccombe and Smith (1996) noted that

their use had increased from 2% in 1993 to 5% in 1996.

The ®ndings highlight the need for sound research in this

area and the incorporation of relevant ®ndings into

management policy, if the ef®ciency and the effectiveness

of the nursing workforce is to be maximized.

Acknowledgement

The authors were engaged in a study to re®ne and validate

the King's Nurse Performance Scale commissioned by

Miss Wilma MacPherson, Director of Quality and Nursing,

Guy's and St Thomas' Hospitals NHS Trust and assisted

by the generosity of Guy's and St Thomas' Trustees. This

paper draws upon this work.

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