Working hour characteristics and schedules among nurses in three Nordic countries - a comparative study using payroll data

Remote work - the new normal needs more research

One of the recent global crises has been the COVID-19 pandemic, drastically changing how we work in expert positions or otherwise do work that can be performed using mobile devices. This change has been seen in many studies since the onset of the pandemic. In the Scandinavian Journal of Work, Environment & Health, papers about remote work (alternative search terms telework, hybrid work) have increased from zero, before 2021, to four [see eg,(1–4)]. However, the increase is even more clear in PubMed-indexed papers, where the number of articles was 1–10 per year from 1990 to 2019, 134 in 2020, and 346–470 per year in 2021–2023. However, despite this urgent interest in this topic (5, 6), we still have some knowledge gaps. The sweet child has many names Although remote work has existed for decades (7), it has many names. As indicated above, terminology that has been used in the literature varies, such as telework, work from home, and hybrid work, where people work both remotely and at their employer’s premises. The European Foundation for the Improvement of Living and Working Conditions (Eurofound) has used the term telework, defining it as “a work arrangement in which work is performed outside a default place of work, normally the employer’s premises, by means of information and communication technologies (ICT). The characteristic features of telework are the use of computers and telecommunications to change the usual location of work, the frequency with which the worker is working outside the employer’s premises, and the number of places where workers work remotely (mobility)” (8). Thus, these terms capture a variety of definitions while measures have mainly relied on survey items. Although surveys can specify the timing, ie, “Have you worked remotely in the past week?” or the average of the past month, they are self-reported and thus prone to recall and reporting biases. On the other hand, earlier research indicates that sometimes workers work a part of a specific day from home and the other part from their employer’s premises, thus the same day can be both an on-site and a remote workday (9, 10). How are these differences reflected in the survey items or should they be monitored differently? Since the last decade, the use of employer-owned register data for studies of working hours has increased [eg, (11-13)] and such data could enable investigation of place for work (ie, where) in addition to timing (when) (14, 15). Thus, longitudinal studies using employer’s register data for working hours and places for working are needed to deepen the knowledge about the various ways of combining remote work and work at the employer premises and the subsequent effects on employee health, well-being, and work performance.

The COVID-19 pandemic time dominates research on remote work, but we do not know much about the post-pandemic worklife Besides the measures of remote work, another aspect hampering the current knowledge is the fact that studies of remote work among knowledge workers have been focused on the preceding or early years of the pandemic (16–19) or used cross-sectional design and/or survey data (18, 20–21) mainly focused on the psychosocial aspects of the work environment. Thus, studies combining a longitudinal design with register data are needed (14, 19). Various factors influenced remote work during the COVID-19 pandemic. Regulations and guidelines at global, national, and regional levels dictated remote work practices, particularly concerning infectious disease symptoms. Logistical factors—such as the availability of public transportation and workspace capacity at employer premises—also impacted whether employees intended to work remotely, had the opportunity to do so, or were even allowed to by their employers (22, 23). Furthermore, infrastructure issues, such as fast internet connectivity and affordability of housing with a workspace (ie, enablers for working from home remotely) influence the possibility and attractiveness of remote work (24–26). These infrastructure issues related to nations and their cities, and employers might play a role that has not yet been elaborated for the future of work.

Regulations and monitoring are needed Remote work challenges employee well-being as we have become aware via national legislation to restrict connectivity after work (27). However, such restrictions are rather few; in Europe only nine countries (Belgium, Croatia, France, Greece, Italy, Luxembourg, Portugal, Slovakia, and Spain) have legislation providing a right to disconnect. Although interest in disconnecting after work has existed for decades, the research seems to be characterized by similar weaknesses as studies of remote work in general: vague terminology, cross-sectional designs, and self-reported data as indicated by a recent mapping review (28). Still, the evidence is rather clear on the mental and physical health benefits of allowing employees to disconnect and recover (29). This might suggest that along with the high prevalence of remote work, studies and efforts should be invested in national and local regulations and longitudinal, high-quality studies using daily register data on working when and where to address the link to employee well-being, health, and productivity (30). Daily register data could be targeted to monitor working hours (14, 31) and computer use (32) and access control to premises or other intelligent workplace systems (33) that enable the monitoring of employees or wearable technology such as smartwatches or access tags (34) for research purposes. Thus, by deepening our understanding of remote work and detachment from work, we might improve workplace productivity and human resources.

From the responsibility of the employers to the freedom of employees Remote work is often done from home or a place owned by the employee (ie, vacation home). Sociodemographic factors such as income and educational attainment strongly determine home sizes and their locations (ie, whether they are in cities or more rural) (25). Given the fact that a home is a private place where individuals live alone or with others, employers do not have a say on the living or working conditions. This is a challenge from the occupational safety and health (OSH) perspective. Most of the OSH legislation dictates the role of the employer in safeguarding their employees from risks and hazards. In remote work, employees set their working conditions and work, some with state-of-the-art workstations with wide screens and separate keyboards and electronic tables, while others might not have any dedicated workspaces but work sitting on the sofa or at the kitchen table. In the short-term or occasionally, this might be fun. However, the long-term effects of poor physical working conditions or positions may negatively impact musculoskeletal organs, eye ergonomics, or cognitive functions (35, 36). This is especially concerning since young employees or those with lower socioeconomic status might be more vulnerable to these working conditions in their homes and have less economic incentives or knowledge of possibilities to adjust them. This aspect related to office ergonomics in remote work has been acknowledged in the literature (37), but further research and emphasis should be placed on avoiding any new pandemic of musculoskeletal or other health complaints due to working from home.

The rise and shine of remote work One may speculate if the increased rates of remote work will remain. If we think about the employer perspective, working both remotely and on-site has been, and will continue to be, challenged, and potentially adds costs as the use of premises varies a lot. Even though there are a lot of positive aspects of remote work from the employee perspective, some negative aspects have also been highlighted such as social isolation, lack of peer or supervisor support, and spillover of work to leisure time, all of which have increased due to remote work (5, 6, 18). These do not account for the fact that, in general, the possibility of employees having control over their work is an important factor that is strongly linked with well-being and health (38, 39). Therefore, even in the discussion about remote work, an important reminder is needed. Remote work is a form of flexible working that can be defined as having employment agreements that promote employees’ control over when, where, for how long, and how continuously the employee works (40–42). This form of employee-oriented flexibility refers to the employee’s entitlement to influence when and where they work and according to their individual needs and wishes. This contrasts with arrangements in which the employer determines the employees’ working times and location according to the company’s needs (company-based flexibility). Another important fact that has been missed in the current remote work discussion is the fact that flexibility helps people align their work commitments with their private lives. Besides, flexibility allows employees better opportunities to recover from the strain and effort associated with work, both during and outside work. In these mechanisms, the immediate impact of flexibility leads to a reduction in stress, thereby promoting better health (43, 44). Thus, I dare to claim that soon, within 1–5 years, we will not discuss remote work but rather flexibility. The discussion will lead to legislation and regulations enabling flexibility in a way that promotes the health and employee well-being while at the same time ensuring a safe and healthy work environment. Such legislation and regulations will exist locally, nationally, and internationally as such flexibility will also enable working across country borders.

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Night shift work and breast cancer risk - 2023 update of epidemiologic evidence

Introduction

Night shift work is a complex and frequent occupational exposure, and breast cancer stands as the most prevalent cancer in women. The International Agency for Research on Cancer (IARC) has twice classified night shift work as a probable breast carcinogen, with the latest classification in June 2019. Since that time, new epidemiologic data has emerged.

Methods

We searched PubMed for original articles based on cohort and case-control studies of "breast cancer and night shift work" published after the IARC evaluation in June 2019.

Results

In total six cohorts and four case-control studies were included in our review. Overall, we observed some support for associations between persistent (long duration or high frequency) night shift work and an increase in breast cancer risk, though most studies were relatively small and statistically under-powered. Moreover, the recent studies do not contribute further evidence regarding the interaction with menopausal status, diurnal preference, hormonal subtypes of breast cancer or gene-environment aspects, which were issues that were left from the IARC evaluation.

Conclusions

The available new results somewhat consolidate the epidemiological evidence from IARC's 2019 evaluation, and do not provide further evidence regarding interaction of interest, e.g. menopausal status, etc. Therefore, long term follow-up of prospective cohorts or nested case-control studies, including precise exposure assessment and examinations of relevant interactions such as menopausal status, diurnal preference, hormonal subtypes of breast cancer and gene-environment aspects, are warranted. Meanwhile, protective measures for the night workers should be considered.

Airport security personnel's working hour characteristics and associations with sickness absence-a retrospective cohort study in 2016-2019

We aimed to investigate the associations of working hour characteristics based on the international and local definitions with sickness absence (SA) among airport security personnel. The payroll-based registry data of daily working hours for 2016-2019 at one airport was limited to those with ≥30 work shifts in a year (n=377-687 employees). The conditional Poisson model for incidence rate ratios (IRR) with 95% confidence intervals (CI) was used for analyses. Based on the international definitions, only a few associations were found: each one-unit increase in weekly working hours and the number of consecutive working days were associated with a lower likelihood of SA. The local definitions were more consistently associated with SA: Each one-unit increase in shift length and time between shifts, higher variation in shift length, and the number of consecutive evening and night shifts were associated with a higher likelihood of SA. To conclude, especially the local definitions of working hour characteristics seem to be important limits for short SA. Thus, high variability of shift lengths and prolonged shifts could be avoided to reduce the risk of SA. Overall, keeping the working hours within any of the recommendations among airport security personnel could support well-being and health.

The association between vigour and flexibility with injury and alertness during shift work

Models of shift work and health suggest that individual differences in circadian rhythm characteristics may moderate the relationship between night shift work and injury, but this argument has not been directly tested. In this study, we tested the efficacy of two circadian rhythm characteristics-vigour and flexibility-as moderators of the path between shift work and injury. In addition, we aimed to replicate the association between vigour, flexibility, and alertness by time of day, and the measurement properties of the Circadian Type Inventory. We recruited 401 healthcare workers from Australia and Great Britain. After controlling for confounding variables, the results showed that vigour moderated the association between shift work and injury. Participants with values of vigour at the mean (β = 0.5120, p < 0.0013, 95% CI = [0.2018, 0.8223) and one standard deviation below the mean (β = 0.9048, p < 0.0001, 95% CI = [0.4648, 1.3447] reported significantly more injuries. No moderation was found for flexibility. Significant differences in alertness by time of day were observed in participants with higher levels of vigour compared to lower levels of vigour. No differences in alertness were observed for the flexibility scale. These results indicate that vigour may be a robust indicator of shift work tolerance. We replicated the posited two-factor structure of the Circadian Type Inventory, found the scales to have good reliability, and established for the first time, criterion-related validity for the vigour scale.

Concurrent Trajectories of Objectively Measured Insufficient Recovery and Workload Among a Cohort of Shift Working Hospital Employees: Quantitative Empirical Research

AIM

To investigate concurrent changes in short shift intervals (< 11 h) and workload among hospital employees.

DESIGN AND DATA SOURCES

This cohort study of 1904 employees in one hospital district in Finland utilised data on employees' working hours for short shift intervals and workload based on the patient classifications aggregated to a 3-week period level across 2 years, 2018-2019. The data was analysed by group-based trajectory modelling and multinominal regression models.

RESULTS

The seven trajectories model had the best fit to the data-Group 1: very few short shift intervals that are decreasing and low workload (15.0%); Group 2: a low amount of short shift intervals that are decreasing and stable low workload (14.2%); Group 3: moderate amount of short shift intervals that are slightly increasing and low workload (25.1%); Group 4: a low amount of short shift intervals that are slightly decreasing and stable low workload that is slightly increasing (12.1%): Group 5: a moderate amount of both short shift intervals and workload (19.8%): Group 6: short shift intervals that are clearly decreasing, with higher than the average workload decreasing (5.6%); Group 7: moderate amount of short shift intervals and very high workload (8.3%).

CONCLUSIONS

Only a minority of hospital employees were found to have both high workloads and insufficient recovery possibilities, but the time-related increases in objective workload were not compensated by better recovery possibilities in working hours. For shift scheduling, it is noteworthy that older employees might seek to work at units in which the workload is lower, which could be considered to support workability.

REPORTING METHOD

Record.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

Acute effects of a simulated quick return on subjective sleepiness, mood, and cognitive performance: A laboratory crossover controlled trial

Sleep loss due to short time off between shifts has been proposed as a mechanism contributing to impaired functioning in occupational settings. This laboratory crossover trial (ClinicalTrials.gov identifier: NCT05162105, N = 66) compared subjective sleepiness, mood, and cognitive performance on a day shift after an evening shift with only 8 h off between shifts (quick return, QR) to a day shift after another day shift with 16 h off between shifts (control). Results indicated higher subjective sleepiness (Karolinska Sleepiness Scale) during the QR condition compared to the control condition (p < 0.001). No significant differences were found on mood (Positive and Negative Affect Schedule) and cognitive performance (Psychomotor Vigilance- and Digit Symbol Substitution Test) between the conditions. Findings of increased subjective sleepiness corroborate previous field studies. This trial is to our knowledge the first to compare mood and cognitive performance after a QR to a longer shift transition using an experimental design. Future research should explore the effects of accumulated sleep loss associated with QRs (e.g. having several QRs within a short time period) on behavioral outcomes.

Balancing act: exploring work-life balance among nursing home staff working long shifts

BACKGROUND

Nursing home staff often face challenges in achieving a satisfactory work-life balance, particularly because of the nature of shift work. While long shifts offer extended periods off work, their impact on the delicate balance between work and leisure remains understudied in the context of nursing homes. This study investigated the experiences of nursing home staff in Norway working long shifts lasting 12-14 h and their perceptions of the balance between family life and work.

METHODS

Eighteen nursing home staff members were interviewed following a semi-structured qualitative approach. The participants worked in three types of long shifts and provided insights into their experiences, addressing issues such as work hours, shift patterns, and work-family balance.

RESULTS

The study revealed four main categories: (1) impact of long shifts on family life-the highs and lows; (2) maximizing time off with long shifts; (3) reducing job stress with long shifts; and (4) full-time work leads to predictable hours and stable income. The participants emphasised the distinct separation between work and leisure during long shifts, acknowledging limited social life during working periods but appreciating extended periods off. Family life posed challenges, especially with young children, but the participants found benefits in the longer periods of family time during days off. Longer rest periods and reduced commuting time were perceived as advantages of long shifts, contributing to better sleep, reduced stress and overall well-being. Long shifts also allowed for more predictable working hours and income, supporting a stable work-life balance.

CONCLUSION

Balancing work and family life involves more than just the number of hours spent at work; it also encompasses the quality of those hours both at work and at home. Our findings underscore the complex interplay between work and family life for nursing home staff working long shifts. While challenges exist, benefits such as extended time off, improved sleep, reduced stress, and predictable working hours contribute positively to their work-life balance. Long shifts in nursing homes offer a unique perspective on achieving work-life balance, revealing both the challenges and advantages inherent in such schedules. Understanding the experiences of nursing home staff in this context can inform future innovations in shift scheduling, promoting a more balanced and sustainable work environment for healthcare professionals. For some healthcare staff, extended shifts can lead to a better work-life balance.

Working hours and health - key research topics in the past and future

OBJECTIVE

This paper discusses the past and present highlights of working hours and health research and identifies key research needs for the future.

METHOD

We analyzed over 220 original articles and reviews on working hours and health in the Scandinavian Journal of Work, Environment & Health published during the last 50 years. Key publications from other journals were also included.

RESULTS

The majority of identified articles focussed on the effects of shift and night work, with fewer studying long and reduced working hours and work time control. We observed a transition from small-scale experimental and intensive field studies to large-scale epidemiological studies utilizing precise exposure assessment, reflecting the recent emergence of register-based datasets and the development of analytic methods and alternative study designs for randomized controlled designs. The cumulative findings provide convincing evidence that shift work and long working hours, which are often associated with night work and insufficient recovery, increase the risk of poor sleep and fatigue, sickness absence, occupational injuries, and several chronic health conditions such as cardiovascular diseases and cancer. The observed risks are strongly modified by individual and work-related factors.

CONCLUSIONS

Although the observed health risks of shift work and long working hours are mostly low or moderate, the widespread prevalence of exposure and the hazardousness of the many associated potential outcomes makes such working time arrangements major occupational health risks. Further research is needed to identify exposure-response associations, especially in relation to the chronic health effects, and to elucidate underlying pathways and effective personalized intervention strategies.

Relationship among sleep, work features, and SARS-cov-2 vaccine antibody response in hospital workers

STUDY OBJECTIVES

Immunity is influenced by sleep and the circadian rhythm. Healthcare workers are predisposed to both insufficient sleep and circadian disruption. This study aimed to evaluate the relationship between sleep and work characteristics and the antibody response to the mRNA SARS-CoV-2 vaccine BNT162b2.

METHODS

The authors' prospective cohort study ("COVI3") evaluated the effect of a third (booster) dose of the BNT162b2 vaccine. A subset of participants provided information on anthropometric measures, sleep, stress and work characteristics including shift work and number of work hours per week. Blood samples for anti-S1-RBD IgG antibody levels were obtained 21 weeks following receipt of the third dose of the vaccine.

RESULTS

In total, 201 healthcare workers (73% women) were included. After adjustment for age, body mass index (BMI), shift work, smoking status, and perceived stress, short sleep duration (<7 h per night) was associated with lower anti-S1-RBD IgG levels (Odds ratio 2.36 [95% confidence interval 1.08-5.13]). Participants who performed shift work had higher odds of lower anti-S1-RBD IgG levels compared to those who did not work in shifts [odds ratio = 2.99 (95% confidence interval 1.40, 6.39)] after accounting for age, short sleep duration, BMI, smoking status and perceived stress.

CONCLUSIONS

Shift work and self-reported short sleep duration were associated with a lower antibody response following a booster dose of the SARS-CoV-2 vaccine. These findings suggest that the efficacy of vaccination, particularly among healthcare workers, may be augmented by addressing both sleep and circadian alignment.

Sleep quality and the need for recovery among nurses working irregular shifts: A cross-sectional study

BACKGROUND

Shift work affects the mental and physical health of nurses, yet the effect of working irregular shifts on sleep and its association with the need for recovery is under-explored.

OBJECTIVE

The purpose of this study was to investigate the sleep quality of nurses working irregular shifts, including night shifts, and to determine whether sleep quality is associated with the need for recovery.

METHODS

This cross-sectional study included 405 nurses working irregular shifts. Data were collected using an online questionnaire that included sociodemographic characteristics, the Sleep-Wake Experience List, sleep problems, sleep duration, and the Need for Recovery scale. Data analyses included descriptive statistics, chi-square tests, t-tests, logistic and multiple linear regressions.

RESULTS

Nurses who worked irregular shifts had poor sleep quality. Those who also worked night shifts, had significantly poorer sleep quality and experienced more difficulties in daily functioning than those who did not work night shifts. Sleep quality was significantly associated with the need for recovery and this remained so after controlling for confounding variables (β= .554, p = .001).

CONCLUSION

The findings indicate that in nurses who work irregular shifts, the sleep quality is low. In this group, the sleep quality in nurses who work night shifts is lower than in nurses who do not work night shifts. Furthermore, better sleep quality was associated with lower need for recovery. These findings suggest that improving sleep quality in nurses working irregular shifts may lower their need for recovery, which may improve health, and reduce burnout and sickness absence.

Impact of sleep-wake features on fatigue among female shift work nurses

BACKGROUND

Sleep disturbance and fatigue are prevalent in nurses. Little is known about the characteristics of shift work nurses' sleep-wake features and their subsequent impact on work performance. The study aimed to describe the characteristics of the sleep-wake index, reaction time, saliva cortisol level, and fatigue severity among female shift work nurses.

METHODS

This is a cross-sectional exploratory study. A convenience sample of 152 female nurses (8-hour day-evening-night, n = 70; 12-hour day-night, n = 82) participated in this study from nine intensive care units (ICUs) from two teaching hospitals in Beijing, China. A consecutive 7-day actigraphy data were used to analyse sleep-wake indexes, including total sleep time (TST) and circadian activity rhythms (CAR). Before and after shifts, the following data were collected, psychomotor vigilance task for reaction time, saliva cortisol for the level of alertness, and self-reported fatigue severity with the Lee Fatigue Scale-Short Form.

RESULTS

All nurses reported clinically significant fatigue severity. Compared with the 8-hour shift nurses, the 12-hour shift nurses had significantly more TST (456 vs. 364 min), higher saliva cortisol levels before the day shift (0.54 vs. 0.31), but longer reaction time before the night shift (286 vs. 277 ms). In both shifts, those with better CAR had significantly longer TST.

CONCLUSION

Female nurses experienced fatigue and desynchronized CAR, especially nurses on a 12-hour shift. The CAR-friendly shift work schedule is needed to minimize the health and safety impacts of circadian misalignment for nurses.Key messagesThis is the first use of consecutive 7-day actigraphy data to explore the link between sleep disturbances as a stressor to CAR, salivary cortisol, and reaction time among clinical nurses.CAR may be a helpful indicator for overworked nurses, and it can serve as a modifiable target for interventions to enhance nurses' well-being.

Influence of Shift Work on Arterial Stiffness and Systemic Inflammation: A 3-Year Follow-up Study in Industry

OBJECTIVE

To assess changes in cardiovascular disease risk factors during a 3-year follow-up among 57 rotating shift workers and 29 day workers in industry.

METHODS

We collected demographics by questionnaire, examined blood pressure, heart rate, pulse wave velocity, carotid media thickness, and maximal oxygen uptake. We assessed blood samples for determination of lipids, glycosylated hemoglobin, C-reactive protein, markers of inflammation, and particle concentrations/respirable dust. Baseline comparisons were analyzed using logistic regression (plaque) and linear regression for all other outcomes. We applied mixed models to assess differences in change in health outcomes between the shift workers and the day workers.

RESULTS

At baseline, the adhesion molecules soluble vascular cell adhesion molecule 1 and soluble P-selectin were elevated among the shift workers compared with that of the day workers. There was a significant difference in change in pulse wave velocity between shift workers (1.29-m/s increase) and day workers (0.11-m/s increase) over the 3-year follow-up. Respirable dust levels were below the Norwegian occupational exposure limit.

CONCLUSIONS

Shift work in industry is associated with arterial stiffening reflecting increased risk for future cardiovascular disease. More uncertainly, we found some support for systemic inflammation.

The Prolonged Effect of Shift Work and the Impact of Reducing the Number of Nightshifts on Arterial Stiffness-A 4-Year Follow-Up Study

AIM

To assess changes in blood pressure (BP) and arterial stiffness among 84 rotating shift and 25 dayworkers (control subjects) at two industrial plants during a 4-year follow-up, and to assess changes in outcome variables among shift workers at the two plants after a reduction in the number of night shifts during the last year of follow-up in one of the plants.

METHODS

We collected demographic data using a questionnaire, examined systolic and diastolic blood pressure (sBP, dBP), central systolic and diastolic aorta pressure (cSP, cDP), augmentation pressure (AP), central pulse pressure (cPP), and pulse wave velocity (PWV). We registered sleep quality. The last 4-14 months of follow-up one plant implemented a 12-week shift plan reducing the total number of night shifts and consecutive night shifts from 16.8 to 14 and from 7.2 to 4. To assess differences in change of outcomes between study groups we applied linear mixed models.

RESULTS

The dayworkers were older, more hypertensive, reported less sleep disturbance, and smoked/snuffed less than the shift workers did. The adjusted annual increase in PWV was 0.34 m/s (95%CI, 0.22, 0.46) among shift workers and 0.09 m/s (95%CI, -0.05, 0.23) in dayworkers, yielding a significant difference of change of 0.25 m/s (95%CI, 0.06, 0.43). No significant differences were found between the two groups of shift workers in any cardiovascular disease (CVD) outcome during the last year of follow-up.

CONCLUSIONS

Shift work in industry is associated with arterial stiffness, reflecting an increased risk of future CVD. No significant changes in arterial stiffness were identified as a consequence of a small reduction in the number of night shifts and consecutive night shifts.

Shift work with and without night shifts and breast cancer risk in a cohort study from Finland

OBJECTIVES

To examine the association of shift work with and without night work with breast cancer among women in the public sector.

METHODS

Using the Finnish Public Sector cohort study (N=33 359, mean age of 40.6 years at baseline), we investigated the associations of shift work and potential confounders with incident breast cancer. Exposure to permanent day work or shift work was defined from first two consecutive surveys from 2000, 2004, 2008 or 2012 and past information on exposure in a subcohort (n=20 786). Incident cases of breast cancer (n=1129) were retrieved from the National Cancer Register and the cohort members were followed to the end of 2016. HR and 95% CI from Cox proportional hazard regression models were calculated.

RESULTS

Shift work with and without night shifts was not overall associated with breast cancer. When stratified according to age, both shift work without nights (HR 2.01, 95% CI 1.12 to 3.60) and shift work with nights (OR 2.05, 95% CI 1.04 to 4.01) were associated with an increased risk after a period of 10 years or more follow-up among women aged 50 years or older, when adjusted for age, socioeconomic status, children, smoking, alcohol and body mass index. In a subgroup with past information on exposure to shift work, the increased risk by longer exposure to shift work was not significant.

CONCLUSIONS

This study provides support for an increased risk of breast cancer among elderly shift workers. However, insufficient information on exposure and intensity of night work may attenuate the risk estimates.

Sequence analysis of the combinations of work shifts and absences in health care - comparison of two years of administrative data

BACKGROUND

In health care, the shift work is arranged as irregular work shifts to provide operational hours for 24/7 care. We aimed to investigate working hour trends and turnover in health care via identification of time-related sequences of work shifts and absences among health care employees. The transitions between the work shifts (i.e., morning, day, evening, and night shifts), and absences (days off and other leaves) over time were analyzed and the predictors of change in irregular shift work were quantified.

METHODS

A longitudinal cohort study was conducted using employer-owned payroll-based register data of objective and day-to-day working hours and absences of one hospital district in Finland from 2014 to 2019 (n = 4931 employees). The working hour data included start and end of work shifts, any kind of absence from work (days off, sickness absence, parental leave), and employee's age, and sex. Daily work shifts and absences in 2014 and 2019 were used in sequence analysis. Generalized linear model was used to estimate how each identified sequence cluster was associated with sex and age.

RESULTS

We identified four sequence clusters: "Morning" (60% in 2014 and 56% in 2019), "Varying shift types" (22% both in 2014 and 2019), "Employee turnover" (13% in 2014 and 3% in 2019), and "Unstable employment (5% in 2014 and 19% in 2019). The analysis of transitions from one cluster to another between 2014 and 2019 indicated that most employees stayed in the same clusters, and most often in the "Varying shift types" (60%) and "Morning" (72%) clusters. The majority of those who moved, moved to the cluster "Morning" in 2019 from "Employee turnover" (43%), "Unstable employment" (46%) or "Varying shift types" (21%). Women were more often than men in the clusters "Employee turnover" and "Unstable employment", whereas older employees were more often in "Morning" and less often in the other cluster groups.

CONCLUSION

Four clusters with different combinations of work shifts and absences were identified. The transition rates between work shifts and absences with five years in between indicated that most employees stayed in the same clusters. The likelihood of a working hour pattern characterized by "Morning" seems to increase with age.

Analysis and mapping of global research publications on shift work (2012-2021)

BACKGROUND

The main objective of the study was to identify research trends, collaboration patterns, and the most impactful publications in the field of shift work.

METHODS

Documents published in scientific journals indexed in the Scopus database on shift work were retrieved and analyzed using the title/abstract search methodology. The study period was from January 1st, 2012, to December 31st, 2021.

RESULTS

Two thousand three hundred twenty-eight documents were retrieved with an h-index of 71 and an average number of 4.5 authors per document. The cumulative number of publications showed a linear growth pattern, while that of citations showed an exponential pattern. The most frequent author keywords, excluding keywords related to shift work, were sleep, fatigue, and nursing. The average annual growth rate was 4.3, and the average doubling time was 3.2. No significant correlation was found between the number of publications and national income among prolific countries. Cross-country research collaboration was weak while the degree of author-author collaboration was relatively high. The Chronobiology International journal was the most prolific, while Harvard University was the most active institution in the field of shift work.

CONCLUSIONS

Given the volume and the negative health impact of shift work, better human resource management is needed to create safer and healthier working schedules.

Night Work and Sustainable Working Life-A Prospective Trajectory Analysis of Swedish Twins

The aim was to investigate the changes in sustainable working life over 10-13 years of follow-up and the effect of baseline night work. Data from the Swedish national registers were used to define sustainable working life. Survey data in the 1998-2003 "SALT" with 34,680 twins or in the 2004-2006 "STAGE" with 19,637 twins were utilized to assess night work at baseline. Group-based trajectory and multinomial regression models were applied. The results of the SALT cohort yielded five trajectory solutions: stable sustainable working life (40%), stable lack of sustainable working life (25%), later decreasingly sustainable working life (15%), increasingly sustainable working life (14%), and early decreasingly sustainable working life (7%). In the STAGE cohort, four trajectories were detected: stable sustainable working life (83%), decreasingly sustainable working life (7%), stable lack of sustainable working life (5%), and increasing sustainable working life (5%). Night work was associated with the decreasing or increasing sustainable working life in the trajectory groups. To conclude, the largest parts of both cohorts followed trajectories of stable sustainable working lives. Night work was associated with both the trajectories of decreasing and increasing sustainable working lives.

A Longitudinal Study on Trajectories of Night Work and Sickness Absence among Hospital Employees

This study aimed to investigate trajectories of night shift work in irregular shift work across a 12-year follow-up among hospital employees with and without sickness absence (SA). The payroll-based register data of one hospital district in Finland included objective working hours and SA from 2008 to 2019. The number of night shifts per year was used in group-based trajectory modeling (GBTM). The results indicate that, among those who had any sickness absence episodes, the amount of night work decreased prior to the first SA. In general, trajectories of night shift work varied from stably high to low-but-increasing trajectories in terms of the number of shifts. However, a group with decreasing pattern of night work was identified only among those with sickness absence episodes but not among those without such episodes. To conclude, the identified trajectories of night work with or without sickness absences may indicate that, among those with sickness absence episodes, night work was reduced due to increasing health problems. Hence, the hospital employees working night shifts are likely a selected population because the employees who work at night are supposed to be healthier than those not opting for night work.

Working hour characteristics in the Finnish retail sector - a registry study on objective working hour data

Earlier research is lacking on the prevalence and nature of objective working hour characteristics in the retail sector. We developed a codification in the retail sector and investigated differences in objective working hour characteristics by part-time work, sex and age. The payroll-based registry data of objective working hours consisted >12,000 employees of the retail sector in Finland for 2018-2020. Descriptive statistics for means, standard deviations (SD) and range of annual working hour characteristics were calculated, the differences in means were tested, partially based on the protocol established for health care sector. The final sample had 60-63% part-time employees and 23% men. Morning shifts were more frequent (48-51%) among full-time employees compared to 27-30% of the part-time employees. Evening shifts, 43-46%, were frequent among part-time employees vs. 26% in full-time. No sex differences were detected, and age group differences only among part-time employees. To conclude, the codification for registry-based working hour data enables us to identify individual differences in working hour characteristics. The working hour characteristics differed between part-time and full-time employees, not between sexes, whereas age differences were minor and among part-time employees. The codification could be used in studies of the retail sector in association with health and wellbeing.

Length of exposure to long working hours and night work and risk of sickness absence: a register-based cohort study

Background

There is inconsistent evidence that long working hours and night work are risk factors for sickness absence, but few studies have considered variation in the length of exposure time window as a potential source of mixed findings. We examined whether the association of long working hours and night work with sickness absence is dependent on the length of exposure to the working hour characteristics.

Methods

We analysed records of working hours, night work and sickness absence for a cohort of 9226 employees in one hospital district in Finland between 2008 and 2019. The exposure time windows ranged from 10 to 180 days, and we used Cox’s proportional hazards models with time-dependent exposures to analyse the associations between working-hour characteristics and subsequent sickness absence.

Results

Longer working hours for a period of 10 to 30 days was not associated with the risk of sickness absence whereas longer working hours for a period of 40 to 180 days was associated with a lower risk of sickness absence. Irrespective of exposure time window, night work was not associated with sickness absence.

Conclusions

It is important to consider the length of exposure time window when examining associations between long working hours and sickness absence, whereas the association between night work and sickness absence is not similarly sensitive to exposure times.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07231-4.

Results of survey on perception of patient safety culture among emergency nurses in Jordan: Influence of burnout, job satisfaction, turnover intention, and workload

BACKGROUND

Patient safety culture is an essential factor in the decreasing of medical errors and development of the institutions. This study was conducted to determine to what extent the selected variables, including age, weekly working hours, years of experience, burnout, turnover intention, workload, and job satisfaction, predict perceived patient safety culture among emergency nurses in Jordanian hospitals.

METHODS

A cross-sectional design with convenience sampling approach was used. A total of 157 emergency nurses from governmental and public hospitals were participated in the study and completed the study's survey: Hospital Survey on Patient Safety Culture (PSC), Copenhagen Burnout Inventory-Student Survey (CBI-SS), NASA Task Load Index (NASA-TLX), Nursing Workplace Satisfaction Questionnaire (NWSQ) and turnover intention scale (TIS).

RESULTS

The results showed that there was a negative relationship found between nurses' age and PSC perception (r=-.166, P=.039), personal burnout and PSC (r=-.160, P=.048), and there was also a negative relationship between turnover intentions and perceived PSC (r=-.334, P=.000). The results from the regression model indicated that turnover intentions, reporting patient safety events, and the number of events reported predicted PSC. The results showed that R²=.29, adjusted R²=.287, F(6,141)=9.45, P<0.01.

CONCLUSION

Our results suggests that nurses' managers may pay attention to decreasing burnout and analyze turnover intention among nurses in order to improve the culture of patient safety.

Working Time Characteristics and Mental Health among Corrections and Transportation Workers

OBJECTIVES

Mental health disorders are a leading cause of work disability and while the psychosocial workplace environment plays a critical role, working time characteristics are also implicated. We sought to examine the association between working time characteristics and mental health in a cohort of two unionized, full-time worker populations, correctional supervisors, and transportation maintainers.

METHODS

Using a cross-sectional study design, we surveyed workers on working time characteristics across seven domains including length of the shift, the intensity or proximity of sequential shifts, the time of day, and social aspects of work hours including predictability, variability, control, and free time. Burnout symptoms (Oldenburg Burnout Inventory) and depressive symptoms (eight-item Centers for Epidemiologic Studies Depression Scale) were assessed along with the psychosocial work environment and health behaviors. We used log-binomial regression models to estimate prevalence ratios and 95% confidence intervals after adjusting for age, gender, and company.

RESULTS

A total of 318 workers were surveyed. The majority (72%) of workers reported a fixed shift. The prevalence of burnout symptoms was higher among workers reporting more frequent shift intensity (working 6 or more days in a row) (PR: 1.15, 95% CI: 1.01, 1.31; P = 0.04). Low psychological demands and high worker social support were associated with fewer burnout symptoms, independent of working time characteristics. The prevalence of depressive symptoms was higher in workers reporting more frequent unpredictable work (PR: 1.17, 95% CI: 1.01, 1.35; P = 0.04) and was lower among workers reporting increased schedule control (PR: 0.86, 95% CI: 0.77, 0.96; P = 0.01). Higher worker social support as well as sufficient sleep and adequate exercise were associated with fewer depressive symptoms, independent of working time characteristics.

CONCLUSIONS

Different working time characteristics were associated with work-related mental health (i.e. burnout) as well as general mental health (i.e. depressive symptoms). Work intensity was associated with the prevalence of burnout symptoms and the results suggest that the mechanism may be through the need for recovery from the psychosocial exposures of work. Both schedule control and predictability were associated with depressive symptoms and the results suggest that work-life imbalance and lack of recovery may be implicated. Comprehensive prevention policies that consider work organization along with the psychosocial work environment and work-life balance may help to improve workers' mental health.

Patterns of working hour characteristics and risk of sickness absence among shift-working hospital employees: a data-mining cohort study

OBJECTIVES

Data mining can complement traditional hypothesis-based approaches in characterizing unhealthy work exposures. We used it to derive a hypothesis-free characterization of working hour patterns in shift work and their associations with sickness absence (SA).

METHODS

In this prospective cohort study, complete payroll-based work hours and SA dates were extracted from a shift-scheduling register from 2008 to 2019 on 6029 employees from a hospital district in Southwestern Finland. We applied permutation distribution clustering to time series of successive shift lengths, between-shift rest periods, and shift starting times to identify clusters of similar working hour patterns over time. We examined associations of clusters spanning on average 23 months with SA during the following 23 months.

RESULTS

We identified eight distinct working hour patterns in shift work: (i) regular morning (M)/evening (E) work, weekends off; (ii) irregular M work; (iii) irregular M/E/night (N) work; (iv) regular M work, weekends off; (v) irregular, interrupted M/E/N work; (vi) variable M work, weekends off; (vii) quickly rotating M/E work, non-standard weeks; and (viii) slowly rotating M/E work, non-standard weeks. The associations of these eight working-hour clusters with risk of future SA varied. The cluster of irregular, interrupted M/E/N work was the strongest predictor of increased SA (days per year) with an incidence rate ratio of 1.77 (95% confidence interval 1.74-1.80) compared to regular M/E work, weekends off.

CONCLUSIONS

This data-mining suggests that hypothesis-free approaches can contribute to scientific understanding of healthy working hour characteristics and complement traditional hypothesis-driven approaches.

Prevalence of Shift Work Disorder: A Systematic Review and Meta-Analysis

Objectives: No systematic review or meta-analysis concerning the prevalence of shift work disorder (SWD) has been conducted so far. The aim was thus to review prevalence studies of SWD, to calculate an overall prevalence by a random effects meta-analysis approach and investigate correlates of SWD prevalence using a random-effects meta-regression.

Methods: Systematic searches were conducted in ISI Web of Science, PsycNET, PubMed, and Google Scholar using the search terms “shift work disorder” and “shift work sleep disorder.” No restrictions in terms of time frame were used. Included studies had to present original data on the prevalence of SWD in an occupational sample published in English. A total of 349 unique hits were made. In all, 29 studies were finally included from which two authors independently extracted data using predefined data fields. The meta-regression included four predictors (diagnostic criteria, study country, type of workers, and sample size).

Results: The overall prevalence of SWD was 26.5% (95% confidence interval = 21.0–32.8). Cochran Q was 1,845.4 (df = 28, p < 0.001), and the I² was 98.5%, indicating very high heterogeneity across the observed prevalence estimates. Diagnostic criteria (International Classification of Sleep Disorders-2 = 0, International Classification of Sleep Disorders-3 = 1) and sample size were inversely related to SWD prevalence.

Conclusions: The prevalence of SWD was high across the included studies. The between-study disparity was large and was partly explained by diagnostic criteria and sample size. In order to facilitate comparative research on SWD, there is a need for validation and standardization of assessment methodology as well as agreement in terms of sample restrictions.

Night work for hospital nurses and sickness absence: a retrospective study using electronic rostering systems

There is conflicting evidence on the effect of night work on sickness absence. Most previous studies used self-reporting to identify shift patterns and measure levels of sickness absence. In contrast, this study used objective data from electronic rosters to explore the association of nurses' patterns of night work and sickness absence. This was a retrospective longitudinal study of nurse roster data from 32 general medical and surgical wards in a large acute hospital in England. We used data from 3 years and included both registered nurses and unregistered nursing assistants. We used generalized linear-mixed models to explore the association between night work and the subsequent occurrence of sickness absence. Of 601,282 shifts worked by 1944 nursing staff, 38,051 shifts were lost due to sickness absence. After controlling for potential confounders including proportion of long (≥12 h) shifts worked, proportion of overtime shifts, proportion of shifts worked in the past 7 days, and staff grade, we found that staff working more than 75% of their shifts in the past 7 days as night shifts were more likely to experience sickness absence (aOR = 1.12; 95% CI: 1.03-1.21), compared to staff working on day only schedules. Sub-group analysis found that an association between a high proportion of night shifts worked and long-term sickness (aOR = 1.31; 95% CI: 1.15-1.50), but not short-term sickness. Working high proportions of night shifts, likely representing permanent night work schedules, is associated with a higher risk of long-term sickness absence for nurses working in inpatient adult wards in acute hospitals. The higher sickness absence rates associated with permanent night shifts could result in additional costs or loss of productivity for hospitals. This study challenges the assumption that permanent night schedules maximize circadian adjustment and, therefore, reduce health problems.

The association between 12-hour shifts and nurses-in-charge's perceptions of missed care and staffing adequacy: a retrospective cross-sectional observational study

Background

Due to worldwide nursing shortages and difficulty retaining staff, long shifts for nursing staff (both registered nurses and nursing assistants) working in hospitals have been adopted widely. Because long shifts reduce the daily number of shifts from three to two, many assume that long shifts improve productivity by removing one handover and staff overlap. However, it is unclear whether staffing levels are more likely to be perceived as adequate when more long shifts are used.

Objectives

To investigate the association between the proportion of long (≥12‐hour) shifts worked on a ward and nurses-in-charge's perceptions that the staffing level was sufficient to meet patient need.

Methods

A retrospective cross-sectional study using routinely collected data (patient administrative data and rosters) linked to nurses-in-charge's reports from 81 wards within four English hospitals across 1 year (2017). Hierarchical logistic regression models were used to determine associations between the proportion of long shifts and nurses-in-charge's reports of having enough staff for quality or leaving necessary nursing care undone, after controlling for the staffing level relative to demand (shortfall). We tested for interactions between staffing shortfall and the proportion of long shifts.

Results

The sample comprised 19648 ward days. On average across wards, 72% of shifts were long. With mixed short and long shifts, the odds of nurses-in-charge reporting that there were enough staff for quality were 14-17% lower than when all shifts were long. For example, the odds of reporting enough staff for quality with between 60-80% long shifts was 15% lower (95% confidence interval 2% to 27%) than with all long shifts. Associations with nursing care left undone were consistent with this pattern. Although including interactions between staffing shortfalls and the proportion of long shifts did not improve model fit, the effect of long shifts did appear to differ according to shortfall, with lower proportions of long shifts associated with benefits when staffing levels were high relative to current norms.

Conclusions

Rather than a clear distinction between wards using short and long shifts, we found that a mixed pattern operated on most days and wards, with no wards using all short shifts. We found that when wards use exclusively long shifts rather than a mixture, nurses-in-charge are more likely to judge that they have enough staff. However, the adverse effects of mixed shifts on perceptions of staffing adequacy may be reduced or eliminated by higher staffing levels.

ISRCTN 12307968.

Tweetable abstract

12-hour shifts in nursing: a mix of short and long shifts may be worse than all long shifts.

The association between 12-hour shifts and nurses-in-charge's perceptions of missed care and staffing adequacy: a retrospective cross-sectional observational study

BACKGROUND

Due to worldwide nursing shortages and difficulty retaining staff, long shifts for nursing staff (both registered nurses and nursing assistants) working in hospitals have been adopted widely. Because long shifts reduce the daily number of shifts from three to two, many assume that long shifts improve productivity by removing one handover and staff overlap. However, it is unclear whether staffing levels are more likely to be perceived as adequate when more long shifts are used.

OBJECTIVES

To investigate the association between the proportion of long (≥12-hour) shifts worked on a ward and nurses-in-charge's perceptions that the staffing level was sufficient to meet patient need.

METHODS

A retrospective cross-sectional study using routinely collected data (patient administrative data and rosters) linked to nurses-in-charge's reports from 81 wards within four English hospitals across 1 year (2017). Hierarchical logistic regression models were used to determine associations between the proportion of long shifts and nurses-in-charge's reports of having enough staff for quality or leaving necessary nursing care undone, after controlling for the staffing level relative to demand (shortfall). We tested for interactions between staffing shortfall and the proportion of long shifts.

RESULTS

The sample comprised 19648 ward days. On average across wards, 72% of shifts were long. With mixed short and long shifts, the odds of nurses-in-charge reporting that there were enough staff for quality were 14-17% lower than when all shifts were long. For example, the odds of reporting enough staff for quality with between 60-80% long shifts was 15% lower (95% confidence interval 2% to 27%) than with all long shifts. Associations with nursing care left undone were consistent with this pattern. Although including interactions between staffing shortfalls and the proportion of long shifts did not improve model fit, the effect of long shifts did appear to differ according to shortfall, with lower proportions of long shifts associated with benefits when staffing levels were high relative to current norms.

CONCLUSIONS

Rather than a clear distinction between wards using short and long shifts, we found that a mixed pattern operated on most days and wards, with no wards using all short shifts. We found that when wards use exclusively long shifts rather than a mixture, nurses-in-charge are more likely to judge that they have enough staff. However, the adverse effects of mixed shifts on perceptions of staffing adequacy may be reduced or eliminated by higher staffing levels. ISRCTN 12307968. Tweetable abstract 12-hour shifts in nursing: a mix of short and long shifts may be worse than all long shifts.

Working time characteristics and long-term sickness absence among Danish and Finnish nurses: A register-based study

BACKGROUND

Working time regimes in Denmark and Finland share many similarities such as nursing personnel working in highly irregular shift systems. Yet, there are also differences for example in policy on when and how the employers are compensated for sickness absence.

OBJECTIVE

We aimed to investigate the association between different working hour characteristics and long-term sickness absence and whether these associations differed within various age groups in two large datasets of nursing personnel from Denmark and Finland.

DESIGN

Based on objective payroll data we used Poisson regression models to calculate incidence rate ratios with 95% confidence intervals to prospectively assess the risk of long-term sickness absence in relation to annual working hour characteristics. The analyses were adjusted for age, sex, short-term sickness absence, and weekly working hours.

SETTING(S)

Danish and Finnish nursing personnel.

PARTICIPANTS

31,729 Danish and 6970 Finnish nursing personnel with ≥ 0.5 Whole-Time Equivalent, registered in the database ≥ 1 year, 18-67 years of age with less than 30 days sickness absence in baseline year 2008.

METHODS

Working hour characteristics were assessed for 2008: time of day; day; evening; night. Duration of shift; long shifts (9-12 h); very long shifts (12-24 h); quick returns (< 11 h between two shifts); long weeks (> 40 h/week); very long weeks (> 48 h/week); and consecutive night shifts (≥ 5 night shifts). Long-term sickness absence was assessed as first incidence of 30 or more consecutive days off in 2009-2015.

RESULTS

The Danish data showed having evening work or five or more consecutive night shifts were associated with higher risk of long-term sickness absence. When excluding pregnant women, night work was also associated to higher risk of sickness absence. When stratifying on age groups, we observed a lower risk of sickness absence in the youngest age groups and a higher risk among the oldest. The Finnish results showed a higher risk of sickness absence when working nights, longs shifts, quick returns, and long work weeks. When stratifying on age groups, the results showed similar tendencies as the Danish.

CONCLUSIONS

The results show that the scheduling of working hours is likely to affect the risk of long-term sickness absence and that the risk differs in different age groups. No consistent picture was found for the results from Denmark and Finland. Differences may be due to contextual differences thus comparison of risk of sickness absence in relation to working hours between countries should be performed with caution. Tweetable abstract: A recent study from Denmark and Finland shows higher risk for long sickness absence among nurses with five or more consecutive night shifts.

The association between 12-hour shifts and nurses-in-charge's perceptions of missed care and staffing adequacy: a retrospective cross-sectional observational study

BACKGROUND

Due to worldwide nursing shortages and difficulty retaining staff, long shifts for nursing staff (both registered nurses and nursing assistants) working in hospitals have been adopted widely. Because long shifts reduce the daily number of shifts from three to two, many assume that long shifts improve productivity by removing one handover and staff overlap. However, it is unclear whether staffing levels are more likely to be perceived as adequate when more long shifts are used.

OBJECTIVES

To investigate the association between the proportion of long (≥12-hour) shifts worked on a ward and nurses-in-charge's perceptions that the staffing level was sufficient to meet patient need.

METHODS

A retrospective cross-sectional study using routinely collected data (patient administrative data and rosters) linked to nurses-in-charge's reports from 81 wards within four English hospitals across 1 year (2017). Hierarchical logistic regression models were used to determine associations between the proportion of long shifts and nurses-in-charge's reports of having enough staff for quality or leaving necessary nursing care undone, after controlling for the staffing level relative to demand (shortfall). We tested for interactions between staffing shortfall and the proportion of long shifts.

RESULTS

The sample comprised 19648 ward days. On average across wards, 72% of shifts were long. With mixed short and long shifts, the odds of nurses-in-charge reporting that there were enough staff for quality were 14-17% lower than when all shifts were long. For example, the odds of reporting enough staff for quality with between 60-80% long shifts was 15% lower (95% confidence interval 2% to 27%) than with all long shifts. Associations with nursing care left undone were consistent with this pattern. Although including interactions between staffing shortfalls and the proportion of long shifts did not improve model fit, the effect of long shifts did appear to differ according to shortfall, with lower proportions of long shifts associated with benefits when staffing levels were high relative to current norms.

CONCLUSIONS

Rather than a clear distinction between wards using short and long shifts, we found that a mixed pattern operated on most days and wards, with no wards using all short shifts. We found that when wards use exclusively long shifts rather than a mixture, nurses-in-charge are more likely to judge that they have enough staff. However, the adverse effects of mixed shifts on perceptions of staffing adequacy may be reduced or eliminated by higher staffing levels. ISRCTN 12307968. Tweetable abstract 12-hour shifts in nursing: a mix of short and long shifts may be worse than all long shifts.