A longitudinal study on the association between quick returns and occupational accidents

Simulated quick returns in a laboratory context and effects on sleep and pre-sleep arousal between shifts: a crossover controlled trial

This trial presents a laboratory model investigating the effect of quick returns (QRs, <11 h time off between shifts) on sleep and pre-sleep arousal. Using a crossover design, 63 participants worked a simulated QR condition (8 h time off between consecutive evening- and day shifts) and a day-day (DD) condition (16 h time off between consecutive day shifts). Participants slept at home and sleep was measured using a sleep diary and sleep radar. Compared to the DD condition, the QR condition reduced subjective and objective total sleep time by approximately one hour (both p < .001), reduced time in light- (p < .001), deep- (p = .004), rapid eye movement (REM, p < .001), percentage of REM sleep (p = .023), and subjective sleep quality (p < .001). Remaining sleep parameters and subjective pre-sleep arousal showed no differences between conditions. Results corroborate previous field studies, validating the QR model and indicating causal effects of short rest between shifts on common sleep parameters and sleep architecture.

Organisational-level risk and health-promoting factors within the healthcare sector-a systematic search and review

Introduction

The healthcare sector is globally experiencing increasing demands and workplace interventions on an organisational level is sought to create healthy workplaces. The aim of this study was to provide an overview of Nordic research on the work environment and health of healthcare professionals, with a focus on identifying organisational-level risk and health-promoting factors.

Methods

This systematic search and review was based on an analysis of studies published in peer-reviewed journals between 1 January 2016 and 3 January 2023. The selected studies investigate the relationships between organisational-level risk and health-promoting factors and measures of health and well-being among healthcare professionals during ordinary operations. To increase applicability, this systematic search and review was limited to the Nordic countries as they share the same context with a publicly-funded widely accessible healthcare system. A total of 2,677 articles were initially identified, with 95 original studies meeting the criteria for relevance and quality.

Results

Identified organisational risk and health-promoting factors were categorised into five categories: work schedule distribution, operations design and work methods, ergonomic conditions, working conditions and personnel policies, and the organisation's ethical environment. In addition, two themes across the categories emerged, providing further insight into the implications for practice. The first theme emphasises risk and health-promoting factors in the actions that employers take to fulfil the organisation's goals. The second theme emphasises risk and health-promoting factors in connection with the ability of employees to do their jobs at a level of quality they deem acceptable.

Conclusion

Several organisational-level risk and health-promoting factors were identified, and the results indicate that the actions that employers take to fulfil the health-care organisation's goals and promote the ability of employees to provide high-quality care are important for the health and wellbeing of healthcare employees.

The consequences of after-hours work: a fixed-effect study of burnout, pain, detachment and work-home conflict among Norwegian workers

OBJECTIVES

Working outside the workplace and ordinary work hours has become common for a larger part of the working population. The objective of the current study was to examine the relationship between working after-hours and employee burnout, musculoskeletal pain, detachment and work-home conflict, delineating the independent effect of four different types of after-hours work, and the moderating role of work-time control.

METHODS

The data comprised longitudinal questionnaire data from 1465 full-time employees in Norway across four waves (2021-2022). We examined the link between four types of after-hours work: (i) long daily work hours (>10 hours); (ii) late evening work (after 21:00 hours); (iii) quick returns (<11 hours continued rest); and (iv) long weekly work hours (>40 hours a week) and employee health and wellbeing (ie, work-home conflict, detachment, burnout, and musculoskeletal pain), in fixed effects models. We stratified the analyses by working-time control.

RESULTS

The results support a link between late evening work, long daily and weekly work, and higher work-home conflict and lower detachment as well as between weekly work hours and higher burnout. The findings yielded limited support for work-time control as a moderating factor; the link between quick returns and burnout was only evident for employees with below-average work-time control.

CONCLUSIONS

The four types of after-hours work were all independently related to at least one employee outcome, although the link with quick returns was only evident when work-time control was below average. The results are important for practitioners aiming to implement family-friendly and healthy practices.

Quick returns, sleep, sleepiness and stress - An intra-individual field study on objective sleep and diary data

OBJECTIVES

Quick returns (<11 hours of rest between shifts) have been associated with shortened sleep length and increased sleepiness, but previous efforts have failed to find effects on sleep quality or stress. A shortcoming of most previous research has been the reliance on subjective measures of sleep. The aim of this study was to combine diary and actigraphy data to investigate intra-individual differences in sleep length, sleep quality, sleepiness, and stress during quick returns compared to day-day transitions.

METHODS

Of 225 nurses and assistant nurses who wore actigraphy wristbands and kept a diary of work and sleep for seven days, a subsample of 90 individuals with one observation of both a quick return and a control condition (day-day transition) was extracted. Sleep quality was assessed with actigraphy data on sleep fragmentation and subjective ratings of perceived sleep quality. Stress and sleepiness levels were rated every third hour throughout the day. Shifts were identified from self-reported working hours. Data was analyzed in multilevel models.

RESULTS

Quick returns were associated with 1 hour shorter sleep length [95% confidence interval (CI) -1.23- -0.81], reduced subjective sleep quality (-0.49, 95% CI -0.69- -0.31), increased anxiety at bedtime (-0.38, 95% CI -0.69- -0.08) and increased worktime sleepiness (0.45, 95%CI 0.22- 0.71), compared to day-day transitions. Sleep fragmentation and stress ratings did not differ between conditions.

CONCLUSIONS

The findings of impaired sleep and increased sleepiness highlight the need for caution when scheduling shift combinations with quick returns.

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.

Effects of a work schedule with abated quick returns on insomnia, sleepiness, and work-related fatigue: results from a large-scale cluster randomized controlled trial

STUDY OBJECTIVES

To investigate the effect of a work schedule with abated quick returns (i.e. > 11 hours between two shifts) on insomnia, daytime sleepiness, and work-related fatigue compared to a shift schedule maintaining the usual number of quick returns.

METHODS

A two-armed cluster randomized controlled trial including 66 units was conducted at a university hospital in Norway. Units with healthcare workers on rotating shift schedules were randomly assigned to a shift schedule with abated quick returns (intervention) or to continue with a schedule including quick returns as usual (control) for 6 months. Questionnaires assessed symptoms of insomnia (Bergen Insomnia Scale [BIS]), daytime sleepiness (Epworth Sleepiness Scale [ESS]), and work-related fatigue (Revised Swedish Occupational Fatigue Inventory) at baseline and towards the end of the intervention. Data were analyzed using multilevel linear mixed-effects models, and Cohen's d was used to calculate the effect size between groups.

RESULTS

Overall, 1314 healthcare workers (85.2% female) completed the baseline questionnaire (response rate 49.1%), and 552 completed the follow-up questionnaire. The intervention reduced quick returns from an average of 13.2 (SD = 8.7) to 6.7 (SD = 6.0), while the control group's average remained relatively unchanged from 13.2 (SD = 8.7) to 12.0 (SD = 9.3). Results showed a small improvement in symptoms of insomnia (BIS; d = -0.13, p = .022) and daytime sleepiness (ESS; d = -0.14, p = .013) in favor of the intervention. No effects were observed on work-related fatigue.

CONCLUSIONS

Reducing the number of quick returns in the work schedule resulted in improvements in insomnia and daytime sleepiness. The findings highlight the importance of sufficient daily rest time in the work schedule of healthcare workers.

CLINICAL TRIAL

Health Promoting Work Schedules: The Effect of Abolishing Quick Returns (HeWoS); clinicaltrials.gov/ct2/show/NCT04693182; Registered at ClinicalTrials.gov with the identifier NCT04693182.

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.

Managing Sustainable Working Hours within Participatory Working Time Scheduling for Nurses and Assistant Nurses: A Qualitative Interview Study with Managers and Staffing Assistants

Aim

To bring insights into how healthcare managers and staffing assistants work to achieve sustainable working hours within a participatory scheduling system.

Background

Hospital nurses and assistant nurses often work on rotating shifts, which affects their opportunities for sleep, recovery, and work-life balance. In Sweden, a participatory scheduling approach is commonly used, where working hours are planned in collaboration between employees, managers, and staffing assistants. Influence over working hours is related to positive outcomes among shift workers. However, it also places responsibility on the employee to schedule working hours that promote health and patient safety, i.e., sustainable working hours. Accordingly, the organisation has responsibilities to support the employee in this regard.

Methods

Semistructured individual interviews were conducted with 11 managers and 9 staffing assistants from four Swedish regions and analysed using thematic analysis.

Results

Several key factors for achieving sustainable working hours within the context of participatory scheduling were described: distribution and clarity of responsibilities, allocating time for scheduling, establishing shared responsibility, considering fairness, fostering an individual relationship with the employee, managing dissatisfaction, providing support, clarifying guidelines for sustainable scheduling, managing inconsistencies between employee requests and sustainable working hours, and considering recovery opportunities and the competence mix on shifts. Additionally, contextual factors, such as staffing levels, working procedures, working time arrangements for night work, and technological support, were highlighted as important.

Conclusion

Achieving sustainable working hours within participatory scheduling involves considering the interactions between factors at the levels of the organisation, the individual, and the technological systems. Implication for Nursing Management. Nurse managers and staffing assistants must work closely with their employees during participatory scheduling to ensure sustainable working hours. Key goals in this regard include establishing a shared responsibility, clarifying responsibilities and guidelines for sustainable scheduling, and allocating time for the scheduling process.

Synergistic interaction between long shifts and short rest periods on depression in shift workers: A cross-sectional study from Korea

BACKGROUND

Long shifts and short rest periods (SRP) between shifts are important factors that greatly affect shift workers' health. However, reports on the psychological effects of shift work, such as depression, have been inconsistent. Therefore, this study aimed to investigate the combined effect of long shifts and SRP on depression in shift workers.

METHODS

This cross-sectional study included 3295 shift workers in the sixth Korean Working Conditions Survey. The relative excess risk due to interaction (RERI) was computed to estimate the combined effect of long shifts and SRP on depression.

RESULTS

Depression in shift workers was not significantly associated with long shifts or SRP after adjustment, but the risk was significantly increased when exposed to both factors simultaneously (odds ratio 1.36, 95% confidence interval 1.03-1.79). The RERI between the two factors was statistically significant (p = 0.020), indicating a synergistic interaction with depression. Sensitivity analysis by occupation showed a significant interaction in the combined group of office and service workers (p = 0.034).

CONCLUSIONS

Simultaneous exposure to SRP and long shifts should be avoided when planning shift work schedules or devising health policies for shift workers. Special consideration is needed for healthcare and service workers, who may be particularly vulnerable to negative health impacts due to shift work.

Factors associated with injury among Maine logging workers

INTRODUCTION

Despite dramatic improvements in safety, logging remains one of the most dangerous industries in the United States. The purpose of this study was to explore longitudinal injury trends among Maine logging workers.

METHODS

Loggers participated in seven quarterly surveys, over the course of 18 months. Categorical and free text data related to traumatic and acute injury, musculoskeletal disorders (MSD), and chronic pain were exported from REDCap into SAS 9.4, Excel, and NVivo, for quantitative and qualitative analysis, respectively. Time to injury was modeled using two different approaches: (1) time to the occurrence of first injury modeled by proportional hazard regression and (2) an intensity model for injury frequency. Two research team members also analyzed qualitative data using a content analysis approach.

RESULTS

During the study, 204 injuries were reported. Of the 154 participants, 93 (60.4%) reported musculoskeletal pain on at least one survey. The majority of injuries were traumatic, including fractures, sprains, and strains. Lack of health insurance was found to be related to increased risk of first injury [HR = 1.41, 95% CI = 0.97-2.04, p = 0.069]. Variables found to be related to injury intensity at the univariate level were: (1) a lack of health insurance [HR = 1.51, 95% CI = 1.04-2.20, p = 0.030], (2) age [HR for 10-year age increase;= 1.12, 95% CI = 0.99-1.27, p = 0.082], and (3) years employed in logging industry [HR for 10-year increase = 1.12, 95% CI = 0.99-1.26, p = 0.052]. Seeking medical attention for injury was not a priority for this cohort, and narratives revealed a trend for self-assessment. A variety of barriers, including finances, prevented loggers from seeking medical attention.

DISCUSSION

We found that loggers still experience serious, and sometimes disabling, injuries associated with their work. It was unsurprising that many injuries were due to slips, trips, and falls, along with contact with logging equipment and trees/logs. The narratives revealed various obstacles preventing loggers from achieving optimal health. Examples included geographic distance from healthcare, lack of time to access care, and entrenched values that prioritized independence and traditional masculinity. Financial considerations were also consistently cited as a primary barrier to adequate care.

CONCLUSION

There is a continued need to emphasize occupational health and safety in the logging industry. Implementation of relevant safety programs is key, but it is likely that the benefits of these will not be fully realized until a cultural shift takes place within this industry.

Pros and cons of quick returns-a cross-sectional survey among Swedish nurses and nurse assistants

Short rest (<11h) between evening and day shifts-known as quick returns (QRs)-impede recovery and may impair health. Nevertheless, QRs remain popular among some shift workers. This study explores nurses' and nurse assistants' perceptions of the merits and demerits of QRs from individual and organizational perspectives. Participants were recruited from eleven wards at two Swedish hospitals as part of a larger quasi-experimental intervention study. The majority (79%) had influence over their work schedules. Frequency distributions of responses are presented. Ninety six undertook a baseline survey regarding recovery, tolerance and work performance in relation to QRs. A majority experienced difficulties unwinding before bedtime (76%), insufficient sleep (80%), and daytime fatigue (72%). A third experienced an increased risk of errors and mistakes. However, QRs appeared to facilitate taking reports from patients and planning work, as this task was more often rated as 'very easy' following a QR compared to other shift combinations. Tolerance of QRs varied substantially. In conclusion, QRs seem to benefit continuity in work processes, but may do so at the expense of recovery and safety. Wards planning to reduce QRs-through participatory or fixed schedule models-should consider impacts on work processes.

Shift work organization on nurse injuries: A scoping review

BACKGROUND

Extended work hours and shift work can result in mistimed sleep, excessive sleepiness, and fatigue, which affects concentration and cognition. Impaired concentration and cognition negatively affect employee safety.

OBJECTIVE

To examine the evidence of the impact of shift work organization, specifically work hours and scheduling, on nurse injuries including needlestick and sharps injuries, drowsy driving and motor vehicle crashes, and work-related accidents causing a near miss or actual injury to the nurse.

METHODS

A scoping review was conducted using search results from five bibliographic databases.

RESULTS

Through database searching, 7788 articles were identified. During the title and abstract screening, 5475 articles were excluded. Full text screening eliminated 1971 articles. During the data extraction phase, 206 articles were excluded leaving 34 articles from 14 countries in the scoping review. The results of the review suggest a strong association in nurses between long work hours and overtime and an increased risk for needlestick and sharps injuries, drowsy driving and motor vehicle crashes, and other work-related accidents. Rotating shifts increase the risk for needlestick and sharps injuries and other work-related accidents while night and rotating shifts increase the risk for drowsy driving and motor vehicle crashes.

CONCLUSIONS

Proper management of work hours and scheduling is essential to maximize recovery time and reduce or prevent nurse injuries. Nurse leaders, administrators, and managers, have a responsibility to create a culture of safety. This begins with safe scheduling practices, closely monitoring for near miss and actual nurse injuries, and implementing evidence-based practice strategies to reduce these occurrences.

Relationship between insomnia and rest time between shifts among shift workers: A multicenter cross‐sectional study

Objectives

A rest time of less than 11 h taken by a shift worker between shifts is defined as quick return (QR). QR is shown to decrease sleep time by virtue of decreasing rest time, diminishing sleepiness and exhaustion, and increasing the number of sick days taken by employees. Therefore, in this multicenter retrospective study, the association between QR and the incidence of insomnia was established using the night‐shift questionnaire from the Korean Workers Health Examination‐Common Data Model.

Methods

Three hospitals collected the night‐shift profiles and baseline demographic data of 33 669 workers between January 2015 and December 2017. The most recent date of examination was used for participants who had been examined multiple times at the same institution. We used multiple logistic regression to calculate the odds ratios (ORs) and 95% confidence intervals (CIs). The pooled ORs were estimated using combined results from the three institutions.

Results

The proportion of men was higher than that of women in the QR group at each institution. The pooled ORs were computed using combined data from the three institutions. Workers who reported a QR had the highest risk of sleeplessness (OR, 1.21; 95% CI, 1.12–1.31) compared to those workers who reported a slow return, after adjusting for possible confounders.

Conclusions

A substantial correlation was established between QR and insomnia using the CDM approach and data from multiple centers. This study may serve as a foundation for developing guidelines to enhance the health of shift workers and prevent occupational accidents.

Health-promoting work schedules: protocol for a large-scale cluster randomised controlled trial on the effects of a work schedule without quick returns on sickness absence among healthcare workers

INTRODUCTION

In shift work, quick returns refer to transitions between two shifts with less than 11 hours available rest time. Twenty-three per cent of employees in European countries reported having quick returns. Quick returns are related to short sleep duration, fatigue, sleepiness, work-related accidents and sickness absence. The present study is the first randomised controlled trial (RCT) to investigate the effect of a work schedule without quick returns for 6 months, compared with a work schedule that maintains quick returns during the same time frame.

METHODS AND ANALYSIS

A parallel-group cluster RCT in a target sample of more than 4000 healthcare workers at Haukeland University Hospital in Norway will be conducted. More than 70 hospital units will be assessed for eligibility and randomised to a work schedule without quick returns for 6 months or continue with a schedule that maintains quick returns. The primary outcome is objective records of sickness absence; secondary outcomes are questionnaire data (n≈4000 invited) on sleep and functioning, physical and psychological health, work-related accidents and turnover intention. For a subsample, sleep diaries and objective sleep registrations with radar technology (n≈ 50) will be collected.

ETHICS AND DISSEMINATION

The study protocol was approved by the Regional Committee for Medical and Health Research Ethics in Western Norway (2020/200386). Findings from the trial will be disseminated in peer-reviewed journals and presented at national and international conferences. Exploratory analyses of potential mediators and moderators will be reported. User-friendly outputs will be disseminated to relevant stakeholders, unions and other relevant societal groups.

TRIAL REGISTRATION NUMBER

NCT04693182.

Characteristics of Occupational Injuries among Spanish Nursing Workers

Introduction: Nursing professionals face a multitude of daily occupational hazards that can cause occupational accidents. AIM: The objective of this work is to analyze the personal variables included in official accident reports, to evaluate their influence on occupational accidents suffered by nursing and nursing assistant professionals. Methodology: A total of 187,821 occupational accidents recorded in Spain from 2011 to 2019 were analyzed in the sector using contingency tables, chi-square, and corrected standardized residuals. Results: The results showed that the older the professional, the probability that once the accident had occurred, its severity would be more serious. Regarding gender, men are more likely to suffer more serious accidents compared to accidents registered by women. Results about the length of service and nationality did not reach statistical significance in the group of accidents analyzed. Conclusions: The planning of preventive measures must be adapted to the profiles of the workers in the most vulnerable sector.

Non-Pharmacological Interventions to Improve Chronic Disease Risk Factors and Sleep in Shift Workers: A Systematic Review and Meta-Analysis

Shift work is associated with adverse chronic health outcomes. Addressing chronic disease risk factors including biomedical risk factors, behavioural risk factors, as well as sleep and perceived health status, affords an opportunity to improve health outcomes in shift workers. The present study aimed to conduct a systematic review, qualitative synthesis, and meta-analysis of non-pharmacological interventions targeting chronic disease risk factors, including sleep, in shift workers. A total of 8465 records were retrieved; 65 publications were eligible for inclusion in qualitative analysis. Random-effects meta-analysis were conducted for eight eligible health outcomes, including a total of thirty-nine studies. Interventions resulted in increased objective sleep duration (Hedges' g = 0.73; CI: 0.36, 1.10, k = 16), improved objective sleep efficiency (Hedges' g = 0.48; CI: 0.20, 0.76, k = 10) and a small increase in both subjective sleep duration (Hedges' g = 0.11; CI: -0.04, 0.27, k = 19) and sleep quality (Hedges' g = 0.11; CI: -0.11, 0.33, k = 21). Interventions also improved perceived health status (Hedges' g = 0.20; CI: -0.05, 0.46, k = 8), decreased systolic (Hedges' g = 0.26; CI: -0.54, 0.02, k = 7) and diastolic (Hedges' g = 0.06; CI: -0.23, 0.36, k = 7) blood pressure, and reduced body mass index (Hedges' g = -0.04; CI: -0.37, 0.29, k = 9). The current study suggests interventions may improve chronic disease risk factors and sleep in shift workers; however, this could only be objectively assessed for a limited number of risk factor endpoints. Future interventions could explore the impact of non-pharmacological interventions on a broader range of chronic disease risk factors to better characterise targets for improved health outcomes in shift workers.

How to schedule night shift work in order to reduce health and safety risks

Objectives This discussion paper aims to provide scientifically based recommendations on night shift schedules, including consecutive shifts, shift intervals and duration of shifts, which may reduce health and safety risks. Short-term physiological effects in terms of circadian disruption, inadequate sleep duration and quality, and fatigue were considered as possible links between night shift work and selected health and safety risks, namely, cancer, cardio-metabolic disease, injuries, and pregnancy-related outcomes. Method In early 2020, 15 experienced shift work researchers participated in a workshop where they identified relevant scientific literature within their main research area. Results Knowledge gaps and possible recommendations were discussed based on the current evidence. The consensus was that schedules which reduce circadian disruption may reduce cancer risk, particularly for breast cancer, and schedules that optimize sleep and reduce fatigue may reduce the occurrence of injuries. This is generally achieved with fewer consecutive night shifts, sufficient shift intervals, and shorter night shift duration. Conclusions Based on the limited, existing literature, we recommend that in order to reduce the risk of injuries and possibly breast cancer, night shift schedules have: (i) ≤3 consecutive night shifts; (ii) shift intervals of ≥11 hours; and (iii) ≤9 hours shift duration. In special cases - eg, oil rigs and other isolated workplaces with better possibilities to adapt to daytime sleep - additional or other recommendations may apply. Finally, to reduce risk of miscarriage, pregnant women should not work more than one night shift in a week.