Industrial Health 1999, 37, 228-236 Original Article

Shift Work-Related Problems in 16-h Night Shim Nurses

(2): Effects on Subjective Symptoms, Physical Activity,
Heart Rate, and Sleep

Masaya TAKAHASHII*, Hideki FUKUDA1, Keiichi MIKI1, Takashi HARATANII,

Lumie KURABAYASHI1, Naomi HISANAGAI, Heihachiro ARIT01,
Hideko TAKAHASHI2, Makiko EGOSHI2 and Misuzu SAKURAI2

' National Institute of Industrial Health

, 21-1 , Nagao 6 chome, Tama-ku, Kawasaki 214-8585, Japan
2 Department of Nursing 1-3, Hongo 3 chome, Bunkyo-ku, Tokyo 113-8431, Japan
, Juntendo Hospital,

Received December 10, 1998 and accepted February 24, 1999

Abstract: We compared the shift work-related problems between 16-h night shift and 8-h evening/
night shifts among nurses in a university hospital with respect to subjective symptoms, physical
activity, heart rate (HR), and sleep. The nurses of one group (n=20) worked a 16-h night shift under
a rotating two-shift system, while those of the other group (n=20) worked an 8-h evening or night
shift under a rotating three-shift system. The 16-h night shift was staffed by three or four nurses
who alternately took a 2-h nap during the shift, and had at least one day off after each shift. Subjective
symptoms and daily behavior were measured every 30 min by the nurses before, during, after each
shift as well as during days off using a time-budget method. Also, physical activity, heart rate (HR),
and posture were recorded during shifts. The results showed similar or lower levels of sleepiness,
difficulty in concentration, fatigue, physical activity, and HR during the 16-h shift compared to the
8-h shifts. No differences in subjective symptoms between the two shift schedules were observed
before or after the shifts or during days off. The main sleep was longer after the shifts and during
days off in the 16-h shift group than in the 8-h shift group. Our results suggest that the work-related
problems in 16-h night shift nurses may not be excessively greater than those in 8-h evening/night
shift nurses, as long as appropriate countermeasures are taken during and after the extended shift.

Key words: Shift work, l6-h shift, Nurse, Fatigue, Sleep

Introduction is that night shifts are longer than 8 h. The number of hospitals
in Japan that have a 16-h night shift is expected to increase
A two-shift system has been rapidly introduced as a work significantly in the future, as legislation has recently been
schedule for hospital nurses in Japan instead of the existing passed allowing night shifts as long as 16 h to be implemented
three-shift system (percentage of two-shift systems in Japan: in national hospitals5~.
26.6% in 1993 and 43.9% in 1996)1). The main reason for Although previous studies in 12-h shift nurses have had
this move to a two-shift system is the advantages it offers, contrasting findings, they have nonetheless revealed a number
such as lengthened days off resulting from longer intervals of negative consequences associated with increased shift
between shifts, fewer days of night shifts, and reduced length, including an increase in the number of health and
commuting time2_4~.However, one drawback to this system fatigue complaints6' 7) and decreased quality and quantity of
nursing care8-10~. In a related finding, studies involving
*To whom correspondence should be addressed . industrial workers on 12- and 14-h night shifts have showed
NURSES' STRESS ASSOCIATED WITH 16-H NIGHT SHIFT 229

Table 1. Age and shift work experience of nurses by ward under two- and three-shift systems

an increased level of fatigue and sleepiness, and poor
performance, especially during the final few hours of the
shift1-14~.Hence, the 16-h night shift may exacerbate shift
work-related problems in the nurses working it15~
In the present study, we compared the 16-h night shift
with the 8-h evening and night shifts among nurses in a
university hospital with respect to subjective symptoms,
physical activity, heart rate, and sleep. This hospital has
taken several measures for minimizing the potential
disadvantages of the 16-h night shift. Such measures have
included 1) increasing the number of nurses working each
16-h shift, 2) allowing the nurses a 2-h nap period during
each 16-h shift, 3) reducing nursing duties during shift; for
example, reducing the number of written records when
appropriate, and 4) scheduling at least one day off after each
16-h shift. Particular attention was given to the following
issues: differences in shift work-related problems between
wards'' 16),time courses of the subjective and objective
parameters, and sleep"' 'g). Parts of the present results have
been reported previously19>,
Methods
Participants
The present study was conducted in a private university
hospital located in an urban area of Tokyo, Japan.
numbers of nurses working under rotating two- and three-
shift systems were 53 and 62, respectively. The nurses were
chosen to be participants if they were in twenties, worked
shift for two or more years, were single, and lived alone in
a dormitory or an apartment. Thirty and twenty-seven nurses
met these selection criteria under the two- and three-shift
systems, respectively. Then, 20 nurses were randomly
selected from each group (Table 1). The wards studied
included one surgical and two mixed wards under the two-
shift system, while two surgical, one internal, and one mixed
wards under the three-shift system. All the participants were
given explanations concerning the details of this research
and recording methods for subjective symptoms and
physiological measures prior to the start of the study, and
gave written informed consent. The study protocol was
approved by the Ethic Committee of our institute.
Shift schedules
Under the two-shift system, the nurses worked three 8-h
day shifts (8:00-16:10) and one 16-h night shift (15:50-
8:10) followed by at least one day off a week. Three nurses
worked each 16-h night shift on the surgical and one mixed
wards, and four nurses on the other mixed ward. The 16-h
night shift nurses were allowed to alternately take a 2-h nap
between 22:00 and 6:00 on a bed prepared in a resting room
within a nurse station (Fig. 1). The mean numbers of the 8-
h day shifts, l6-h night shifts, and days off were 11.3 ± 2.2
SD, 4.9 ± 2.2, and 9.3 ± 0.9 times in one month during the
present study, respectively. The two-shift system was
The introduced four to nine months before the study. Under the
three-shift system, the nurses in principle worked a day shift
(8:00-16:10) followed by one day off, one to two night shifts
(23:30-8:10), one to two evening shifts (15:50-0:00), and
one day off, though the shift schedules varied between the
230 M TAKAHASHI et al.

catecholamines, and cortisol in both urine and saliva. Results

on these measures will be reported elsewhere.

Data analysis
Data for the 16-h night, 8-h evening and night shifts were
obtained from 20, 20 and 19 nurses, respectively. Data during
days off under the 16-h and 8-h shift schedules were obtained
from 19 and 17 nurses, respectively.
The subjective symptoms, daily behavior, physical activity,
Fig. 1. The number of nurses working 16-h night, 8-h evening and and HR were analyzed using the 4-h averaged values. This
night shifts. was done to prevent any missing values from the 2-h nap
during the 16-h shift from affecting the results and to obtain
data from equally segmented periods of time for analysis of
four wards. Two nurses worked each 8-h night shift and variance (ANOVA). For each participant, the percentages
were not allowed to take a nap. One or more additional of time with each subjective symptom and time spent in
nurses worked during the evening shift and the end of the each daily behavior within each 4-h period were calculated
night shift (Fig. 1). The mean numbers of the 8-h day, before, during, after the shifts and during days off. Then,
evening, night shifts, and days off were 11.5 ± 1.7, 4.9 ± the resultant percentages were averaged over the participants.
0.9, 4.1 ± 1.3, and 10.4 ± 2.2 times in one month during the Thirty-sec values of physical activity and HR during shifts
present study, respectively. were averaged for each 4-h period, while those data recorded
during napping on the 16-h shift were excluded from the
Study design calculation of an average score.
Based on the results of a pilot study made in the same We examined whether the subjective symptoms, physical
hospital, and as a result of other more practical considerations activity, and HR recorded during the shifts differed between
such as a necessity of completing the data collection by April the surgical, internal, and mixed wards by the Kruskal-Wallis
1997, we designed to investigate only the first shift of 16-h test. The results indicated that those measures were generally
night, the first shifts of 8-h evening and night, and the day higher on the surgical wards than on the internal or mixed
off under each schedule. By design, each day of data wards. Therefore,the subjective symptoms, physical activity,
collection was preceded by three days of day shifts and/or and HR recorded during the shifts were compared between
days off in order to minimize any possible carry-over effects the 16-h and 8-h shifts on the surgical or on the internal/
of a prior night shift. mixed wards separately.
The timing and length of sleep and naps were examined
Measures on each shiftday and day off. Napping was definedaccording
The methods used for data collection in this study have to the criteria of Rosa24~;that is, any extra period of sleep
been described in detail in a companion article20~.Briefly, lasting over 30 min with a time interval of more than 1 h
subjective symptoms and daily behaviorwere measured every from the main (i.e. longest) sleep period.
30 min and recorded by the nurses on a self assessment form
("Check Sheet") using a time-budget technique. The Statistical analysis
measurement was made during two (for the 8-h shifts) or The subjective symptom data for each 4-h period during
three (for the 16-h shift) consecutive days starting at 0:00 shifts were compared between the 16-h and 8-h shifts on all
on the day of each shift. The same measurement was made wards by the Mann-Whitney U-test. The data also were
during day off for each schedule. Additionally, physical compared between the two schedules on the surgical wards
activity, HR, and posture were continuously recorded every or on the internal/mixed wards separately by the Mann-
30 sec during each shift with an ambulatory monitor worn Whitney U-test. The 4-h averaged physical activity and
on the nurses' waist (ACTIVTRACER AC-300, GMS, HR during shifts were examined on all wards by two-way
Japan). The following information was also collected: repeated measures ANOVA with the Greenhouse-Geisser
subjective fatigue feeling21~,subjective assessment of sleep correction25~. For the ANOVA, shift schedule (16-h, 8-h)
quality22~, morningness-eveningness type23~, urinary was a between-subject factor, and time of day (16:00-20:00,

Industrial Health 1999, 37, 228-236

NURSES' STRESS ASSOCIATED WITH 16-H NIGHT
Table 2. Average percentages of time with each subjective symptom in each 4-h period during shifts on all wards and on surgical and
internal/mixed wards
20:00-0:00, 0:00-4:00, 4:00-8:00) was a within-subject
factor. Also, the physical activity and HR data were analyzed
on the surgical wards or on the internal/mixed wards
separately by the shift schedule x time of day ANOVA.
The subjective symptom data before and after shifts and
during days off were compared between the two schedules
on all wards by the Mann-Whitney U-test. The sleep/nap
data were compared between the two schedules on all wards
by unpaired t-test. All statistical analyses were performed
using SAS software (Release 6.12, SAS Institute, USA).
This paper reports the results of 5 subjective measures
(sleepiness, difficulty in concentration, fatigue, physical
dullness, and busy at work), 2 objective measures (physical
activity and HR), and sleep/nap data.
Results
1. Subjective symptoms during shifts
On the subjective symptoms variables collapsed across
all wards under each schedule (Table2), sleepiness, difficulty
in concentration, and fatigue during the 16-h shift increased
SHIFT 231
between 0:00 and 4:00, and was significantly higher than
during the 8-h night shift (p<0.05). Yet, those symptoms
lessened subsequently. As a result, their peak levels during
the 16-h shift were almost equal or lower than during the 8-
h evening or night shift. Physical dullness increased with
the elapsed time of each shift, and thereby was significantly
higher between 0:00 and 4:00 during the 16-h shift than
during the 8-h night shift (p<0.05). Overall, the number of
times the nurses reported being busy at work was fewer during
the 16-h shift than during the 8-h shifts. Similar results to
those mentioned above were obtained from both the surgical
and on the internal/mixed wards, but the differences between
the 16-h and 8-h shifts were not significant because of a
high level of variances in the scores (Table 2).
2. Physical activity during shifts
Significant reductions in physical activity were observed
during the 16-h shift compared to the 8-h shifts on all wards,
consistently between 0:00 and 8:00 (the effect of shift
schedule: F=17.38, df=1,37, p<0.01; Fig. 2). The effect of
time of day was significant (F=30.03, df=3,111, p<0.01),
 232 M TAKAHASHI et al.

Fig. 2. Time courses for physical activity during both 16-h night ( 0 ) and 8-h evening ) and night A ) shifts on all wards, on
surgical and internal/mixed wards. Values are means and SD.

Fig. 3. Time courses for heart rate during both 16-h night (0) and 8-h evening ( A) and night ( A) shifts on all wards, on surgical and
internal/mixed wards. Values are means and SD.

but the interaction between the two factors
statistically significant. These results were confirmed by a
separate ANOVA with two factors of shift schedule and time
of day with two levels ([16:00-20:00, 20:00-0:00] or [0:00-
4:00, 4:00-8:00]). In either the surgical ward (F=9.34,
df=1,12, p<0.01) or the internal/mixed wards (F=4.23,
df=1,23, p=0.051), lowered physical activity was observed
during the 16-h shift than during the 8-h shifts, especially
between 0:00 and 8:00 (Fig. 2).
3. HR during shifts
The HR was significantly lower during the 16-h shift than
was not during the 8-h shifts on all wards (the effect of shift schedule:
F=6.58, df=1,37, p<0.05; Fig. 3). A significant effect for
time of day was found (F=37.67, df=3,111, p<0.01) with a
non-significant interaction between the two factors. The
results were supported by a separate ANOVA with two factors
of shift schedule and time of day with two levels. Figure 3
shows the decreased HR during the 16-h shift compared to
the 8-h shifts both on the surgical and on the internal/mixed
wards, with a greater decrease apparent between 0:00 and
8:00. However, neither the effect of shift schedule nor the
interaction of shift schedule by time of day was statistically
significant on each ward. Only the effect of time of day

Industrial Health 1999, 37, 228-236

NURSES' STRESS ASSOCIATED WITH 16-H NIGHT SHIFT 233

was significant on the surgical (F=16.57, df=3,36, p<0.01)

and internal/mixed wards (F=17.66, df=3,69, p<0.01).
The above mentioned results may make it reasonable to
conclude that the differences in the dependent measures
(subjective symptoms, physical activity, and HR) observed
during the shifts were due to the shift schedule, rather than
the different specialities of the various wards.

4. Subjectivesymptomsbefore/after shifts and during days off

None of the subjective symptoms in any of each 4-h period
before and after the shifts were significantlydifferentbetween
the 16-h and 8-h shifts. Additionally, the measures taken
during days off did not differ significantly between the 16-
h and 8-h shifts, except for increased sleepiness observed
from 16:00 to 20:00 for the 16-h shift nurses compared to
the 8-h shift nurses (10.7 ± 15.2 vs. 3.7 ± 15.2%, p<0.05).

5. Timing and length of sleep/nap on both workdays and

days off
Figure 4 depicts the temporal distributions of the main
sleep and naps under the 16-h and 8-h shift schedules on
both workdays and days off. Table 3 summarizes the data
for timing and length of the main sleep and naps before,
during, after shifts and during days off. A longer main sleep
occurred before the 16-h shift than before the 8-h evening
shift (p<0.05). A 3.2-h nap was taken before the 8-h night
shift by 16 out of 19nurses. During the 16-h shift, an average
of 1.50 ± 1.30 h of nap was taken by almost all nurses. The
time for the beginning of nap was distributed from 22:00 to
4:00. After the 16-h shift, 4.2-h nap was obtained from 14:00
to 18:00, and this time period coincided with the main sleep
following the 8-h night shift. The main sleep following the
16-h shift started at midnight of the following day, and was
significantly longer (9.13 ± 2.00 h) than that following either
the 8-h evening shift (7.28 ± 1.92 h, p<0.01) or the 8-h night
shift (5.90 ± 2.02 h, p<0.01).
The main sleep during days off significantly increased
by 1.4 h for the 16-h shift nurses compared to the 8-h shift
nurses (8.70 ± 1.33 vs. 7.30 ± 1.77 h, p<0.05, Fig. 4). This
appeared to be due to both an earlier bedtime (p=0.14) and
a later wake-up time (p=0.08) for the 16-h shift nurses (Table
3). Data on the naps during days off did not significantly
differ between the 16-h and 8-h shift nurses.
Discussion
The present results indicate that the 16-h night shift
produced similar or lower levels of sleepiness, difficulty in
Fig. 4. Temporal distributions of main sleep and naps on workdays
and days off among 16-h and 8-h shift nurses. 16-N, 16-h night shift;
8-h E, 8-h evening shift; 8-h N, 8-h night shift. The ordinate means
the percentage of nurses who took a main sleep and nap for each 30-
min time period.
concentration, fatigue, physical activity, and HR during the
shift compared to the 8-h shifts. Although these symptoms
were elevated 12 h after the start of the 16-h shift, they
decreased afterwards. An analysis by wards suggested that
these results were due to the shift schedule, not to the
specialties of the various wards. Also, similar levels of
subjective symptoms before and after the shifts or during
days off were observed between the 16-h and 8-h shift nurses.
The sleep duration after the shifts and during days off was
longer for the 16-h shift nurses than for the 8-h shift nurses.
Our findings are consistent with those of previous studies
showing similar or reduced fatigue among the 12-h shift
nurses compared to the 8-h shift nurses16,26,27), Studies
involving other types of shift workers have suggested that
fatigue and sleepiness may be comparable between the
extended (12-14 h) and 8-h shifts28-32),In terms of the
subjective symptoms and sleep associated with the 8-h shifts,
our data agree with those of previous reports involving the
234
Table 3. Main sleep and naps taken before, during,
8-h shift nurses in Japan33-35).
The lack of excessively adverse consequences
connection with the 16-h night shift may be attributed to
the number of measures taken, which were outlined in the
Introduction. In particular, the increased number of nurses
working each 16-h night shift may be a crucial factor in
that it allows the nurses to take turns napping during the
shift. A minimum of two nurses works the shift between
22:00 and 6:00, and thus a nurse can take a 2-h nap
throughout. Indeed, the nurses spent an average of 1.5 h in
bed during the nap opportunity (Table 3). This may maximize
the beneficial effects of napping36-39). We previously
suggested that despite the effects of sleep inertia immediately
after napping, the nap taken during the 16-h shift may prevent
such symptoms as fatigue, sleepiness, and physical dullness
from increasing further40~. Moreover, reduction of the nursing
duties during the 16-h night shift may have been an important
contributing factor. The nurses working the 16-h shift can
pace their duties over the course of the shift, and in this way
reduce any feelings of stress related to a lack of time. This
may be related to nurses working the 16-h shift being less
busy at work than those working the 8-h shifts (Table 2).
M TAKAHASHI et al.
after each shift and during days off
Scheduled days off following the 16-h night shift may be
in essential for the institution of such a long shift. In the hospital
studied, the 16-h shift nurses have 48 h of rest by the next
day shift, whereas the 8-h shift nurses have only 16 h of
rest by the second day of each shift. The longer period of
non-work time resulted in 13.4 (9.13 + 4.23) h of sleep
following the 16-h night shift, which included a nap, as
opposed to 5.9 h of sleep following the 8-h night shift (Table
3). The increased amount of sleep may allow the nurses to
recuperate from their prior extended shift15,18,
41) Our results
also showed that the main sleep during days off was longer
among the 16-h shift nurses than among the 8-h shift nurses
(Table 3), suggesting the added advantage of taking more
sleep on their days off for the 16-h shift nurses. Alternatively,
the 16-h shift nurses, in order to recover completely, seem
unable to avoid taking the extra sleep during their days off.
In any case, it is reasonably assumed that if the measures
were not taken as in this hospital, the 16-h night shift would
produce a substantial increase in occupational health and
safety risk among the nurses.
Besides the effects of appropriate measures, the
characteristics of a given participant may have contributed
Industrial Health 1999, 37, 228-236
NURSES' STRESS ASSOCIATED WITH 16-H NIGHT
to our findings. Aging has been known to decrease the ability
to adjust to night work42'43) In addition, nurses with small
children are not able to set aside enough time to get a sufficient
amount of sleep or leisure compared to those without
children34,44),The fact that the 16-h shift nurses in our study
had mean age of 25.2 years, were single, and lived alone
may thus have made the 16-h night shift less problematic.
We did not compare objective levels of sleepiness and
performance using electroencephalogram and behavioral
tasks or the job content between the 16-h and 8-h shift nurses.
Night shifts have been shown to increase the risk of
medication error and needle stick injury45'46).Some studies
have revealed poor and less patient care during the 12-h
shiftsS-10).Further study is thus needed to examine the 16-
h shift effects on those variables.
In summary, the present study shows that the work-related
problems in 16-h night shift nurses may not be excessively
greater than those in 8-h evening and night shift nurses. Our
findings suggest the importance of the countermeasures taken
for minimizing the fatigue/stress resulting from a 16-h night
shift.
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