International Journal of Occupational Safety and

Ergonomics

ISSN: 1080-3548 (Print) 2376-9130 (Online) Journal homepage: http://www.tandfonline.com/loi/tose20

The effects of consecutive night shifts and shift

length on cognitive performance and sleepiness: a
field study

Rashid Haidarimoghadam, Reza Kazemi, Majid Motamedzadeh, Rostam

Golmohamadi, Alireza Soltanian & Mohamad Reza Zoghipaydar

To cite this article: Rashid Haidarimoghadam, Reza Kazemi, Majid Motamedzadeh,

Rostam Golmohamadi, Alireza Soltanian & Mohamad Reza Zoghipaydar (2016): The
effects of consecutive night shifts and shift length on cognitive performance and
sleepiness: a field study, International Journal of Occupational Safety and Ergonomics, DOI:
10.1080/10803548.2016.1244422

To link to this article: http://dx.doi.org/10.1080/10803548.2016.1244422

Accepted author version posted online: 04

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Publisher: Taylor & Francis & Central Institute for Labour Protection – National Research Institute
(CIOP-PIB)

Journal: International Journal of Occupational Safety and Ergnomics

DOI: 10.1080/10803548.2016.1244422

The effects of consecutive night shifts and shift length on cognitive performance and
sleepiness: a field study

1- Rashid Haidarimoghadam: Assistant professor, Ergonomics Department, Hamedan

University of Medical Sciences, Iran

Dr_haidari@yahoo.com

2- Reza Kazemi (correspondence) : PhD student of occupational health, Hamadan

University of Medical Sciences, Reza_kazemi2007@yahoo.com

Tel.: +98 813 8380025, +98 813 8380026; fax: +988138380509.

3- Majid Motamedzadeh: Full professor, Ergonomics Department, Hamedan University

of Medical Sciences, Iran

motamedzade@yahoo.com

4- Rostam Golmohamadi; Associate professor, Department of Occupational Hygiene,

School of Public Health, University of Medical Sciences, Hamadan,

5- Alireza Soltanian: Associate professor, Hamadan University of Medical Sciences,

Dept. of Biostatistics & Epidemiology

A_sultanian@yahoo.com

6- Mohamad Reza Zoghipaydar: Assistant professor, Buali Sina University Department

of Psychology

zoghipaidar@yahoo.com
1
Short title: consecutive night shifts effects on cognitive performance and sleepiness

Abstract:

Introduction: The aim of this study was to evaluate the effects of consecutive night shifts (CNS) and shift length
(SL) on cognitive performance and sleepiness. Materials and methods: This study evaluated the sleepiness and
performance of 30 control rooms operators (CROs) working in a 7 nights, 7 days, 7 days off (7N7D7O) and 30
CROs working in a 4 nights, 7 days, 3 nights, 7 days off (4N7D3N7O) shift pattern in a petrochemical complex
in the last night shift before swinging into the day shift. To assess the cognitive performance, n-back test,
continuous performance test (CPT) and simple reaction time test were employed. For assessing sleepiness the
Karolinska sleepiness scale (KSS) were used. Results: Results from the both schedules indicated that the correct
responses and responses time of working memory were reduced (p = 0.001), while intentional errors and
sleepiness increased during the shift work (p = 0.001). CNS had a significant impact on reaction time and
commission errors (p = 0.001). Conclusion: The main duty of CROs at a petrochemical plant is checking
hazardous processes which require appropriate alertness and cognitive performance. As a result, planning for
appropriate working hours and suitable number of CNS in a rotating shift system is a contribution to improving
CROs performance and enhancing the safety.

Keywords: consecutive night shift, performance, sleepiness

1. Introduction:

Technological and economic needs have led to an increase in the number of shift workers. In developed
countries, about 20% of the workforce is engaged in shift work and one third of them are working in night
shifts. [1-3]

Shift work and in particular night shift work is associated with many problems such as sleep deprivation,
sleepiness, decreased cognitive performance, increased human errors, and fatigue; it is also one of the major
contributors of increasing the likelihood of risk of accidents in the industry. [4] During the night shifts, the
length of the hours one sleep become 2 h less than a day shift and it mainly affects the second stage of sleep and
rapid eye movement (REM) sleep. Subjective and objective assessments such as electro-encephalogram and
electrooculogram have shown that the level of sleepiness will increase during the night shifts. [5]

2
All health and safety problems caused by shift work are rooted in the mismatch between the body's internal
clock and the environment which consequently lead to desynchronization and deregulation in circadian rhythm.
[6] Different shift schedules, with respect to length of shifts (8 or 12 h), rotation (fast or slow), direction of
rotation, and the number of CNS, are common in different industries. [7] Better matching between individuals’
circadian rhythm and night shift and higher work performance can be achieved via designing an appropriate
work shift pattern; [8] however, the main challenge is to identify and determine the optimum speed of rotation
of the shift, the number of CNS, and the length of the shifts. It is still controversial whether the increase in the
number of CNS will lead to a desirable match or not. [5] Based on the ergonomics recommendations,
minimizing the number of CNS and quick rotations can reduce the effects of shift work. [9] Quick rotations (3
to 5 shifts) are used In European countries and Japan with the aim of maintaining the stability of circadian
rhythm, However slow rotation (more than 7 shifts) are used in the USA with the aim of matching persons with
the night work. [8] Studies have shown that cognitive and motor disorders are more common among night
workers with quick rotations and they are more likely to commit a human error than shift workers with slower
rotating shifts. [7] Previous studies have demonstrated that circadian rhythms adaptation due to the consecutive
night works leads to improvement of the cognitive function and decreases sleepiness. [10] Studies on workers of
offshore oil rigs have shown that a match between sleep patterns and reduced sleepiness is achieved in shift
works with 4–6 consecutive night work. On the other hand, some other studies on offshore workers have
reported that the circadian rhythm adaptation was not achieved after seven CNS, and even some other studies
said that the adaptation was not achieved even after two weeks. [5, 11] Overall, previously conducted studies
have shown that offshore workers and people who were studied in simulated environments can more quickly
adapt themselves with night shifts which might be attributed to the control of confounding factors like sounds,
light, environmental conditions, and social and family commitments. [12, 13] On the other hand, some studies
have reported that working 12 h CNS reduced the visual memory capacity. [14] Previous studies have suggested
that the loss of consciousness and fatigue due to the night shifts are among the major causes of industrial
accidents such as the Chernobyl and Three Mile Island Accident accidents. [3]

In addition, based on ergonomic recommendations, 8-h shifts are more preferred than 10 h or 12 h long term
shifts; [9] the disadvantages of 12 h shifts are: increased fatigue, reduced performance, and increased risk of
accidents. [15] The CORs in Iran petrochemical industry commonly work in two shift work systems; these two
systems are 4 nights, 7 days, 3 nights, 7 days off (4N7D3N7O) and 7 nights, 7 days, 7 days off (7N7D7O),
which differ only in the number of consecutive nights. So far, no study has been conducted to assess the effects
of night shifts on cognitive performance and sleepiness in control rooms. Also, there is no information available
about the comparison of the two mentioned shift systems. CORs in petrochemical industry are responsible for
the safety of inherently hazardous processes via using complex displays [16] and their main task is to
continuously monitor processes, hence they need to have a good performance and enough consciousness and
they have to maintain their abilities throughout the shift. [16, 17] In view of that, it is very important to choose
better shift systems to reduce the risk of errors and dangerous events. This study was aimed to evaluate the
cognitive performance and sleepiness at the last night shift before shift rotation in the two abovementioned shift
schedules; the study tried to assess and compare the effects of SL and CNS on shift workers in a real

3
environment. Taking into consideration the tasks of CORs, the cognitive functions under the study included
working memory, sustained attention, and speed of reaction. [18]

2. Methods:

2.1. Procedures and Participants:

In this study we recruited a total of 60 individuals who were working as control room operators in petrochemical
industries which is the largest petrochemical complex in south of Iran; they were equally distributed in two
common shift work systems. Exclusion criteria were the use of hypnotic drugs, mental illness, major systemic
diseases, and sleep disorders. In both groups, day shift was from 7:00 to 19:00, night shift was from 19:00 to
7:00; the shift rotation from night shift to day shift was counter clockwise (backward). To study the effect of SL
on cognitive functions, the measurements were carried out at the first and the last half an h at beginning and the
end of the shifts, and to study the sleepiness, participants presented their sleepiness rates at 2 h intervals.
Moreover, to determine the effects of the number of CNS on cognitive performance and sleepiness,
measurements were carried out on the last night before rotating shifts (on the seventh night (NNNNNNN) in the
7N pattern, and on the fourth night (NNNN) in the 4N pattern). The demographic data which were collected
included age, education, history of shift work, number of caffeinated drink consumed during each shift and the h
of sleep during the previous day/night off. To observe ethical concerns, a written consent from was obtained
from all the participants prior to the study.

2.2. Measurements

2.2.1 Working Memory

Working memory is a limited capacity part of the human memory system and plays an important role in
performing complex tasks such as reasoning, comprehension, and learning. [19] To assess working memory we
used n-back test (manufactured by Sinapsycho, Iran), which has been frequently used to evaluate the memory
performance. [17] Although this test has rarely been used to assess shift workers in real work environments, it
has been repeatedly used in the laboratory to assess the impact of sleep deprivation on working memory. [20,
21] The n-back test is used to assess the ability to process, select, and save information in a short time. In this
study, the computer type and n = 1 was used because it has been shown that 1-back test is more sensitive for
people who have to deal with sleep deprivation.[20] In this test, a total of 120 numbers, one by one, are shown
in the center of the computer screen for 5 min, with an interval of 1500 ms. Participants should compare the last
number appeared in the screen with the one shown before; if the last two consecutive numbers are the same,
individuals should instantly press the answer button on the keyboard. The number of correct answers (scores)
and response time (ms) are recorded as the dependent variables of the study. This test is highly reliable for
evaluating the working memory. [22]

2.2.2. CPT

CPT (manufactured by Sinapsycho, Iran) is a standardized computer test which has an appropriate level of
reliability. This test is used for quantitative assessment of sustain attention over time. [23] Through the test, 150
4
visual stimuli are displayed on the computer screen, of which 20% of them are target stimuli, and when a target
stimulus is shown, the participants must press the space bar as soon as possible. Every visual stimulus is
presented for 150 ms, with a 500-ms interval between every two stimuli. Commission error, omission error, and
response time (ms) were recorded as the dependent variables of the study.

2.2.3. Simple reaction time test:

In this study, 5-min simple reaction time test (manufactured by Sinapsycho, Iran) was used on a personal
computer to measure the speed of reaction (Dell, model: Vostro 1320). This test has been validated for
measuring the performance, sleepiness, and fatigue. [15] The test was consisted of black squares that appeared
randomly on the screen with distributed time intervals. The participants were instructed to press a key on the
keyboard as soon as they observed the stimulus. The software recorded the response time in milliseconds. If no
response was given within 1750 ms, the new period would begin; if a participant pressed the key 120 ms before
or after displaying the stimulus, the answer was deleted and a warning signal alarmed. To eliminate device
errors, we used a personal computer for all participants. The mean and standard deviation were recorded as the
dependant variables.

2.2.3. KSS

Karolinska sleepiness scale (KSS) is used to measure sleepiness via self declaration. This test has a fairly good
level of reliability and validity. [24] KSS has a 9-point scale, where 1 = very alert; 3 = alert; 5 = neither alert
nor sleepy; 7 = sleepy; 9 = very sleepy and trying to stay awake.

2.2.4. Statistical analysis

Using mean and standard deviation indices we described the data which had been collected by each
measurement. To investigate the effects of the variables time shifts and the number of CNS on sleepiness and
cognitive functions, we made use of repeated measures analysis and linear Generalized estimating equation
(GEE) schedule. In this study, the effects of mental workload and IQ variables, as covariates of cognitive
functions, were modified and entered into the schedule. Kolmogorov–Smirnov test was used to evaluate the
normality of the data. The significance level was considered to be less than 0.05 and the data analyses were
performed using SPSS 20.

3. Results

Table 1 presents the demographic characteristics of the participants from the two shift work schedules, including
age, number of years of education, work experience, body mass index, number of caffeinated drinks consumed
per shift, and the amount of sleep one’s had in the 24 h prior to the study. That there was no difference between
two groups demographic and baseline. Characteristics in all the analyses related to cognitive performance, the
effects of the two confounding factors, i.e., IQ and mental workload, were adjusted. First, the effect of SL on
cognitive functions including working memory, sustain attention, and reaction time was evaluated in both

5
groups separately (figure 1 and Table 2). In schedule 7N, the independent variable, i.e., SL had a statistically
significant effect on the correct answers to n-back test (β = – 7, p < 0.001), response time in n-back test (β = 62,
p < 0.001), the number of commission errors in CPT test (β = – 6, p < 0.001), and reaction time (β =14,
p =0.040), however, it had no significant effect on the number of omission errors (B = – 1.2, p = 0.140), and
response time in CPT test (β = 14, p = 0.056). In schedule 4N, the SL had a significant effect on all the studied
variables including the correct answers to n-back test (β = – 1, p < 0.001), response time in n-back test (β = 72,
p < 0.001), number of commission errors (β = – 7, p < 0.001), reaction time (β = 41, p <0.001), the number of
omission errors (β = – 1.7, p = 0.040), and response time in CPT test (β = 23, p = 0.001). The results of the GEE
statistical analysis (Table 2) showed that the number of CNS had a significant effect on commission errors (β =
– 2, p = 0.010) and reaction time (β =17, p = 0.040) while it had no significant effect on other variables
including the n-back score (β = 2, p =0.130), response time to n-back test (β = 17, p = 0.500), omission error (β
= 0.7, p = 0.100), and response time in CPT test (β = – 0.8, p = 0.900). The mean of sleepiness during the shift
was 3.2 (2) in 7N and 3.6 (2.2) in 4N. Figure 2 shows the pattern of subjective sleepiness during the shift in the
two schedules; as shown in the figure, the sleepiness index was significantly rising in both patterns, however it
raised a steeper slope in 4N (β = 0.9, p = 0.001) than in 7N (β = 0.3, p =0.001). There was no significant
difference between the two schedules in terms of the mean sleepiness index (p = 0.150), and the interaction
effect of the number of CNS also was not significant (p = 0.300). On the other hand, as shown in Figure 2, the
mean value of sleepiness index associated with 3:00 and 5:00 in schedule 4N reached its maximum during the
shift and it was significantly different from that of schedule 7N (p = 0.01).

4. Discussion:

In the petrochemical industry, CROs usually play a key role in maintaining the safety of inherently dangerous
processes, hence they need to be alert and have a good performance. So these people need to be alert and have a
good performance. [16]

The results showed that independent variable of SL had negative effects on all the three studied cognitive
functions i.e. working memory, attention, and reaction time. To justify this finding we should point out the
factors that can affect the cognitive functions of shift workers. Previous studies suggested that the decline of
cognitive functions in shift workers could be due to circadian rhythm disorders, sleep deprivation, and fatigue
[25]

The most important influencing factor is the circadian rhythm disorder observed in night shift workers which
has been mentioned by many studies. [26] In a study by Ramírez et al. it was reported that a 1-h phase delay in
circadian rhythm was associated with a significant reduction in visual working memory and a 3-h phase delay in
circadian rhythm was associated with the reduction of audio and verbal working memory. [27]

Lack and deprivation of sleep is also highly associated with decreased cognitive functions. [28] Various studies
have mentioned that the night work interferes with the sleep/wake cycle and reduces the quantity and quality of
sleep. [10, 13] Night work decreases about 2 h of sleep and affects the second stage of sleep and REM sleep. [5]
On the other hand, working memory and attention, which were both assessed in this study, are associated with
6
the performance of the frontal lobe; moreover, the frontal parts of the brain are vulnerable and sensitive to sleep
deprivation. In the present study it was observed that the mean hours of sleep in the 24 h prior to the study in the
two groups was lower than the amount of sleep normally required by an individual, i.e., about 8 h; in addition,
the quality of sleep was also poor in both groups.

Another factor which declines the normal performance is the operators’ fatigue during the shift. In this study,
one of the performance assessment tools was the simple reaction time test that has a good level of reliability for
assessing fatigue. [15] Decreased reaction times at the end of the shift in both groups indicated the increased
level of fatigue at the end of 12-h shifts. Increased fatigue can reduce the capacity of working memory via
reducing information processing rate and slowing down information update in working memory, and it is also
likely to increase forgetfulness; the results of this study confirmed such findings. [20] Previous studies have
expressed fatigue as one of the main disadvantages of 12-h shifts which can reduce cognitive performance and
alertness and also increase the risk of accidents. [28] In line with the results of this study, Baulk et al. say that
fatigue significantly increases at the end of 12-h night shifts and this is associated with decreased cognitive
functions, particularly reaction time. [15] based on ergonomic recommendations, 8-h shifts are more preferred
than 10-h or 12-h shifts; because of the disadvantages of 12-h shifts such as increased fatigue, reduced
performance, and increased risk of accidents. [9] Fatigue and decreased alertness towards the end of a 12 hour
shift can be a real concern, particularly when the job is monotonous and sedentary such as monitoring Visual
Display Units (VDU) screens in control rooms. [15]
In the present study, the number of CNS was the other independent variable which was studied in addition to the
shift length. The results showed that the number of CNS had a significant effect on the parameters such as
reaction time and commission errors; as a result, participants in schedule 4N group who were working four
consecutive nights had lower cognitive performance.

Concerning the other parameters, though, no statistically significant difference was found between people
working at the two shift work patterns, schedule 4N had a relatively weaker performance. The findings of the
current study are in line with those of Chang et al. [7] they compared cognitive performance among three groups
of 2, 3, and 4 CNS workers and concluded that 2 night shift workers’ cognitive performance was lower than that
of 4N workers. Such results can be attributed to the differences in circadian rhythms adaptation to night work in
the two studied groups and its impact on the performance. Many studies have examined the effect of night work
on adaptation, and the majority of them reported that it is possible for circadian rhythms to be adapted to night
work; however the rate and speed of adaptation have been different in these studies. [6, 13, 26, 29]

The results of our study showed that in the shift pattern 7N, participants had higher levels of adaptations than in
shift pattern 4N, and consequently they had a better cognitive performance. In fact, it can be concluded that
there are some evidences indicating that with the increase in the number of CNS, people are more adapted to
night work, but the adaptation process is slow. This finding is consistent with the results of other studies, [7, 13,
14] but it is almost contrary to the findings of a study conducted by Bjorvatn et al.; they conducted a study on
workers of an offshore oil rig in the North Sea who were working at 12-h shifts and 14 consecutive nights (14-
day 12-h night shift). They found that adaptation was quickly occurred and was completed over 4 to 6 working
days and it improved cognitive functions. The difference in circadian rhythms adaptation reported by different
7
studies can be attributed to environmental conditions, particularly exposure to the light early in the morning.
[29, 30] Light is considered as an important factor suppressing melatonin. [2] The effect of exposure to light can
be measured by parameters such as intensity and the length of exposure. [31] An intensity of above 1000 lux
leads to severe suppression of melatonin and enhances alertness and performance; on the other hand, it has been
reported that accidental exposure to the bright light can generate more strong changes in circadian rhythm phase
than continuous light. [30] In this study, subjects were exposed to the relatively similar level of light during the
shift and there was a little difference between the average brightness of the control rooms. Nevertheless,
exposure to morning light, after finishing the shift and while returning to the home, might have contributed to
the reduced level of adaptation. Bjorvatn et al. reported that exposure to the early morning light had a negative
effect on adaptation and led to a delayed phase. [5] But contrary to expectations, the simultaneous effect of SL
and the number of CNS on cognitive performance was not significant. This means that the effect of time (shift
length) on cognitive functions was the same in both shift patterns, while it was expected that due to the higher
adaptation in the 7N, the slope of changes in cognitive function (parameter β) would be slower than the 4N. This
can be due to the larger number of working hours during each shift which resulted in fatigue at the end of the
shift. Appropriate conclusions cannot be reached because the parameters were measured only at the beginning
and end of the shift, hence, further studies are needed to extend measurements throughout the shift to answer the
question.

Sleepiness was the other dependant variable which was studied, and it had an increasing trend in both the shift
patterns; this finding was consistent with our first hypothesis saying that sleepiness increases during the shift.
This result is consistent with the principles of circadian physiology. [31] and the results of other similar studies.
[15, 32]

Quality and quantity of sleep are the next influencing factors; as the results showed, both studied groups had
poor sleep quantity and quality. Although there was no statistically significant difference in the slope of changes
in sleepiness during the shift between the two groups, the peak of fatigue was observed at 3:00. [7] It is
observed that in comparison with the 7N, people in the 4N pattern were suffering more from sleepiness. This
finding indicates that with increasing the number of consecutive nights, adaptation increases. The results of our
study are in line with the results of Waage et al.’s study which reported that with the increase in the number of
night shifts, sleepiness decreased due to circadian rhythm adaptation. [12] In addition, in Baulk’s study, the
sleepiness in the second night decreased and was less than the first night; this is in line with the results of our
study. [15]

Although our observations suggest that slower rotation shift can be used as a promising schedule to cope with
cognitive performance and drowsiness in sensitive situation such as control rooms, however this is conflicted
with others that suggest a rapid shift rotation is better than of slow rotation. They suggest fast rotation (2–3
consecutive nights) system may reduce disruption to body rhythms and physiological disorders and also
provides time for some social interaction each week. [9] But reduce the performance is one of the disadvantages
of schedules with quick rotation. [5,7] Therefore, considering the results of this study for places like control
rooms, in which proper performance of shift workers is preferable for safe working, the shifts with

8
slow rotations can be better than rapid rotations. Of course, these results cannot be generalized to all jobs or
industries, because priorities for the prevention of the shift work effects can be varied in different spaces.

Limitations of the Study:

Similar to the other studies, this study had several methodological limitations which are worth mentioning. The
first limitation was the limited number of measurements during the shift. Cognitive functions were measured at
the beginning and the end of shift and consequently it did not allow a proper evaluation of the effect of time.
Given the association between circadian rhythms and time and its impact on performance, increasing the
number of measurements will results in more complete results. The lack of a control group was another
weakness of the study. This problem can be solved in two ways: first, comparing the results of the
measurements with the first night of the shift in both shift patterns; second, the use of a control group of non-
shift workers. to compare these two shift patterns, there is a need for a more comprehensive study to address the
entire cycle of work (night, day, and off) in both shift patterns; Finally, although it was considered that cognitive
performance decline is related to increased human error and accident rate but, the significant findings in this
study cannot be generalized to safety at night shift working. Thus, future research should compare the safety and
accident rate between the two night work schedules. However, this study had two advantages: first, it was
conducted as a field study; second, the confounding factors, especially exposure to light, the task of operators,
and participants’ sex and age, were similar in both groups. Hence, this study had the features of an in
experimental study and consequently such a condition increases the reliability of the results.
In conclusion, in line with the previous studies, our study showed that at the end of the 12-h shifts cognitive
performance reduced and sleepiness increased. Such a condition can increase the risk of committing human
errors and process accidents. On the other hand, cognitive performance and sleepiness index were better in 7N
pattern than in 4N pattern, which indicated the more convenient adaptation in 7N pattern. The slow adaptation
might be attributed to the interference of environmental conditions, particularly exposure to morning light, as
well as individual differences. Utilization of appropriate shift lengths and proper number of CNS in a rotating
shift system can enhance the CROs’ performance and attention and therefore improve the level of safety in the
workplace.

Acknowledgements

This study was supported by Hamadan University of Medical Sciences and was conducted in partnership with
National Petrochemical Company. The authors of this paper would like to appreciate the financial support
provided by Hamadan University of Medical Sciences and would like to thank the manager of Health, Safety
and Environment (HSE) department of Iran's National Petrochemical Company who helped us to conduct the
study.

9
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 Figure1: Mean n-back and CPT data (SEM) at start (dark), and end (bright) of shift across
night shift schedule, for (a) Mean n-back correct response; (b) n-back response time (ms); (c)
omission error in CPT; (d) commission error in CPT, (e) responses time in CPT and (f)
simple reaction time (ms)

Note: error bars denote 95% confidence interval (CI) of a mean. 4N = 4 nights, 7 days, 3 nights, 7 days
off shift pattern; 7N = 7 nights, 7 days, 7 days off shift pattern; CPT = continuous performance test

Fig2. Mean KSS values in two different shift schedules

Note: 4N = 4 nights, 7 days, 3 nights, 7 days off shift pattern; 7N = 7 nights, 7 days, 7 days off shift pattern;
KSS= Karolinska sleepiness scale.

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Table 1: Comparison the baseline of Mean±SD for studied participants between two groups

Variables 7N 4N p

Age 31.1 ± 2.6 29.2 ± 1.9 0.300‡

Shiftwork 6.3 ± 1.0 5.5 ± 0.9 0.060‡

experience

Sleep quantity 7.0 ± 1.12 6.47 ± 0.95 0.267‡

Sleep quality 6.7 ± 3.62 6.4 ± 3.12 0.163‡

Caffeine 2.72 ± 1.46 2.86 ± 1.2 0.698‡

B.Sc. or higher 19 ± 63.3 19 ± 63.3 0.605†

degree

Note: ‡ t test, † χ² test

Note: 4N = 4 nights, 7 days, 3 nights, 7 days off shift pattern; 7N = 7 nights, 7 days, 7 days
off shift pattern;

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 Table2: Generalized Estimating Equation (GEE) Analysis Results for Cognitive Measures
with Significant Effects

SL effect

4N
7N CNS effect
β [95%CI] p β [95%CI] p β [95%CI] p
Cognitive variables
n-back Correct number –7[–10,–4] 0.001 –13 [–16,–9] 0.001 2 [–2,5] 0.130

Response time 62[88,23] 0.001 72[98,29] 0.001 17[–32,66] 0.500

CPT Commission error –6[ –6,–5] 0.001 –7[–7,–1] 0.001 –2[–3,–1] 0.010

Omission error –1.2[–3,0.37] 0.141 –1.7[–4,0.5] 0.040 0.7[–2,0.30] 0.100

Response time 14[–0.154 0.056 23[11,35] 0.001 –0.815[–13,11] 0.900

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 ,28]

Simple Reaction time test 14[.656,27] 0.040 41[10,29] 0.001 13[4,24] 0.04

Note: 4N = 4 nights, 7 days, 3 nights, 7 days off shift pattern; 7N = 7 nights, 7 days, 7 days
off shift pattern; CNS = consecutive night shift; CPT= continues performance test, SL = shift
length.

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