Working Hours at workplace

2007:7

Healthy Working HoursReport of the research and development project

2KUVAILULEHTIPRESENTATIONSBLADPRESENTATION

Tekij(t) - Frfattare - Author(s)

Marja Paukkonen, Tiina Pohjonen, Tarja Hakola, Harri Lindholm, Heli Sistonen and Riitta SimoilaJulkaisun nimi Publikationens titel Title of the PublicationHealthy Working Hours : report of the research and development project

Julkaisija - Utgivare - Publisher

City of Helsinki Health Centre

Julkaisuaika - PublikationsdatumPublished

2007

Sivumr, liitteet - Sidoantal, bilagorPages, appendixes

45Sarja - Serie - Series

Helsingin kaupungin terveyskeskuksen raporttejaOsanumero - Del nummerPart number

2007:7ISSN

1459-9112ISBN

978-952-223-191-8Kieli - Sprk - Language

englishTiivistelm - Referat Abstract

The purpose of the Healthy working hours research and development project was to implement shift workarrangements as recommended in basic health care. The goal was to produce healthier shift design for nursesirregular shift work and to measure the effects of the changes to the shifts. In practice, the change implementedwas the reduction of quick returns (the evening shift followed by the morning shift). The off-duty time betweenshifts was extended with the idea that this would ensure good recovery from work. There were a total of sixdepartments participating, all from the City of Helsinki Health Centre acute and long-term care. There was aquestionnaire conducted among the nurses (n=75) both before the new shift arrangements (in 2005) and after theintervention (in 2006). In addition, the effects of the intervention were assessed by occupational physiologicalmeasurements.

Extending the recovery time in connection of evening and morning shifts improved significantly the nurses sleepquality and alertness, their well-being at work and their perceived health, and facilitated their taking on leisure timeactivities regardless of their age group. Along with the longer recovery times, work was felt to be less strenuousphysically in both morning and evening shifts even though the working processes as such were not changed andthe work load remained unchanged. Every fourth participant had their cardio-respiratory fitness below the levelrecommended for good health. During the working day, the energetic demand was the highest during treatmentprocedures, occasionally reaching up to mid-levels in energy expenditure.

The conclusion drawn was that healthier organization of working times is possible in nursing. By altering shiftarrangements appropriately, it is possible to facilitate well-being at work and improve health statuses. According tothe results, ergonomic shift planning should be the recommended mode of shift planning for nursing, supportinghealthy careers and total well-being for employees. From the point of view of the well-being of employees, it isessential to adhere to sufficient recovery and rest periods. Nursing work as such is not enough to ensure thesufficient cardio-respiratory fitness. To maintain work ability, leisure time exercise is necessary, too. Sufficientlevels can be reached by brisk walks a few times a week or other similar activities.

The Healthy working hours research and development project is venture No. 105273 of the Finnish WorkEnvironment Fund.

Marja Paukkonen: City of Helsinki Health CentreTiina Pohjonen: City of Helsinki Occupational Health CentreTarja Hakola: Finnish Institute of Occupational HealthHarri Lindholm: Finnish Institute of Occupational HealthHeli Sistonen: Finnish Institute of Occupational HealthRiitta Simoila: City of Helsinki Health Centre

Avainsanat - Nyckelord - Key words

Shift work planning, rota planning, working hours, shift work, personnel, health, health careHintaPrisPrice

JulkaisumuotoPublikationsformPublishing form

Julkaisun myynti ja jakelu:Sosiaali- ja terveydenhuollon tietopalveluPL 7010, 00099 HELSINGIN KAUPUNKIPuhelin: 310 43772Telekopio: 310 43151Shkposti: [email protected]: Sosv Kirjasto Hki/Sosv

Distribution och frsljning:Social- och hlsovrdens informationstjnstPB 7010, 00099 HELSINGFORS STADTelefon: 310 43772Telefax: 310 43151E-post: [email protected]: Sosv Kirjasto Hki/Sosv

Distribution and sales:Social and Health Care Information ServicesPB 7010, 00099 Helsingin kaupunkiTelephone: +358-9-310 43772Telefax: +358-9-310 43151E-mail: [email protected]: Sosv Kirjasto Hki/Sosv

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3TABLE OF CONTENTS

1 BACKGROUND AND PREMISES FOR THE PROJECT .................................................. 4

1.1 Organization of the project........................................................................................................................41.2 Ergonomic shift planning and health ........................................................................................................51.3 Shift work and work-related stress in the field of nursing........................................................................61.4 Occupational physiological measurements................................................................................................7

2 GOALS ............................................................................................................................. 8

3 PERSONNEL STUDIED, METHODS OF STUDY ............................................................. 8

3.1 Departments...............................................................................................................................................83.2 Changes to shift schedules .........................................................................................................................93.3 Methods applied....................................................................................................................................... 123.3.1 Questionnaire........................................................................................................................................... 123.3.2 Occupational physiological measurements and performance capacity tests .......................................... 143.3.3 Statistical methods ................................................................................................................................... 15

4 PROJECT PROGRESS .................................................................................................. 16

5 RESULTS AND DISCUSSION........................................................................................ 18

5.1 Results of the intervention on the basis of the questionnaire .................................................................. 185.2 Physiological impacts of the intervention ................................................................................................ 265.3 Physical stress of nursing and performance capacity.............................................................................. 27

6 EXPERIENCES OF THE PROGRESS AND IMPLEMENTATION OF THE PROJECT ... 30

7 CONCLUSIONS AND RECOMMENDATIONS ............................................................... 33

41 Background and premises for the project

1.1 Organization of the projectThe Healthy working hours project (Terveet tyajat) was a joint venture by the City ofHelsinki Health Centre, City of Helsinki Occupational Health Centre and Finnish Instituteof Occupational Health, funded by the Finnish Work Environment Fund and the City ofHelsinki (appropriations for well-being at work).

The ethical committee of the Hospital District of Helsinki and Uusimaa, HUS,commended the research plan on 8 November, 2005. On 22 June, 2005, the managingdirector of the Health Centre gave the project the approval to proceed with the researchon the basis of the presentation given by the research coordination team.

The project coordination and communications were the responsibility of the projectcoordinator, Ms. Marja Paukkonen. The steering group of the project dealt with projectprogress issues in its meetings and guided the project in its work towards the agreedgoals on the agreed schedules. The steering group met ten times during the period 16November 2005 - 4 September 2007. The composition of the steering group was thefollowing:

Health Centre- Riitta Simoila, Development Director, Chair- Marja Paukkonen, Safety Officer (as of May 2007, Occupational Health and

Safety Manager), Secretary- Seija Meripaasi, Director of Nursing Services, Kivel hospital- Hannele Hyvnen, Vocational Nurse, Kivel hospital

Occupational Health Centre- Tiina Pohjonen, Development Manager- Jarmo Tuominen, Chief Occupational Health Physician (until May 2006)- Marjatta Pekkarinen, Occupational Health Physician (as of May 2006)

Personnel Centre- Elli Pekkarinen, Labor Law Attorney (until May 2006)- Pivi Rissanen, Labor Law Attorney (as of May 2006)

Institute of Occupational Health- Tarja Hakola, Senior Specialist- Harri Lindholm, Medical Specialist in Clinical Physiology

The project group established for the venture dealt with issues of practical shift planning,implementation of measurements and measuring instructions, and helped in honoring theoverall project plan. The project group met seven times during the period 17 December2005 - 29 March 2007. The composition of the project group was the following:

Health Centre- Marja Paukkonen, Safety Officer (as of May 2007, Occupational Health and

Safety Manager), Chair- Marketta Anttila, Head Nurse, Laakso hospital, department 1- Veli Sova, Head Nurse, Herttoniemi hospital, department 7

(until January 2006)- Ritva Monto, Head Nurse, Herttoniemi hospital, department 7

(as of January 2006)

5- Marja Hartikainen, Head Nurse, Kivel hospital, department 3- Jaana Kairenius, Head Nurse, Kivel hospital, Secretary- Kirsti Kosonen, Head Nurse, Kivel hospital, department 21

(as of January 2006)- Seija Hnnikinen, Head Nurse, Suursuo hospital, department 11 (on working

leave 2006), deputized by Marjatta Halme, Assistant Head Nurse- Paula Huovinen, Head Nurse, Koskela hospital, department F3- Ritva Jntti, Director of Nursing Services, Herttoniemi hospital- Jaana Tevalin, Vocational Nurse, Herttoniemi hospital

Occupational Health Centre- Taina Veikkola, Occupational Health Nurse

Personnel Centre- Elli Pekkarinen, Labor Law Attorney (until May 2006)- Pivi Rissanen, Labor Law Attorney (as of May 2006)

Institute of Occupational Health- Tarja Hakola, Senior Specialist- Heli Sistonen, Specialist

1.2 Ergonomic shift planning and health

Irregular working hours are common in nursing, affecting both the well-being of patientsand the health of employees. There are studies on the effects of fatigue on theperformance of especially doctors and nurses (Felton 1998). Vocational nurses havebeen studied quite little even though their input is so important from the point of view ofpatients' well-being. Their working hours in hospital departments extend over all the 24hours of the day 7 days a week.

Nursing is demanding and involves high accountability, and its total work load isconsiderable. The quality of patient care depends directly on the work of skilful andcaring nurses; therefore, the health and work capacity of personnel form a critical factorin the view of the results of the work.

The need of professional, skilled nurses will increase as the population ages while theshortage of nurses is the reality already. Nurses are stressed further by inconvenientworking hours like extensive working hours, weekend work, evening and night-time work,insufficient breaks during working shifts, and even having to take on two jobs in order tomake reasonable pay. Stress experienced in the field of nursing is on the increase eventhough work-related strain in other fields is declining. The growing conflict between thedemand and the resources available creates an increasing amount of overload(Wickstrm 2001).

Irregular shift work has an effect on a persons health (Hakola et al, 2007). For example,the risks of cardiovascular diseases, sleep disturbances and accidents are all increased(Terveystarkastukset tyterveyshuollossa 2006, Physical examinations in occupationalhealth services in 2006). Recent studies have shown that onsets of diseases are causedby disturbances in diurnal rhythms. Factors contributing to shift work-related diseasesinclude exposure to e.g. stress, insufficient off-duty time to recover from work andunhealthy ways of life (as to exercise and nutrition) and management of fatigue byartificial means (cigarettes, alcohol, medicines, stimulants).

Irregular working hours have an effect on a persons mental well-being also, affectingmoods and leading to anxiety and strain, even to exhaustion. Working conditions

6compounded to inconvenient working hours produce joint effects causing still moreoverload.

The shift schedule can be planned to be more or less ergonomic from the point of view ofthe employees health, functional capacity and well-being (Knauth and Hornberger 2003).The features of an ergonomic shift plan include? regularity? fast forward rotation system? 8-10 hour shifts? 10-12 hours off-duty between shifts and? periods of days off uninterrupted, weekends as well.

The more regular the schedule, the more predictable it is. This increases the well-beingof employees and makes the planning of shifts easier. Another important factor is theappropriate timing of work and rest periods. The third factor to consider is the positioningof free day periods within the shift system.

Under the Working Hours Act, the working hours in hospitals are flexible. According tothe Act, the working hours in a three-week period must not exceed 114 hours and 45minutes. The daily working hours are limited by the stipulations in the Act concerning theminimum rest periods. In the general municipal agreement, the maximum length of aworking day is 10 hours, but exceptions are allowed as agreed by the labor union andthe employer locally (KVTES, Working Hours Act, local agreements).

1.3 Shift work and work-related stress in the field of nursing

In a study conducted within the municipal sector, almost every third woman of over 55 felttotally exhausted after her working day (Forma et al. 2003). Women in geriatric workwould seem to have their work ability noticeably weakened as early as in the age of 40-44, and significantly weakened after the age of 55 (Pohjonen 2001a).

According to recent domestic estimates (Rauhala et al. 2007), an increase of 30% to theoptimum level of strain in nursing work increases the number of sick leaves 1.5 times. Atthe yearly level, this means about 12 extra days for sick leaves.

Risk factors connected to life-style diseases increase the absenteeism of nurses in bothdaytime work and in shift work. The joint occurrence of high cholesterol, overweight, highblood pressure and disturbed sugar levels lead to the risk of absenteeism 2.2 timeshigher than in cases where this combination of risk factors is nonexistent (Kivimki et al.2006). Follow-up studies have shown that certain unsatisfactory features of work such aspoor opportunities to exert influence and insufficient social support networks increase therisk of careworkers physical condition and functioning capability deteriorating (Cheng etal. 2000, Brown et al. 2006).

Work load measurements conducted in shift work environments in the field of geriatricinstitutionalized care show that some employees work at levels that drain theirfunctioning capacity perhaps eventually causing problems of fatigue. In nursing, differingfrom industry, employees take on morning shifts immediately after evening shifts, whichcauses them a shortage of night time sleep preventing them from having the 7-8 hoursrequired. During the night after an evening shift, the recovery of the autonomous nervoussystem is deficient and the hormonal load is initially higher in the morning of the nextworking day than after a morning shift. People adjust to shift systems in their individual

7ways, but morning shifts immediately following evening shifts may increase the risk ofoverstrain situations (Pohjonen et al. 2003).

1.4 Occupational physiological measurements

Traditionally, the work-related fatigue and strain experienced by employees has beenstudied by surveys inquiring into their mental well-being. Inquiries about energypotentials and symptoms do not always suffice to assess the work-related strain. Inaddition to paper surveys, information on employees adjustment and recovery capacityis acquired by testing autonomic neural function and hormone content. Long-term stressdrains on a persons regulatory systems weakening the hormone secretion especially.Autonomic imbalance and disturbed hormonal secretion may contribute to the onset ofillnesses (Lindholm 2004).

Constantly increasing arousal in the sympathetic nervous system, detected inreactivity tests of the autonomous nervous system, has been presented as apredisposing factor for blood vascular diseases in recent studies. Good organizationof work and good management can thus have great significance in the prevention ofunwanted health-related effects. Physiological measurements can be used assupplementary methods in studying work-related loading but their results mustalways be put in relation to other assessments and the interpretation of the resultspresumes high expertise especially in case of aging employees. Especially inphysically straining work, the need for recovery time increases as the person ages(Lindholm 2004).

The state of the autonomous nervous system can be assessed by heart ratevariation (HRV, Saalasti 2003). A detailed analysis of the heart rate variabilityreflects the balance between the sympathetic, accelerating part and theparasympathetic, relaxing part of the autonomous nervous system (Porges 2003).In stressful situations, the sympathetic part is dominant even when recovery shouldbe taking place. The physical condition of a person has a significant effect on theeffectiveness of his or her stress-regulating systems, capability to adjust to physicaland mental strain and ability to recover from them.

Cortisol, analyzed from saliva samples, is an important stress hormone that iscommonly used for studying of work-related strain. In stress the secretion of cortisolis often consistently high but a very long-term overload can attenuate the secretion.Changes in cortisol balance cause disturbances in carbohydrate metabolism,increase sensitivity to infections and may contribute to the onset of autoimmunediseases. Cortisol has unfavorable effects on the areas of the brain that controlmemory and emotions. Increased cortisol levels may also sensitize to the feelingsof symptoms and uncomfortable sensations (Lindholm and Gockel 2000).

The findings from cross-sectional studies and short interventions of a few weeks arecontradictory regarding physiological and psychological stress variables. Shortinterventions like physical therapy have improved the mental well-being but therehave not always been any changes detected in the physiological stress levels (Bostand Wallis 2006). On the other hand, a guided six month relaxation intervention forFinnish hospital cleaning personnel both improved their coping at work andbalanced their autonomous nervous systems (Toivanen 1993). Longer follow-upstudies have shown the interconnection between nurses moods and stresshormones (Davydov et al. 2007). The characteristics of shift work impactemployees working capacity. In nursing, it has been seen as especially important to

8ensure sufficient recovery time between evening and morning shifts (Sveinsdottir2006).

2 Goals

The primary goal of the project was to develop shift work models that would nurturethe employees health and to assess the function and effectiveness of the changesimplemented in the shift work. In addition, the loads caused by care work wereassessed together with how the recovery from strain took place.

This is the first study to implement the principles of ergonomic shift planning in carework. The physiological effects of changes to working hours have not beenmeasured earlier, either.

3 Personnel studied, methods of study

3.1 DepartmentsThe aim was to find a balanced set of in-patient wards in Helsinki Health Centreacute hospitals, long-term care hospitals and psychiatric wards. The selection ofdepartments took place among volunteer ones who were ready to commit to thegoals of the project. The directors of nursing services, head nurses and otherpersonnel took part in discussions before the selection. On the basis of thesediscussions, the selected participants finally included four long-term caredepartments (Kivel hospital departments 3 and 21, Suursuo hospital department 11and Koskela hospital department F3) and two acute hospital departments (Laaksohospital department 1 and Herttoniemi hospital department 7).

The task of an acute hospital is to diagnose and nurse patients somatic diseasesand to return the patients to their normal functioning capabilities. The key issues inthe human resources management of an acute hospital are ensuring the skill leveland well-being of the personnel and inducting all new employees sufficiently. In orderto ensure the success of recruiting, flexibility and individuality are applied to tasksand working hours.

The basic task of the long-term care department of the Health Centre is to arrangethe long and short term hospital and hospice care for Helsinki people, supportingtheir rehabilitation and functional capacity. Nurses and vocational nurses care forpatients supporting their rehabilitation and functional capacity in a manner that notesthe individuals resources, working in cooperation with the patient, the family and amultidisciplinary team. The majority of the services of acute and long-term carehospitals are provided for elderly patients.

93.2 Changes to shift schedules

Prior to the intervention, the working time arrangements of the participatingdepartments were analyzed with the ergonomics tool of the Shift Plan Assistantsoftware (Ximes, Austria). The six week rotas were used for calculating the durationsof working times, the timing of shifts and the intervals of work and off-duty times. Thenumbers of hours, times of day and numbers of shifts were compared to therecommended load limits. Even though all work arrangements, on average (table 1),were in order there were stress factors in the rotas such as high numbers of weeklyworking hours, recurrent rotations of morning shifts following evening shifts withintervals of nine hours only in between and long stretches of working shifts (even tenconsecutive shifts).

10

Table 1. Sample rota analysis prior to intervention.

Company Hospital Start date 13 Sep Material 19Unit Department End date 24 Oct N:o of shifts 504Job Nurse N:o of days 6 wk N:o of night shifts 60

Description Minimum Maximum Average LimitWorking hours per week 08:00 57:30 36:05 48:00Working hours per day 07:39 09:45 08:13 09:00Morning shift start time 07:00 08:00 07:30 06:00Night shift end time 07:30 07:30Morning shift duration 06:15 08:00 07:25 10:00Evening shift duration 08:00 09:00 08:20 10:00Night shift duration 10:00 10:00 10:00 09:00Consecutive night shifts 4 7 6Consecutive working days 1 8 6

Rest period between shifts 09:00NIGHT

14:00 11:00Weekly rest 32:45 168:00 82:50 36:00Days off on weekends 0 % 83 % 44 % 25 %Consecutive days off 1 7 2,07 2,00

In addition to the results of the ergonomic analysis, the contents of the answers tothe open survey questions were analyzed as to how the pros and cons of theworking hours were experienced (figures 7-8). In practice, the interventionconsisted of decreasing the number of consecutive evening-to-morning shiftrotations in two and three shift work. Shorter working periods was implemented aswell (figure 6). There were no interventions implemented in cases of regular nighttime work, as those were few only, and all of them were based on personalindividual agreements. The intervention began in January 2006 and lasted for 12months.

The implementation of the intervention was monitored throughout the project. Theproject coordinator monitored the rota planning with MD-Titania, an electronic rotaplanning system. The departments kept statistics of the planned and actualevening-to-morning shift rotations, numbers of working hour wishes from thepersonnel, and the unoccupied shifts (appendix 1). The planning was affected bymany department internal and external factors such as number of employees,number of missing employees, the time of year etc. (chapter 6).

At the end of the project, there were ergonomic analyses of the rotas completed,corresponding to those at the beginning. In addition to the evening-to-morning shiftrotations, the rotas were used for counting the distribution of days off. Figures 1show an example of a departments rota prior to the intervention and after it. It isnoticeable how the evening-to-morning shift rotations decreased with theintervention. In addition, the single days off did not increase essentially (figure 2).Appendix 2 shows the situations in other departments prior to the shift changes andafter them.

11

Figure 1. Sample rota (department A) prior to the intervention (above) and after it(below) presented by shift type (D=morning shift, A= evening shift,N=night shift, empty cell=days off, evening-to-morning shift rotations inred and single days off in orange).

0

0,5

1

1,5

2

2,5

3

3,5

1 2 3 4 5 6 7 > 7

days off

beforeafter

Figure 2. Distribution of days off before intervention and after it (6 week average,department A).

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3.3 Methods applied

3.3.1 Questionnaire

The questionnaire was made to learn about the effects of the current shiftarrangements on the physical, mental and social well-being of the employees. Thequestionnaire was based on the international Standard Shiftwork Index (Barton et a.1995).

The basic structure of the questionnaire was the following:- Background information (age, sex, weight, height, profession, work

experience, shift work experience).- Questions relating to work and working hours, clarifying the characteristics

of the current shift system (type of working time, possibilities for exertinginfluence on working hours, timing of shifts, their durations, numbers ofconsecutive shifts and spacing of off-duty days) and the employeesexperiences of the effects of the current system (open questions).

- Questions relating to working conditions and the working community,clarifying the functioning mode of the community (experienced stress,organization of work, goals, working community, quality of managerialwork, work satisfaction).

- Questions relating to sleep and alertness, clarifying the problems typical ofshift work and connected to sleep and sleepiness (amount and quality ofsleep and, sleepiness at work and while off-duty). In addition, varioussomatic symptoms were charted.

- Questions relating to the compatibility of work and private life.- The follow-up study included additional questions on how the changes

implemented during the project had made their impact (working hourarrangements, working conditions, well-being, sleep and alertness).

The questionnaire form was sent to each respondent personally, and was returnedto the occupational health service providers. The main survey was conduced inAugust 2005 and the follow-up in November 2006.

The questionnaire form was distributed to all the employees in all the departments(n=104). There were 98 replies to the main survey and 89 replies to the follow-upone (return percentages 94 and 86 respectively, table 2).

Table 2. Background information, all respondents.

before N=98 after N=89

Average interval Average interval

Age (yrs) 45 20-62 45 20-61

Female (%) 94 94

Work experience (years) 22 0-42 20 0-42

Shift work experience (years) 17 0-40 17 0-38

Current system (years) 10 0-33 6 0-34

13

There were 75 persons who provided answers to both surveys. 95% of them werewomen, and the average age was 46 +10 years. Three groups were created inorder to study the age groups (ages 20-40, n=23, ages 4152, n=26 and ages 5362, n=26).

The job titles involved were nurse (n=29), vocational nurse and practical nurse(n=39), head nurse, assistant head nurse and department secretary (n=7). Theforms of work were two-shift, three-shift, daytime work and night-time work,alternating by department (figures 3-4).

10 7 6 5 618

80

65 69

43

12

9

10

1419

47

63

64

146 5

199

0

25

50

75

100

A B F C D E

night3-shift2-shiftday

Figure 3. Types of working time (%) per department (A-F) before intervention.

9

46

37

88

54

26

12

0

25

50

75

100

day 2-shift 3-shift night

beforeafter

Figure 4. Types of working time (number, n=75) before and after intervention.

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3.3.2 Occupational physiological measurements and performancecapacity tests

The physiological well-being and work strain were monitored during for the durationof two working days and one off-duty day before the intervention. Themeasurements were repeated after the lapse of one year. The energetic load andthe balance of the autonomous nervous system were monitored by heart rateregistration (Suunto T6). The results were analyzed with a special software basedon heart rate variability (Hyvinvointianalyysi, Firstbeat Technologies).

From the recordings the periods of mental and/or physical stress can bedifferentiated. The energetic load caused by work was expressed in units of MET inwhich the energy consumption required by work is compared to the consumption inrest state. The activity of relaxing part of the autonomous nervous system reflectsthe recovery especially during sleep. In addition to physical strain, the activity ofcirculatory system increases during mental stress as well. Nurses have been foundto have changes in the balance of their autonomous nervous systems especially asfar as recovery is concerned (Ishii et al. 2005).

Cortisol measurements of saliva samples were performed during the same dayswith the heart rate measurements. Especially the morning response (fromawakening to one hour after getting up) is widely used in the stress studies(Pruessner 1997). The participants took the samples immediately after awakeningand again in thirty minutes and after one hour and again in the evening before goingto sleep. The analysis was performed with the RIA method (Phoenix Laboratories).

A submaximal ergometer test was performed in order to define the functionalprofiles of the cardiorespiratory system (Fitware, AinoActive, Finland). Themeasurements included measuring pulmonary capacity by a hand-held spirometer(before stress test and after stress when necessary), 12-channel ECG (MaxII,Marquette, USA) and body composition analysis (InBody, Korea). The heart ratewas also registered during the ergometer test (Polar Electro, Finland). Themeasurements were preceded by a medical examination by a physician. Theparticipants physical activity levels were inquired into and scored in sevencategories (0 = completely inactive - 7 = very active). After the ergometer tests,lactate samples were collected to define the intensity of muscular work. Eventhough the ergometer test was submaximal, it was done under the supervision of aqualified physician.

The purpose was to collect a heart rate register of 24 hours from each participant,stored during two working days (preferably in different shifts) and one off-duty day.Some participants worked nights only, some worked days only. Most of them,however, worked in two or three shifts. The first field measurements were started in2005. There was a total of 87 participants, 81 women and 6 men. A total of 237heart rate registrations were entered, 33 of them technically unsatisfactory. Thefollow up measurements were started after the intervention early in the year 2007.There were 71 participants taking measurements, 67 of them women and 4 men. Atotal of 194 registrations were entered this time, 6 of them technically unsatisfactory.

15

The heart rate recorder in the first field measurements was the Suunto T6 wristcomputer equipped with a belt. In general, it was noted that collecting heart ratedata does not interfere with the normal life. Some participants had difficulties instarting the measuring. Measuring heart rate was not a familiar activity, and someparticipants were apprehensive about the use of the button keys on the watch-likeinstrument - for no reason, often. In some cases there was irritation of the skinbecause the registration periods were relatively long and there was muchperspiration during the shift. The main factor harming the registrations were the cut-offs in the connection between the data collector band and the wrist computer. Thepercentage of successes was, however, satisfactory even in the first phase, and itimproved to a good level with the new Suunto SmartBelt used in the follow-upphase field measurements.

Before the field measurements were started, the participants attended informationsessions held in their own work places. Detailed information was provided on howthe measurements should be done. In the information sessions, instructions weredistributed to the participants who also had a change to become acquainted withsaliva tubes and the devices that would collect the heart rate data. Only a few of theparticipants had the opportunity of attending these information sessions, and it wasup to the work place personnel to transmit the relevant information to the otherparticipants in the unit.

The difficulty experienced during the first round of field measurements wasreconciling the timing of the measurements with the work shifts. The problem was,often, the changes in the work shifts which caused slow-downs in the circulation ofthe measuring equipment. Therefore, the first round of field measurements tooktwice as long as the second one. For the second field measurement round therewere precise times defined for each one of the three registrations. As to the salivasamples, a few people considered it unpleasant to chew on the pad in the tube.Many of the participants did not experience that as any problem.

Most of the participants took the health checks and the related tests performed inthe functioning capability laboratory during the second round. People weresomewhat apprehensive coming in for the measurements, but in general, everyonewas satisfied with the measuring event itself as well as its extent.

3.3.3 Statistical methods

The statistical analysis of the results was made by variance analyses of therepeated measurements (the results of one person before and after intervention).

16

4 Project progress

The project was introduced at least twice at every department when it was firststarted, and later on in either department briefings or in the head nurses office. Asfar as rota planning was concerned, the project received support in departmentmeetings and through personal contacts to the head nurses. Informationconcerning the measurements was given at the departments several times. Afterthe follow-up period, every participant got personal feedback on the measurementresults. The one-to-one feedback discussions with the projects physician in chargewere held during autumn 2007.

The departments personnel and line management were informed of the projectsprogress on 6 June and 7 September, 2005, in connection of training sessions, andthey had the opportunity of listening to lectures on Healthy working hours (Ms TarjaHakola, Senior Specialist) and Physiological measurements (Mr. Harri Lindholm,Medical Specialist). The supervisors and line managers were briefed as to theprogress of the project and the commitment to it on 15 February, 2006. Thedepartment personnel and line managers had a training session on Ergonomic shiftplanning (Ms Tarja Hakola, Senior Specialist) on 10 October, 2006. The internalbulletins of the Health Centre and the City of Helsinki had articles on the project,and several interest groups and persons interested in the topic were giveninformation on it. The progress of the project is presented below.

17

Types of shifts Ergonomic factual knowledge base

Constrains of collective agreements Preferences of the workers

Legal constrains Quantitative company goals

Manning of shifts Framework of rota

Case based knowledge base

Ergonomic constrains Areas of increased risks

Listing of priorities

Suggestions for improvementof new shift system

Implemented new shift system

6. Evaluation phase

Experimental new shift system

5. Testing phase

Modified new shift system

4. Design phase

First version of new shift system

3. Analyzing phase

2. Orientation phase

Information for users

1. Preparation phase

September '05- questionnaire

October '05- start of shift plannig

October-November '05- physiological measurements

November-December '05- start of intervention

December '06- follow-up questionnaire- physiological measurements










6. Evaluation phase


5. Testing phase


4. Design phase


3. Analyzing phase













6. Evaluation phase


5. Testing phase


4. Design phase


3. Analyzing phase




September '05- questionnaire

October '05- start of shift plannig

October-November '05- physiological measurements

November-December '05- start of intervention

December '06- follow-up questionnaire- physiological measurements

Figure 5. Progress of the intervention process (Gissel and Knauth 1998).

18

5 Results and discussion

5.1 Results of the intervention on the basis of the questionnaire

Along with the intervention (figure 6) the evening-to-morning shift rotations weredecreased as were the irregularities of working hours and long periods ofconsecutive shifts. The participants felt that the number of single days off wasincreased and longer periods of leisure time were decreased.

11

12

36

11

6

10

8

8

17

23

12

1

11

20

20

23

31

34

39

44

47

80

0 25 50 75 100

days off on weekdays

week-end work

single days off

extras

night work

overtime

long work hours

number of consecutive days off

number of consecutive work days

irregularity of working hours

unfavorable shift sequences

increasedno changeredused

Figure 6. Changes (%) perceived in shift work arrangements during the intervention.

Before the intervention, the participants considered the pros (figure 7) of the shiftsystem to consist of days off on weekdays, long periods of days off and otherreasons that included various individual working time arrangements contributing togood coping at work, such as working nights and part time work. Before theintervention, the participants considered the cons (figure 8) of the system to consistof going from evening to morning shift, single days off, weekend work and longperiods of work.

After the intervention (figure 9), the participants considered the pros of the shiftsystem to consist of its regularity, the fulfillment of employees wishes, off-dutyweekdays and the fact that one did not need to go from evening to morning shift.After the intervention (figure 10) the participants considered the cons of the systemconsist of off-duty time starting in the evening, starting duty in the morning afterleisure time and off-duty periods of single day only.

19

0 10 20 30 40 50

variation

night shift

extras

implementation of personal wishes

rhythm of work and days off

no night shifts

regular schedule

individual reasons

long periods of days off


before

Figure 7. Pros of the shift system before intervention. Percentagesof classified answers to open questions.

0 10 20 30 40 50

early morning shifts

workload

evening shifts

individual reasons

irregular schedule

limits social and family life

long periods of work

weekends at work

single days off

evening-to-morning

before

Figure 8. Cons of the shift system before intervention. Percentagesof classified answers to open questions.

0 10 20 30 40 50

later mornings

days off arrangements

mornings and evenings grouped


rhythm of work and days off

short periods of work


implementation of personal wishes

daytime work, regular

not evening-to-morning

after

Figure 9. Pros of the shift system after intervention. Percentages ofclassified answers to open questions.

0 10 20 30 40 50


evening shift

workload

other reasons

hourly balancing

limits social and family life

consecutive mornings

single days off

day off-to morning shift

evening shift-to day off

after

Figure 10. Cons of the shift system after intervention. Percentages ofclassified answers to open questions.

The implementation of the ergonomic shift planning (figure 11, attachment 1) wasaffected by many department internal and external factors such as number ofemployees, number of missing employees, the time of year etc. (chapter 6).

0

10

20

30

40

50

30.1-

19.2

20.1-

12.3

13.3.

-1.4.

3.4-23

.4.

24.4-

14.5.

15.5.

-4.6.

5.6.-2

5.6.

26.6-

16.7.

17.7-

6.8.

7.8.-2

7.8.

28.8.

-17.9.

18.9.

-8.10

.

9.10-2

9.10

3010

-1911

2011

-1012

1112

-3112

1.1.-2

1.1.

22.1.

-11.2

12.2.

-4.3.

5.3.-2

5.3.

evening-to-morning shift (planned)evening-to-morning shift (actual)unoccupied shiftschanges to schedule (wishes)

Figure 11. Sample shift planning implementation during the project (number,department A).

The opportunities of impacting the rota (figure 12) were decreased somewhatduring the intervention, but the change was not statistically significant, and thepersonal wishes concerning schedules were implemented, on average, relativelyoften.

1 2 3 4 5

Are there problemsrelated to the workingtime arrangements in

your work?

Do you have impact onsolving these problems?

To what extent do youfeel you have control

over the specific shiftsthat you work?

How often are yourpersonal wishes noted

when the rota isplanned?

not at all some a lot

afterbefore

Figure 12. Opportunities to influence rota planning (average, n=75).

21

During the intervention, the start and end times of the shifts were not changed. Thetiming of shifts (figure 13) suited the majority of the participants, however, one fifthconsidered that the morning shift started too early and a quarter considered thatthe evening shift ended too late. A fifth of the respondents thought the night shifttoo long. Satisfaction as to the timing and duration of shifts remained the sameduring the project.

0

25

50

75

100

star

ts to

o ea

rly

star

ts ju

st ri

ght

ends

just

righ

t

dura

tion

just

righ

t

star

ts ju

st ri

ght

ends

just

righ

t

ends

too

late

dura

tion

just

righ

t

star

ts ju

st ri

ght

ends

just

righ

t

dura

tion

just

righ

t

too

long

morning evening night

beforeafter

Figure 13. Suitability of the timing and length of working shifts (%, all respondents).

During the intervention, the shift sequences were shortened (figure 14). Thereduction of morning shifts following evening shifts naturally changed the rhythm ofshifts by increasing the number of consecutive morning and evening shifts. Most ofthe respondents considered the number of morning and evening shifts to beconvenient, however, a generous quarter of the respondents thought that therewere too many consecutive morning shifts. Before the intervention, a quarterthought the number of evening shifts was too small, but however, after theintervention, one fifth of them thought that there were too many consecutiveevenings. Both before and after the intervention, every second respondentconsidered the number of consecutive days off too small.

22

0

25

50

75

100

too

few

just

righ

t

too

man

y

too

few

just

righ

t

too

man

y

too

few

just

righ

t

too

man

y

too

few

just

righ

t

mornings evenings nights days off

beforeafter

Figure 14. Suitability of consecutive working shifts (%, all respondents).

The effects of the shift system on the well-being of the personnel in the variousspheres of life (figure 15) clearly improved during the intervention. Sleep andalertness (p=0.003), well-being at work (p=0.005) and general health status(p=0.02) all improved in a manner that was statistically significant. Leisure timeactivities were also significantly (p=0.02) facilitated. Family and social life werefacilitated, but the change was not statistically significant. The intervention had noimpact on the working atmosphere.

1 2 3 4 5

sleep and alertness

well-being at work

general health

social life

family life

leisure time activities

work climate

disturbs facilitates

afterbefore

Figure 15. Impacts of the shift system on different spheres of life (average, n=75).

Considered per age group (figure 16), the intervention improved the sleep andalertness (p=0.003) and well-being at work (p=0.004) for everyone significantly. Thegeneral heath status in the two eldest groups improved (p=0.09). The impacts of theshift system on compatibility work and other spheres of life (figure 17) were differentin different age groups, but however, the intervention did not cause deterioration in

23

the family and social lives of the respondents. Leisure time activities in all groupswere facilitated (p=0.02).

1

2

3

4

5

before after before after before after

sleep and alertness well-being at work general health

dist

urbs

faci

litat

es

20-40 years41-52 years53-62 years

Figure 16. Impacts of the shift system on well-being per age group (average, n=75).

1

2

3

4

5

before after before after before after

social life family life leisure timeactivities

dist

urbs

fa

cilit

ates

20-40 years41-52 years53-62 years

Figure 17. Impacts of the shift system on compatibility of work and life per agegroup (average, n=75).

The perceived physical strain (figure 18) decreased significantly in connection ofmorning (p=0.0005) and evening (p=0.02) shifts. The physical strain in the nightshift was decreased as well, but not in a significant manner. The perceived mentalstrain did not change during the project.

24

1

2

3

4

5

morning evening night morning evening night

physical mental

light

h

eavy

beforeafter

Figure 18. Perceived physical and mental strain during shifts (n=75, average).

The different shifts had different impacts on sleep and alertness (figures 19-22).Before the intervention, the participants had problems in waking up when workingon morning shift, trouble falling asleep when working on evening shift, and heavysleepiness at work when working on night shift. These problems were significantlyalleviated during the intervention (p=0.03, p=0.003, and p=0.05, respectively). As toother problems related to sleep and alertness, the disturbances either remained thesame or were somewhat decreased.

25

morning shift

1

2

3

4

How often do youhave trouble waking

up?

How often do youhave trouble falling

asleep?

How often do youhave trouble fallingback to sleep afterwaking up in the

middle of your sleep?

How often do you feelvery sleepy at work?

How often do youthink sleepiness hasaffected your work

performance?

neve

r

ra

rely

ofte

n

alw

ays

beforeafter

Figure 19. Problems with sleep and alertness when on morningshift (average, n=75).

evening shift

1

2

3

4


up?


asleep?





performance?

neve

r

rar

ely

ofte

n

a

lway

s

beforeafter

Figure 21. Problems with sleep and alertness when on eveningshift (average, n=75).

night shift

1

2

3

4


up?


asleep?





performance?

neve

r

ra

rely

ofte

n

a

lvw

ays

beforeafter

Figure 20. Problems with sleep and alertness when on night shift(average, n=75).free days holiday

1

2

3

4

How often doyou have

trouble wakingup?


trouble fallingasleep?


trouble fallingback to sleep

after waking upin the middle of

your sleep?


trouble wakingup?


trouble fallingasleep?


trouble fallingback to sleep

after waking upin the middle of

your sleep?

neve

r

rar

ely

o

ften

a

lway

s

beforeafter

Figure 22. Problems with sleep and alertness while off-duty (average,n=75).

26

5.2 Physiological impacts of the interventionThe changes to the morning response to cortisol on working days were analyzed bydividing the participants into groups on the basis of the benefits they had experienceddue to the intervention. Before the intervention, there were no statistically significantdifferences between the groups regardless of whether the intervention wasexperienced as positive, neither positive nor negative, or negative after a years lapse.In all groups on average, the morning response stayed at the reference level but onits upper limit. After the intervention, all groups had an improvement in the morningresponse. The change among the participants experiencing the interventionpositively (improved well being) or neutrally (no change) was statistically significant.Among the nurses experiencing the intervention negatively the improvement of themorning responses in salivary cortisol was however nearly significant (figure 23).Those experiencing it negative had the largest divergence.

0

5

10

15

20

25

positive unchanged negativewell-being

saliv

a co

rtiso

l (um

ol/l)

beforeafter

Figure 23. Change (?mol/l) of saliva cortisol morning response before and afterintervention (one year follow-up) in employees experiencing the changein well-being positive, unchanged, or negative.

On the basis of cortisol, the working time intervention had a beneficial effect onstress levels. However, some participants might have experienced increased stress.When changing working hours, it is important to provide an opportunity for individual,flexible alternatives. On the other hand, it is also good to provide information aboutthe benefits of ergonomic working hour planning to ones own health.

In the analysis of the heart rate variability, on average, there were no changesdetected to the working day stress loads before or after the intervention. As to stress,work in itself remained as straining as before. However, the portion of thoseparticipants who had findings that indicate slow recovery was decreased from 35% to20% during the intervention, and the portion of those participants who had goodrecovery increased from 30% to 52% (figure 24).

27

0

10

20

30

40

50

60

before afterintervention

%slownormalgood

Figure 24. Recovery of the autonomous nervous system after working days bothbefore and after changes to working hours (% of participants).

Very severe cases of overload were not found. Even though the working timeintervention seemed to decrease stress and especially to facilitate recovery, it isimportant to develop all aspects of work comprehensively.

5.3 Physical stress of nursing and performance capacity

The load on the metabolism during a working day was about 2 MET on average,corresponding to results of other studies of the energetic demands of nursing work.The highest energetic loads were detected during treatment activities (figure 25).

28

0

1

2

3

4

5

report

basic care

other care

clinical care

distrib. of medicines

commute work

commute home

hobbies

home work

excercise

restsleep

ME

T averagemaximum

Figure 25. Energy expenditure load levels in various tasks during the working day,expressed in units of MET (multiples of rest metabolism, 1 MET = levelof metabolism during rest).

Nursing work stresses physically more the musculoskeletal system than the cardio-respiratory system. Similar results have been seen earlier in home-care personnel(Pohjonen 2001). Although the mean level of the energetic load of the work is onlymoderate the peaks and the general health of a nurse require the maximal aerobicfitness more than 5-6 MET's. Because the reduced condition of the respiratory andblood-vascular systems is connected to the weakening of muscular strength, themusculo-skeletal system will be strained more easily.

Nursing work as such will not sufficiently assure the adequate cardiovascular fitness.The leisure time physical activity is also needed. The exhausted worker, however,does not have resources to the recreative activities. The total load of work must notexceed ones tolerance level.

About a quarter of the participants had the aerobic fitness below the optimal level ofgeneral health (figure 26). This correlates with the physical exercise taken. Aquarter of the participants performed exercise bouts during the leisure time once aweek or more seldom. Although the physical exercise is only one part of promotinggood health, it is important to guide the risk groups to start a physically active wayof life (Fogelholm et al. 2007).

29

0

10

20

30

40

50

8

MET

%

Figure 26. Cardiovascular performance capacity in the ergometer test. The fitnessbelow the level 7 MET increases the health risks among the middle-agedfemale workers.

Physical activity is important from the point of view of weight control as well. Nursingpresumes sufficient muscular mass. As to weight control, it is important to secure abalanced body composition. Not only is the body mass index important. The weightloss should not decrease the muscular strength. Almost a half of the nurses werefound to have a need for weight reduction of less than 5 kg as proportioned to theirmuscular mass. One third of them had a need for reduction over 10 kg (figure 27).

0

10

20

30

40

50

10

kg

%

Figure 27. The need for weight reduction proportioned to the measured muscularmass (% of participants).

About every sixth participant was found to have limited pulmonary function. Most often,the causes were asthma or early (often undiagnosed) chronic obstructive pulmonarydisease related to smoking. Fewer than 10% of the respondents were found to havean acute change in their health status that required additional examination. Thesecases involved mainly the control and balance of treatments of already knownillnesses.

30

6 Experiences of the progress and implementation ofthe project

The following pages in the project coordinator Ms Marja Paukkonens diary (next page)illustrate well how challenging the change process was. The ergonomic changes inshift planning were so significant that to succeed they required strong commitment onbehalf of those managing the nursing activities. There were a better understanding ofthe changes effects to the employees health and a strong commitment to shiftchanges created through the process. In order to succeed, the head nurses need bothsupport and determined guidance in the process. Ergonomic shift planning methodscannot be directly taken from theory to practice as they require individual application toeach working community before they have a chance to succeed. Wards develop otherfunctions simultaneously, too, and personnel may change and the totality may bealtered thereby.

In general, the personnel were very committed to the project even though there wasquite significant turnover in the staff in the departments. The director of nursingservices in two of the departments and the head nurse in three departments changed.With the exception of one department, there were changes to the personnel in all thedepartments. There were changes to the substitute positions especially. Some of thedepartments suffered from a shortage of personnel all the year 2006. A number ofnurses in certain departments worked shorter hours and some were on long sickleaves. The situation, as to patients, was quite stable throughout the project.

31

Spring andsummer 05

Three long-term departments found immediately, and one acute department as well.Inquiries made as to acute departments, the departments considered it, we got one more.There would have been several long-term care departments eager to participate, weaccepted one. All departments are eager to begin. However, the two project trainingsessions had few participants only, except for one department.

Autumn 05 Initial survey completed. Started rota planning. Got more careful and eager to defend theold, unsure of what changes were to be made. Three head nurses and two directors ofnursing services changed. Commitment in these departments got more difficult aseveryone was not involved from the beginning. Physiological measurements startedsomewhat floundering.

Spring 06 Agreed to keep numbers of evening-to-morning shift rotations low. This facilitated rotaplanning as it is a clear, concrete goal. The plans were monitored by the Titania lists andtheir general follow-up throughout the project. Discussed experiences and feelings in theproject team. Commitment seemed difficult to achieve, still, so the steering group held apep briefing for the middle management and nearest supervisors in February.Commitment and stick-to-it-ness both increased. When problems occurred, the headnurses were contacted and they were positive about this. The steering group work wasvigorous. The project team had discussions and made comparisons. Department-specificplans were created and they were adhered to until the end of the project, except for onedepartment. Managed to get the thank-you cakes, after all.

Summer 06 Some departments stuck to the plan well, one slunk away during summer, and one had ashortage of staff throughout the project. They did what they could. Five departments hadrelatively permanent staff. Three of the departments stuck to what was agreed once theyhad reached it in the spring, and the head nurses explained ergonomic planning tothemselves and others. One had rather individual, varying solutions.

Autumn 06 The department that slunk away in summer got back to the agreed schedule. Gavefeedback as to successes in planning and asked about changes to plans and the reasonsfor them. It required lots of support and listening to descriptions of difficulties but I did notyield because the project duration was limited and the topic was seen as important. Inother words, the planning would have gone off course if it had not been keenly followed upall the time. If I did not get the compilation lists from the head nurses right away, I askedfor them. Finally, I got them smoothly.

Had the follow-up survey and another training session on ergonomic shift planning forthose wishing it and new employees. Hit the right spot!

I wondered throughout the project how often I should visit the departments, how often Ishould call and so on. I phoned the head nurses quite often and visited the departmentswith Tarja at the beginning, and later on I visited every department at least once (i.e.asked about the staff changes in autumn 06). There was a permanently negativeatmosphere and disbelief in the subject. That was very straining at times.

The personal measurements were taken very positively.

Spring 07 Measurements done briskly, rota follow-up ended in April. May results promising. Briefingsfor managers concerning the results, encouraging them to stick to the plans.

Summer 07 Head nurses questioned about progress and feelings. Phone calls in August to ask howthey were doing:- The substitutes exhibited poor commitment, they would have preferred to work morningsonly, the temps got to choose and present wishes as to shifts, and a part of the permanentstaff would also have liked to take on mornings only or been transferred to stand-by staff.- HN wanted clear instructions for rota planning, a stand-by person for the department,and support from the occupational health services.- Not many evening-to-morning shift rotations planned.- Lists the same as during the project: no evening-to-morning rotations (if any, thenextended recovery time), no uninterrupted work stretches of more than 6 days- Ergonomic planning continued, no evening-to-morning rotations.- Ergonomic planning continued: no evening-to-morning rotations, no work stretches ofover 6 days, not even for those who do nights only (clear rota planning rules created withthe director of nursing services).

- The department voted about continuing with ergonomic rota planning - the one half wasfor, the other half was against - and the continuation is open.

32

The head nurses in the participating departments were sent an electronic survey inJune 2007, inquiring as to the implement ability of the intervention. The pros ofergonomic rota planning were seen to include the nurses better recovery and thehead nurses opportunity to promote the health of the employees through shiftplanning. It was noted that the old gripe about the strenuousness of the evening-to-morning rotations was gone, because sufficient rest was assured. Rota planningas such was experiences as easier than before.

The replies showed that ergonomic shift planning had not, to say the least,weakened the organization of the work at the departments. A part of the headnurses felt that the new rota planning had helped committing to the personal nursesystem because the personal nurse was energetic on all working days. The samedepartments improved their communications as well, because the reorganization ofwork was seen as a natural consequence of the changes in the circumstances.

The head nurses will apply ergonomic shift planning in their departments in future,too. The numbers of evening-to-morning shift rotations are kept low; uninterruptedstretches of shifts are kept to no more than five shifts, and a part of the head nurseswill plan shorter night shifts. Individual wishes are paid attention on, but theergonomic thinking is kept as the basis for all shift planning.

The head nurses aim at making the shift planning even more ergonomic than before.There are discussions held at the departments, still, about attitudinal changes. Apart of the head nurses would want to develop participatory rota planning or tryyearly working hours. A part is trying to influence attitudes in their own hospitalenvironments or to market ergonomic shift planning to their colleagues. All therespondents have noted that ergonomic shift planning requires a new way ofthinking and some time to digest.

When asked about the need for support and training in enhancing shift planningmethods, the head nurses wished that the personnel be better briefed about shiftplanning, and also wished to have common, harmonized policy statements as towhat constitutes good and ergonomic shift planning. Shift planning requiresperceiving the total situation at the department precisely, and there are frequentdiscussions held on the topic with the personnel. The shift planning is wished to takeon more flexibility through local agreements and updates to the shift planningsoftware.

33

7 Conclusions and recommendations

1. This study showed that healthier shift work design is possible in nursing. Ergonomicshift planning should be the recommended mode of shift design for nursing,supporting healthy careers and total well-being of the employees.

2. Ergonomic shift planning produced significant benefits experienced by theemployees and measurable, favorable changes in their systems.

In all age groups, well-being improved both at work and on leisure. Theimprovements in shift design made sleep disturbances less common andimproved the quality of sleep, thus improving the total alertness. Well-being atwork improved significantly. In addition, the new shift design created improvedthe opportunities to take on leisure time activities.

Along with the longer recovery times, work was felt to be less strenuousphysically in both morning and evening shifts even though the workingprocesses as such were not changed and the workload remained unchanged.The shift design intervention decreased the measured stress levels and maderecovery more effective.

3. This study supports the view that nursing primarily stresses, physically, themusculo-skeletal systems. The load provided by nursing work is not sufficient,alone, to keep the cardio-respiratory systems healthy. To maintain a good workingcondition, it is necessary to take physical exercise on leisure time or, for endurance,to do physical work as leisure exercise.

From the point of view of their health, about a quarter of the participants hadtheir cardio-respiratory fitness below the recommended levels. Leisure timephysical activities are needed to maintain the cardio-respiratory performancecapacity. Exhausted worker however do not have resources for theseactivities. The total work load must not exceed ones tolerance level.

4. Shift planning is a human resources management tool which, at its best, can beused to bring well-being into nursing.

Numbers of evening-to-morning rotations that were felt to be stressful weredecreased and long periods of work days were made shorter. This did notincrease the number of single days off, but the rotations of evening shift to dayoff to morning shift are experienced as difficult.

Ergonomic shift planning is the basis of modern shift design; informationconcerning it must be made available, and people should be trained in it. Thepractical implementation of shift planning should be developed together withthe staff concerned. The commitment of the staff can be promoted bycombining ergonomic shift planning with opportunities of influencing shift workarrangements.

34

5. On the basis of the results of the project, the steering group is ready to recommendthat the branches of the City of Helsinki where shift work is used similarly implementergonomic shift planning methods. In practice and primarily, this means giving upevening-to-morning shift rotations.

35

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37

Appendix1. Implementation of shift planning in departments B-F during the project (number).

0

10

20

30

40

50

30.1-

19.2

20.1-

12.3

13.3-

2.4.

3.4.-2

3.4.

24.4.

-14.5

15.5.

-4.6.

5.6.-2

5.6.

26.6.

- 16.7

.

17.7-

6.8.

7.8.-2

7.8

28.8.

-17.9

18.9.

-8.10

9.10-2

9.10

30.10

-19.11

20.11

-10.12

11.12

.-31.1

2

1.1.-2

1.1.

22.1.

-11.2

12.2-

4.3.


Department B

0

10

20

30

40

50

30.1-

19.2

20.2-

12.3

13.3-

2.4

3.4-23

.4

24.4-

14.5

15.5-

4.65-2

5.6

26.6-

16.7

17.7-

6.87-2

7.8

28.8-

17.9.

18.9.

-8.10

.

9.-29

.10.

30.10

.-19.1

1

20.11

.-10.1

2.

11.12

.-31.1

2.

1.1. -

21.1.

22.1.

-11.2.

12.2-

4.3.

5.3.-2

5.3.


Department C

38

0

10

20

30

40

50

60

70

80

90

100

30.1-

19.2

20.1-

12.3

13.3.

-2.4.

3.4.-2

3.4.

24.4.

-14.5

15.5.

-4.6.

5.6.-2

5.6.

26.6.

-16.7.

17.7.

-6.8.

7.8.-2

7.8

28.8.

-17.9

18.9.

-8.10

9.10.-

29.10

09.10

-19.11

21.11

-10.12

11.12

-31.12

1.1-21

.1.

22.1-

11.2.

12.2-

4.3.07

5.3-25

.3.20

07


Department D

0

10

20

30

40

50

60

70

80

90

100

30.1-

19.2

20.2-

12.3

13.3-

2.4

3.4- 2

3.4.06

24.4-

14.5

15.5-

4.6

5.6- 2

5.6

26.6-

16.7

17.7-

6.8

7.8-27

.8

28.8-

17.9

18.9-

8.10

9.10-2

9.10

30.12

-19.11

20.11

-10.12

11.12

-31.12

1.1-21

.1.

22.1-

11.2.

12.2-

4.3.07

5.3-25

.3.20

07


Department E

39

0

10

20

30

40

50

60

70

80

90

100

30.1-

19.2

20.1-

12.3

13.3-

2.4

3.4.-2

3.4

24.4.

-14.5.

15.5-

4.6.

5.6.-2

5.6.

26.6.

-16.7

17.7-

6.8

7.8.-2

7.8

28.8-

17.9

18.9.

-8.10

9.10-2

9.10

3010

.19.11

20.11

-10.12

11.12

-31.12

1.1-20

.1.07

21.1-

11.2

12.2-

4.3

5.3-25

.3


Department F

40

Appendix 2. Rota presented by shift type (D=morning shift, A= evening shift, N=night shift, emptycell=days off, evening-to-morning shift rotations in red, and single days off in orange) anddistribution of days off (6 week average) before and after intervention.

Before

After

0

0,5

1

1,5

2

2,5

3

3,5

1 2 3 4 5 6 7 > 7days off

beforeafter

Department B

41

Before

After

0

0,5

1

1,5

2

2,5

3

3,5

1 2 3 4 5 6 7 > 7days off

beforeafter

Department C

42

Before

After

0

0,5

1

1,5

2

2,5

3

3,5

1 2 3 4 5 6 7 > 7days off

beforeafter

Department D

43

Before

After

0

0,5

1

1,5

2

2,5

3

3,5

1 2 3 4 5 6 7 > 7days off

beforeafter

Department E

44

Before

After

0

0,5

1

1,5

2

2,5

3

3,5

1 2 3 4 5 6 7 > 7days off

beforeafter

Department F

Documents

Working Hours at workplace