Research Article
Austin J Nurs Health Care. 2022; 9(2): 1074.
Working Hour and Schedule Characteristics among Nurses: A Retrospective Study
Peršolja M*
Vipava Unit of Faculty of Health Sciences, University of Primorska, Slovenia
*Corresponding author: Peršolja M, Vipava Unit of Faculty of Health Sciences, University of Primorska, Slovenia
Received: September 24, 2022; Accepted: November 01, 2022; Published: November 08, 2022
Abstract
Introduction: To describe and compare characteristics of working hours and work schedules among nurses in 2019 and 2021. Evidence about the association regarding the relationship between nurses’ working hours and schedules with the COVID-19 pandemic is limited.
Materials and Methods: The research was conducted at a medical unit of a secondary care regional hospital in Slovenia. Of 71 employees who were eligible, 24 fulfilled the criteria and their data were included in the study.
Results and Discussion: There were substantial differences in working hour and schedule characteristics between 2019 and 2021. Compared to 2019, nurses in 2021 worked more hours, more long shifts, had fewer free weekends and education days, and almost double the number of sick days.
Conclusion: While the nurse manager managed some of the working hour and schedule characteristics appropriately, additional awareness raising, and implementation of a related computer program, are suggested to optimize and develop work schedules.
Keywords: COVID-19; Nursing Service Hospital; Nurse Scheduling; Workload
Introduction
In 2020 and 2021, medical institutions, especially hospitals, needed to increase their preparedness for patients with COVID-19 who required hospitalization [1]. The pandemic put great psychological pressure on nurses, which increased rates of anxiety, suicide, fear, and depression [2-4], as the qualitative and quantitative changes in their tasks increased the related job demands [5,6]. Moreover, even without a pandemic times the classic schedule (7 am to 3 pm, working only during the week) is an exception among nurses [7]. However, working hours in the EU are governed by the EU’s Working Time Directive (European Parliament, 2003) [8].
Shift scheduling in nursing can be described as having cyclic or non-cyclic patterns. In cyclic scheduling fixed patterns of days on and off are established, and staff are rotated continuously through them [9]. In non-cyclic patterns nurses are asked to sign up for those shifts that they wish to work. Each planning period is considered independently, and new schedules are prepared at the beginning of each month [10]. Adjustments and decisions need to be made daily, and there are many changes in shift at short notice [11]. The objective is to find a balance between satisfying individual preferences and minimizing personnel costs [12,13].
Managers should consider many characteristics of schedules, as they can disrupt employees’ circadian rhythms with improper scheduling patterns. The literature describes the following schedule characteristics as being important for employees: rapid changes in schedule [14,15], the direction and speed of shift rotation [16,17], shift length (mainly 12-hour shifts) [14,17-21], shift start and finish times [14], short breaks between shifts and quick returns [19,21-24], work on scheduled days off [25], and a high number of hours per week (over 60 hours) [26]. The key strategy is to make sleep a priority and adopt a slow, forward-shifting rotation pattern, rotate shifts after 2-week periods and allow an average of 2 days off per week [27], regular breaks [16], choice over shift work schedules [14], and use 8-hour shifts when possible [20]. The organization of work in health care settings has been shown to affect the health of employees [28,29], and a strong risk factor for poor health is shift work [29,30].
This study aimed to describe and compare characteristics of working hours and work schedules among hospital nurses in 2019 and 2021. It was assumed that the COVID-19 pandemic in the year 2021 would result in changed working hours and schedules. The specific objective was to answer the following research questions: Are there differences between 2019 and 2021 in the nurses’ working hour and work schedule characteristics? How many working hours/days do nurses have per week/month? How many consecutive working days? What is the length of work shifts? Which is the direction of rotating shifts? Do nurses have to quickly return? What is the maximum number of consecutive night shifts they do? How many day/evening/ nights shifts do they do per year? How many weekends are nurses free per year? Are there any unusual characteristics of nursing schedules not yet described in the literature?
Compiling data about nurses’ working conditions is important, but most of the published studies on the working hours and schedules of nurses have been done in high income countries, based on shift scheduling computer programs or self-reported data. This paper can contribute to a better understanding of nurses’ working hours and schedules in developing counties, with the aim to intervene to mitigate any possible negative effects. Such knowledge is useful, since it provides insights into how best to deal with the issues raised with various changes to work schedules.
Material and Methods
Study Design
A retrospective observational study was conducted in a Slovenian secondary care regional hospital in 2022. It aimed to observe and describe a situation in two years (2019 and 2021 when the COVID-19 pandemic was active). Data collection was performed by the principal researcher.
Setting
The researched Slovenian hospital has 26 specialty departments with approximately 300 beds. Approximately 430 nursing care personnel – mostly nursing technicians (NT) (n=280; 65.12%), and a third of them being registered nurses (RN) (n=150; 34.88%) – provide the necessary services. The hospital deals with nearly 20,000 prospective payment system episodes a year, with an annual bed occupancy rate of 62%. This research was done on a medical ward with 109-bed capacity and 6,125 hospitalized patients in 2019, and 6,828 in year 2021. The hospital was anonymized at the request of the management of the institution.
Participants and Data Sources
The researcher asked the hospital management for permission to do the research and presented the aims and methods of the study. During the related staff meeting, the nursing manager invited all medical ward nurses to collaborate in this study. All nursing staff participated, but many were excluded from the sample because of their specific tasks: the head nurse, the nurse responsible for ordering supplements, nurses who were deployed on COVID-19 units, students, and nurses who resigned during the research period.
There were 45 NT and 28 RN employed on the researched medical ward on 1 January 2019, and 51 NT and 28 RN on 31 December 2021. Of the 71 employees who were eligible, only 24 (33.8%) fulfilled the criteria and all were included in the study (n=12 nurses were moved to different units; n=13 were absent because of maternity or paternity leave; 8 nurses quit their jobs in the hospital, 5 nurses worked short schedules (4 or 6 hours).
There were 10 (41.7%) RNs and 14 (58.3%) NTs in the sample. Five (20.8%) of the nurses were male. The nurses were mostly (n=13, 54.2%) aged 31 to 40 years, 4 (16.7%) were 30 years or younger, 5 (20.8%) were 41 to 50 years old, and 2 (8.3%) were 51 or older. Most of the nurses had two children (n=10, 41.7%). The age of the youngest child varied from 0 to 33 years (Mean = 8.917, SD=10.21). Nurses were employed in nursing from 4 to 33 years (Mean=14.67, SD=9.47).
Variables
The independent variables were as follows: (a) observation year (2019, 2021); (b) staff demographic data (gender, age, number of children, age of the youngest child, years employed in nursing, shift usually worked); (c) staff education (RN, NT).
The dependent variables were: (a) the characteristics of the schedule (hours of work shift, long weeks (> 40 hours per week), number of consecutive night shifts, number of day shifts per year, number of evening shifts per year, number of night shifts per year, number of free weekends per year, the direction of rotation shifts); (b) the characteristics of the working hours (weekly working hours, number of working days, number of sick days, number of education days, amount of annual leave, working hours per working day, number of consecutive work days).
Shifts were classified according to time of day: day shift (starts after 06:00, ends before 15:00); evening shift (starts after 14:00, ends before 21:30); night shift (starts after 19:00, ends before 07:30). Shift of more than 9 hours were classified as long shifts. The number of working days is not equal to the number of shifts, as nurses can work one or more shifts on the same day. Net working hours are the hours of employee presence at the work place, gross hours include annual leave, sick and education days. Quick returns are when there is less than 11 rest hours between two shifts.
Direction of rotation means the order of shift change: A forward rotation is in the clockwise direction, from day to evening to night shift. A backward rotation is in the counter-clockwise direction, from day to night to evening shift.
Work patterns consisting of combinations of shifts were characterized as long weeks (> 40 hours per week), continuous work days (maximum number of continuous working days), and free weekends (free on Saturday and Sunday).
Characteristics of shifts and work patterns were summed by individual and then divided into four categories: 0, 1-100, 101-200 and >200 shifts/person/year. Day, evening, night, long weeks were also divided into four categories: 0, 1-12, 13-50, and >50 per person/ year.
We also looked at all shifts within the year for each nurse, and classified them as permanent day, morning or evening (no night), rotating or other.
Data Sources
The data was obtained from 24-month nursing schedules (12 from 2019 and 12 from 2021). The schedules were handwritten on paper, in A3 format, and prepared by the head nurse every month for the next 4 weeks. Before the research, the names of nurses were hidden, and every nurse got an identification number which was the same for the years 2019 and 2021. Only the hospital head nurse had the original schedules with the nurses’ names.
Ethics
Ethical approval was received from the hospital included in this study. The need for consent by participants was deemed unnecessary, as the data were anonymized before starting the analysis. The study was conducted in accordance with the Declaration of Helsinki.
Statistical Methods
Reliability was reached in the data analysis with the random selection of those nurses who met the criteria described earlier. Exploratory data were performed to inspect the data and identify inconsistencies. IBM SPSS Statistics 26.0 was used for data analysis, at the level of the individual nurse. Quantitative data analysis was performed using descriptive methods: mean (M), Standard Deviation (SD), frequency (n), percentage (%), Pearson’s correlation (r). Correlation strengths were valued as follows: 0–0.09 not correlated, 0.1–0.3 weak, 0.31–0.6 medium, and 0.61–1 strong correlation (31). The repeated measures t-test and independent groups t-test were used to determine whether the difference between means for two sets of scores was the same or different. The significance was set at p <0.05. Cronbach’s Alpha for the instrument was 0.895 (n=419).
Results and Discussion
The nurses mostly (75%, n = 18) worked rotating shifts, but there were 12.5% (n=3) who worked day or evening but not night shift, and 12.5% (n = 3) with another schedule. In total 24 nurses worked 54,166.26 gross hours in 2019 and 54,707.91 in 2021.
For the rotating schedule it was not possible to define the direction of rotation, as the sequences changed all the time from backward to forward. There were no quick returns in the observed sample.
There was a significant increase in working hours per year in 2021 as compared to 2019 (Table 1). Nurses worked mostly 3 weekends per month with a minimum of 5 (2019, 2021) free weekends per year to a maximum of 44 (2019) and 42 (2021). Nurses had fewer free weekends in 2021. The difference between the annual frequency of sick days is significant, the mean of sick days almost doubled in 2021 (2019: min. = 0, max. = 16 days; 2021: min. 0, max. =50 days). A fifth (20.8%, n=5) of nurses were on sick leave more than 10 days in 2019, and just over a third (37.5%, n=9) in 2021 (Table 2).
Variables
% (n)
2019
2021
Dayshift
0
0 (0)
0 (0)
1 - 100
37.5 (9)
33.2 (8)
101 - 200
62.5 (15)
66.7(18)
> 200
0 (0)
0 (0)
Evening shift
0
12.5 (3)
16.7 (4)
1 - 12
25 (6)
25 (6)
13 - 50
25 (6)
8.3 (2)
> 50
37.5 (9)
50 (12)
Nightshift
0
12.5 (3)
16.7 (4)
1 - 12
16.7 (4)
8.3(2)
13 - 50
41.7 (10)
45.8(11)
> 50
29.2 (7)
29.2 (7)
Long weeks (> 40h / week)
0
0 (0)
0 (0)
1 - 12
0 (0)
0 (0)
13 - 50
0 (0)
0 (0)
> 50
100 (24)
100 (24)
Free weekends
0
0 (0)
0 (0)
1 - 12
8.3 (2)
25 (6)
13 - 50
91.7 (22)
75 (18)
> 50
0 (0)
0 (0)
Long day shift
0
0 (0)
0 (0)
1 - 12
16.7 (4)
8.3 (2)
13 - 50
83.3 (20)
83.3 (20)
> 50
0 (0)
8.3 (2)
Sick days
= 10 days
79.2 (19)
62.5 (15)
> 10 days
20.8 (5)
37.5 (9)
Legend: %: Percent, n: Number
Table 1: Distribution (%) of working hour characteristics summarized by individuals.
Variables (df = 23)
Year
Statistics
Mean
SD
t
Sig.
Total working hours (neto)
2019
1698
135.92
- 7.38
0.00
2021
1901
169.72
No. consecutive night shifts
2019
1.64
0.87
4.12
0.00
2021
1.281
0.85
No. free weekends
2019
23.37
11.04
4.27
0.00
2021
20.29
10.72
No. education hours
2019
8.33
11.67
3.50
0.00
2021
1.00
2.70
No. long shifts
2019
24.29
11.63
- 3.27
0.00
2021
29.29
13.28
No. day shifts
2019
113.83
39.84
2.16
0.04
2021
105.29
43.73
No. sick hours
2019
46.33
39.33
- 2.12
0.04
2021
85.33
84.75
Continuous working days
2019
5.23
0.89
- 1.56
0.13
2021
5.47
1.25
No. evening shifts
2019
35.29
30.06
- 1.24
0.23
2021
38.83
36.06
No. night shifts
2019
36.83
29.69
- 0.85
0.41
2021
39.12
32.30
No. working days
2019
202.79
14.31
- 0.73
0.47
2021
205.29
20.40
Legend: No: Number/Frequency, SD: Standard Deviation, t: t-test coefficient, Sig: Statistical significance
Table 2: Repeated measures t-test results, considering year.
The number of consecutive work days ranged from 3.75 (2019) and 3.17 (2021) to 8.08 and 8.83, with a mean of approximately 5 days. The total number of education hours per year decreased significantly in 2021 compared to 2019.
The number of night shifts per year rose from an average of 36 in 2019 to 39 in 2021. The number of consecutive night shifts was on average 1.64 in 2019 and 1.28 in 2021, with the difference between the observed years being significant. No nurses worked 4 or more consecutive night shifts in either of the years studied. The number of nurses with more than 50 night shifts per year varied from 0% among RNs to 63.6 % among NTs (n=7).
The number of dayshifts per year was significantly lower in 2021, but the frequency of long shifts was significantly higher compared to 2019 (min. 6, max. 45 in 2019; min. 11 and max. 57 in 2021). The frequency of long weeks (>40 hours/week) was similar in both observed years (t=-0.661, df=19, Sig. 0.516).
The correlations show that the nurses did more evening shifts as they got older (r=0.473, p=0.020). As their youngest child got older, the nurses did more working days per year (r=0.466, p=0.022). We then compared two groups of nurses depending on their level of educational, and the data show that both groups differ significantly in many aspects of their schedule and working hour characteristics (Table 3).
Variable (df = 22)
Mean
SD
t
Sig. (2-
tailed)No. evening shifts, 2019
RN
3.30
4.45
- 10.89
0.00
NT
58.14
15.37
Max. length of shift in hours, 2021
RN
21.24
3.37
10.35
0.00
NT
11.78
0.60
No. evening shifts, 2021
RN
0.80
0.78
- 10.33
0.00
NT
66.00
19.82
No. free weekends per year, 2021
RN
31.1
7.14
8.28
0.00
NT
12.57
3.75
Max length of shift in hours, 2019
RN
21.14
4.33
8.05
0.00
NT
11.88
0.34
No. education hours, 2019
RN
20
9.43
8.01
0.00
NT
0
0
No. free weekends per year, 2019
RN
34.2
7.59
7.46
0.00
NT
15.64
4.60
Continuous working days, 2021
RN
4.32
0.57
- 6.17
0.00
NT
6.29
0.88
No. long day shift, 2021
RN
41.3
9.47
5.86
0.00
NT
20.71
7.73
No. day shifts, 2019
RN
147.6
15.68
5.03
0.00
NT
89.71
33.69
No. working days per year, 2019
RN
191.5
7.706
- 4.37
0.00
NT
210.85
12.36
No. day shifts, 2021
RN
139.7
19.30
4.34
0.00
NT
80.71
39.54
Continuous working days, 2019
RN
4.57
0.43
- 3.93
0.00
NT
5.71
0.84
No. working days per year, 2021
RN
191.2
15.22
- 3.48
0.00
NT
215.36
17.73
No. long day shift, 2019
RN
32.1
11.29
3.34
0.00
NT
18.71
8.39
Bruto total hours 2021
RN
2378.3
131.62
2.74
0.01
NT
2208.9
160.82
No. consecutive night shifts, 2019
RN
0.79
0.334
- 2.67
0.01
NT
1.64
0.95
No. consecutive night shifts, 2021
RN
0.82
0.305
- 2.46
0.02
NT
1.607
0.966
Bruto total hours 2019
RN
2324
139.0
2.45
0.02
NT
2209
91.64
No. education hours, 2021
RN
2.4
3.86
2.34
0.03
NT
0
0
Legend: No: Number/frequency, Max: Maximum, RN: Registered Nurse, NT: Nursing Technician, SD: Standard Deviation, t: t-test coefficient, Sig: Statistical significance
Table 3: Mean and independent sample t-test considering nurses’ education degree.
The main findings of the present study were that there were substantial differences in working hour and schedule characteristics among nursing personnel in 2019 and 2021. Unexpected differences were found with regard to the nurses’ schedules and their level of education level, no quick returns, a maximum of 3 consecutive night shifts per month, and relatively few sick days.
The schedule and work hour characteristics for the year 2021, as compared to those for 2019, showed that nurses worked more long shifts in the former. This finding was consistent with Djupedal [32] and Tabrizi et al. [33], who found that approximately 17% of nurses reported experiencing changes in their work schedules due to the COVID-19 pandemic, mostly in an increased number of long workdays. It is known that long work hours increase fatigue, the risk for reduced performance on the job, obesity, injuries, and a wide range of chronic diseases [34-36]. Long shifts are not necessarily associated with health impairments if the total hours worked is not increased [37], but the nurses in the current study worked approximately 200 more hours in 2021 than in 2019. All the sample nurses worked long weeks throughout the periods studied. This is important, as work schedules that include more workdays are said to be a significant predictor of chronic fatigue, increased risk of diabetes, stroke and cardiovascular disease [21,37,38], as well as occupational injuries, such as back, neck, and shoulder musculoskeletal disorders [17]. Our findings show that the observed schedules are rather problematic, as it seems that the nursing manager did not pay enough attention to the shift length. Some authors claim that nurses prefer to work long shifts instead of the usual 8-hour ones [36], others [39] warn that there is the gap between actual working hours and nurses reported preferred working hours. Improving working standards may prevent nurses from working extra hours [40], but a scheduling computer program would increase understanding of the volume of hours worked per year and avoid in this regard [41].
In the pandemic year of 2021 the nurses examine in this study did fewer consecutive night shifts compared to 2019. No nurses worked 4 or more night shifts in a row, in contrast with the shift characteristics reported in some developed countries [42]. As the highest levels of fatigue are reported during night shifts [43], it is recommended [37] that nurse managers plan 3 or fewer consecutive night shifts for those working under them. The nurses in the present study benefited from fewer consecutive night shifts, but this also meant that they had schedules with no strong rhythm and an unpredictable rotation direction. This is important, as rotating shifts are significantly related to acute fatigue [17,44].
The number of free weekends per year during the pandemic year of 2021 fell, and some NTs only had 5 free weekends over the year, but others more than 40. This indicates some inconsistencies and unfair scheduling between nurses, which could lead to conflict and dissatisfaction. Moreover, having less free time to relax may lead to a lower quality of life among nurses [45].
The frequency of sick days rose during the pandemic, in 2021, which is in line with the findings of Rosenström et al. [46], which stated that the strongest predictors of increased sick leave during the pandemic were having a pre-existing illness, exhaustion and fear of becoming infected. We could not find any significant correlation between demographic and schedule characteristics with regard to the variable “sick days”. This was surprising, as the literature claims that increased age predicts a higher risk of sick leave, and that female staff have a greater likelihood of taking time off for sickness than male staff [47,48]. The low average number of days off due to sickness per year of approximately 6 and 10 in 2019 and 2021, respectively, was also unexpected compared to the 12 days per year reported by Marklund [49].
The major strength of the present study was the use of objective data, allowing us to investigate working hour and shift characteristics related to each individual nurse. There are some limitations, however, as follows: (1) small sample; (2) difficult to read the data on the paper schedules; (3) the literature usually examines RNs and not NT or other profiles of nurses; (4) the lack of clear data on RNs shifts, who sometimes worked 2 or 3 shifts together.
Further studies are needed to investigate the characteristics of nursing schedules in developing countries, especially where nurse managers still use paper shift scheduling, and the schedule characteristics are difficult to follow. These findings highlight some of the increased work demands placed on nurses during the COVID-19 pandemic, which need to be monitored and tracked over time.
Conclusion
While nurse manager examined in this study managed some of the schedule and working hour characteristics appropriately, additional and continuous awareness raising is required to optimize and develop schedule management competency. The present research could provide nurse managers and administrators with baseline information in the scheduling field, and encourage them to use a scheduling computer program to avoid errors and improve working standards.
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