2007:7

Healthy Working Hours

Report of the research and development project

2
KUVAILULEHTI
PRESENTATIONSBLAD
PRESENTATION
Tekij(t) - Frfattare - Author(s)

Marja Paukkonen, Tiina Pohjonen, Tarja Hakola, Harri Lindholm, Heli Sistonen and Riitta Simoila
Julkaisun nimi Publikationens titel Title of the Publication

Healthy Working Hours : report of the research and development project

Julkaisija - Utgivare - Publisher

Julkaisuaika - Publikationsdatum
Published

Sivumr, liitteet - Sidoantal, bilagor

Pages, appendixes

City of Helsinki Health Centre

2007

45

Sarja - Serie - Series

Osanumero - Del nummer

Part number

Helsingin kaupungin terveyskeskuksen raportteja

2007:7

ISSN

ISBN

Kieli - Sprk - Language

1459-9112

978-952-223-191-8

english

Tiivistelm - Referat Abstract

The purpose of the Healthy working hours research and development project was to implement shift work
arrangements as recommended in basic health care. The goal was to produce healthier shift design for nurses
irregular shift work and to measure the effects of the changes to the shifts. In practice, the change implemented
was the reduction of quick returns (the evening shift followed by the morning shift). The off-duty time between
shifts was extended with the idea that this would ensure good recovery from work. There were a total of six
departments participating, all from the City of Helsinki Health Centre acute and long-term care. There was a
questionnaire conducted among the nurses (n=75) both before the new shift arrangements (in 2005) and after the
intervention (in 2006). In addition, the effects of the intervention were assessed by occupational physiological
measurements.
Extending the recovery time in connection of evening and morning shifts improved significantly the nurses sleep
quality and alertness, their well-being at work and their perceived health, and facilitated their taking on leisure time
activities regardless of their age group. Along with the longer recovery times, work was felt to be less strenuous
physically in both morning and evening shifts even though the working processes as such were not changed and
the work load remained unchanged. Every fourth participant had their cardio-respiratory fitness below the level
recommended for good health. During the working day, the energetic demand was the highest during treatment
procedures, 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 shift
arrangements appropriately, it is possible to facilitate well-being at work and improve health statuses. According to
the results, ergonomic shift planning should be the recommended mode of shift planning for nursing, supporting
healthy careers and total well-being for employees. From the point of view of the well-being of employees, it is
essential to adhere to sufficient recovery and rest periods. Nursing work as such is not enough to ensure the
sufficient cardio-respiratory fitness. To maintain work ability, leisure time exercise is necessary, too. Sufficient
levels 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 Work
Environment Fund.
Marja Paukkonen: City of Helsinki Health Centre
Tiina Pohjonen: City of Helsinki Occupational Health Centre
Tarja Hakola: Finnish Institute of Occupational Health
Harri Lindholm: Finnish Institute of Occupational Health
Heli Sistonen: Finnish Institute of Occupational Health
Riitta Simoila: City of Helsinki Health Centre

Te-050.doc 3.1.2005

Avainsanat - Nyckelord - Key words

Shift work planning, rota planning, working hours, shift work, personnel, health, health care
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TABLE OF CONTENTS

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

1.1
1.2
1.3
1.4

Organization of the project........................................................................................................................ 4

Ergonomic shift planning and health ........................................................................................................ 5
Shift work and work-related stress in the field of nursing........................................................................ 6
Occupational physiological measurements................................................................................................ 7

GOALS ............................................................................................................................. 8

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

3.1
3.2
3.3
3.3.1
3.3.2
3.3.3

Departments...............................................................................................................................................8
Changes to shift schedules ......................................................................................................................... 9
Methods applied....................................................................................................................................... 12
Questionnaire........................................................................................................................................... 12
Occupational physiological measurements and performance capacity tests .......................................... 14
Statistical methods ................................................................................................................................... 15

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

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

5.1
5.2
5.3

Results of the intervention on the basis of the questionnaire .................................................................. 18

Physiological impacts of the intervention ................................................................................................ 26
Physical stress of nursing and performance capacity.............................................................................. 27

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

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

1 Background and premises for the project

1.1 Organization of the project
The Healthy working hours project (Terveet tyajat) was a joint venture by the City of
Helsinki Health Centre, City of Helsinki Occupational Health Centre and Finnish Institute
of Occupational Health, funded by the Finnish Work Environment Fund and the City of
Helsinki (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 managing
director of the Health Centre gave the project the approval to proceed with the research
on the basis of the presentation given by the research coordination team.
The project coordination and communications were the responsibility of the project
coordinator, Ms. Marja Paukkonen. The steering group of the project dealt with project
progress issues in its meetings and guided the project in its work towards the agreed
goals on the agreed schedules. The steering group met ten times during the period 16
November 2005 - 4 September 2007. The composition of the steering group was the
following:
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 the
overall project plan. The project group met seven times during the period 17 December
2005 - 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)

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 patients
and the health of employees. There are studies on the effects of fatigue on the
performance of especially doctors and nurses (Felton 1998). Vocational nurses have
been studied quite little even though their input is so important from the point of view of
patients' well-being. Their working hours in hospital departments extend over all the 24
hours of the day 7 days a week.
Nursing is demanding and involves high accountability, and its total work load is
considerable. The quality of patient care depends directly on the work of skilful and
caring nurses; therefore, the health and work capacity of personnel form a critical factor
in the view of the results of the work.
The need of professional, skilled nurses will increase as the population ages while the
shortage of nurses is the reality already. Nurses are stressed further by inconvenient
working 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 to
make reasonable pay. Stress experienced in the field of nursing is on the increase even
though work-related strain in other fields is declining. The growing conflict between the
demand 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 occupational
health services in 2006). Recent studies have shown that onsets of diseases are caused
by disturbances in diurnal rhythms. Factors contributing to shift work-related diseases
include exposure to e.g. stress, insufficient off-duty time to recover from work and
unhealthy ways of life (as to exercise and nutrition) and management of fatigue by
artificial means (cigarettes, alcohol, medicines, stimulants).
Irregular working hours have an effect on a persons mental well-being also, affecting
moods and leading to anxiety and strain, even to exhaustion. Working conditions

compounded to inconvenient working hours produce joint effects causing still more
overload.
The shift schedule can be planned to be more or less ergonomic from the point of view of
the 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-being
of employees and makes the planning of shifts easier. Another important factor is the
appropriate timing of work and rest periods. The third factor to consider is the positioning
of free day periods within the shift system.
Under the Working Hours Act, the working hours in hospitals are flexible. According to
the Act, the working hours in a three-week period must not exceed 114 hours and 45
minutes. The daily working hours are limited by the stipulations in the Act concerning the
minimum rest periods. In the general municipal agreement, the maximum length of a
working day is 10 hours, but exceptions are allowed as agreed by the labor union and
the 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 felt
totally exhausted after her working day (Forma et al. 2003). Women in geriatric work
would seem to have their work ability noticeably weakened as early as in the age of 4044, and significantly weakened after the age of 55 (Pohjonen 2001a).
According to recent domestic estimates (Rauhala et al. 2007), an increase of 30% to the
optimum level of strain in nursing work increases the number of sick leaves 1.5 times. At
the yearly level, this means about 12 extra days for sick leaves.
Risk factors connected to life-style diseases increase the absenteeism of nurses in both
daytime work and in shift work. The joint occurrence of high cholesterol, overweight, high
blood pressure and disturbed sugar levels lead to the risk of absenteeism 2.2 times
higher 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 as
poor opportunities to exert influence and insufficient social support networks increase the
risk of careworkers physical condition and functioning capability deteriorating (Cheng et
al. 2000, Brown et al. 2006).
Work load measurements conducted in shift work environments in the field of geriatric
institutionalized care show that some employees work at levels that drain their
functioning capacity perhaps eventually causing problems of fatigue. In nursing, differing
from industry, employees take on morning shifts immediately after evening shifts, which
causes them a shortage of night time sleep preventing them from having the 7-8 hours
required. During the night after an evening shift, the recovery of the autonomous nervous
system is deficient and the hormonal load is initially higher in the morning of the next
working day than after a morning shift. People adjust to shift systems in their individual

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

1.4 Occupational physiological measurements

Traditionally, the work-related fatigue and strain experienced by employees has been
studied by surveys inquiring into their mental well-being. Inquiries about energy
potentials and symptoms do not always suffice to assess the work-related strain. In
addition to paper surveys, information on employees adjustment and recovery capacity
is acquired by testing autonomic neural function and hormone content. Long-term stress
drains on a persons regulatory systems weakening the hormone secretion especially.
Autonomic imbalance and disturbed hormonal secretion may contribute to the onset of
illnesses (Lindholm 2004).
Constantly increasing arousal in the sympathetic nervous system, detected in
reactivity tests of the autonomous nervous system, has been presented as a
predisposing factor for blood vascular diseases in recent studies. Good organization
of work and good management can thus have great significance in the prevention of
unwanted health-related effects. Physiological measurements can be used as
supplementary methods in studying work-related loading but their results must
always be put in relation to other assessments and the interpretation of the results
presumes high expertise especially in case of aging employees. Especially in
physically 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 rate
variation (HRV, Saalasti 2003). A detailed analysis of the heart rate variability
reflects the balance between the sympathetic, accelerating part and the
parasympathetic, relaxing part of the autonomous nervous system (Porges 2003).
In stressful situations, the sympathetic part is dominant even when recovery should
be taking place. The physical condition of a person has a significant effect on the
effectiveness of his or her stress-regulating systems, capability to adjust to physical
and mental strain and ability to recover from them.
Cortisol, analyzed from saliva samples, is an important stress hormone that is
commonly used for studying of work-related strain. In stress the secretion of cortisol
is 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 autoimmune
diseases. Cortisol has unfavorable effects on the areas of the brain that control
memory and emotions. Increased cortisol levels may also sensitize to the feelings
of symptoms and uncomfortable sensations (Lindholm and Gockel 2000).
The findings from cross-sectional studies and short interventions of a few weeks are
contradictory regarding physiological and psychological stress variables. Short
interventions like physical therapy have improved the mental well-being but there
have not always been any changes detected in the physiological stress levels (Bost
and Wallis 2006). On the other hand, a guided six month relaxation intervention for
Finnish hospital cleaning personnel both improved their coping at work and
balanced their autonomous nervous systems (Toivanen 1993). Longer follow-up
studies have shown the interconnection between nurses moods and stress
hormones (Davydov et al. 2007). The characteristics of shift work impact
employees working capacity. In nursing, it has been seen as especially important to

ensure sufficient recovery time between evening and morning shifts (Sveinsdottir
2006).

2 Goals
The primary goal of the project was to develop shift work models that would nurture
the employees health and to assess the function and effectiveness of the changes
implemented in the shift work. In addition, the loads caused by care work were
assessed together with how the recovery from strain took place.
This is the first study to implement the principles of ergonomic shift planning in care
work. The physiological effects of changes to working hours have not been
measured earlier, either.

3 Personnel studied, methods of study

3.1 Departments
The aim was to find a balanced set of in-patient wards in Helsinki Health Centre
acute hospitals, long-term care hospitals and psychiatric wards. The selection of
departments took place among volunteer ones who were ready to commit to the
goals of the project. The directors of nursing services, head nurses and other
personnel took part in discussions before the selection. On the basis of these
discussions, the selected participants finally included four long-term care
departments (Kivel hospital departments 3 and 21, Suursuo hospital department 11
and Koskela hospital department F3) and two acute hospital departments (Laakso
hospital department 1 and Herttoniemi hospital department 7).
The task of an acute hospital is to diagnose and nurse patients somatic diseases
and to return the patients to their normal functioning capabilities. The key issues in
the human resources management of an acute hospital are ensuring the skill level
and well-being of the personnel and inducting all new employees sufficiently. In order
to ensure the success of recruiting, flexibility and individuality are applied to tasks
and working hours.
The basic task of the long-term care department of the Health Centre is to arrange
the long and short term hospital and hospice care for Helsinki people, supporting
their rehabilitation and functional capacity. Nurses and vocational nurses care for
patients supporting their rehabilitation and functional capacity in a manner that notes
the individuals resources, working in cooperation with the patient, the family and a
multidisciplinary team. The majority of the services of acute and long-term care
hospitals are provided for elderly patients.

3.2 Changes to shift schedules

Prior to the intervention, the working time arrangements of the participating
departments were analyzed with the ergonomics tool of the Shift Plan Assistant
software (Ximes, Austria). The six week rotas were used for calculating the durations
of working times, the timing of shifts and the intervals of work and off-duty times. The
numbers of hours, times of day and numbers of shifts were compared to the
recommended 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 weekly
working hours, recurrent rotations of morning shifts following evening shifts with
intervals of nine hours only in between and long stretches of working shifts (even ten
consecutive shifts).

10

Table 1. Sample rota analysis prior to intervention.

Company
Unit
Job

Hospital
Department
Nurse

Start date
End date
N:o of days

Description
Working hours per week
Working hours per day
Morning shift start time
Night shift end time
Morning shift duration
Evening shift duration
Night shift duration
Consecutive night shifts
Consecutive working days

Minimum
08:00
07:39
07:00
07:30
06:15
08:00
10:00
4
1

Rest period between shifts

Weekly rest
Days off on weekends
Consecutive days off

09:00
32:45
0%
1

13 Sep Material
24 Oct N:o of shifts
6 wk N:o of night shifts
Maximum
57:30
09:45
08:00
07:30
08:00
09:00
10:00
7
8
NIGHT
14:00
168:00
83 %
7

19
504
60

Average
36:05
08:13
07:30

Limit
48:00
09:00
06:00

07:25
08:20
10:00

10:00
10:00
09:00
6
6

82:50
44 %
2,07

11:00
36:00
25 %
2,00

In addition to the results of the ergonomic analysis, the contents of the answers to
the open survey questions were analyzed as to how the pros and cons of the
working hours were experienced (figures 7-8). In practice, the intervention
consisted of decreasing the number of consecutive evening-to-morning shift
rotations in two and three shift work. Shorter working periods was implemented as
well (figure 6). There were no interventions implemented in cases of regular night
time work, as those were few only, and all of them were based on personal
individual agreements. The intervention began in January 2006 and lasted for 12
months.
The implementation of the intervention was monitored throughout the project. The
project coordinator monitored the rota planning with MD-Titania, an electronic rota
planning system. The departments kept statistics of the planned and actual
evening-to-morning shift rotations, numbers of working hour wishes from the
personnel, and the unoccupied shifts (appendix 1). The planning was affected by
many 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 shift
rotations, the rotas were used for counting the distribution of days off. Figures 1
show an example of a departments rota prior to the intervention and after it. It is
noticeable how the evening-to-morning shift rotations decreased with the
intervention. 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 and
after 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 in
red and single days off in orange).

3,5

2,5

2
before
after
1,5

0,5

0
1

>7

days off

Figure 2.

Distribution of days off before intervention and after it (6 week average,

department A).

12

3.3 Methods applied

3.3.1 Questionnaire
The questionnaire was made to learn about the effects of the current shift
arrangements on the physical, mental and social well-being of the employees. The
questionnaire 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 exerting
influence on working hours, timing of shifts, their durations, numbers of
consecutive shifts and spacing of off-duty days) and the employees
experiences 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 managerial
work, work satisfaction).
Questions relating to sleep and alertness, clarifying the problems typical of
shift work and connected to sleep and sleepiness (amount and quality of
sleep and, sleepiness at work and while off-duty). In addition, various
somatic 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 hour
arrangements, working conditions, well-being, sleep and alertness).

The questionnaire form was sent to each respondent personally, and was returned
to the occupational health service providers. The main survey was conduced in
August 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-up
one (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

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

0-34

94

13

There were 75 persons who provided answers to both surveys. 95% of them were
women, and the average age was 46 +10 years. Three groups were created in
order to study the age groups (ages 20-40, n=23, ages 4152, n=26 and ages 53
62, 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). The
forms of work were two-shift, three-shift, daytime work and night-time work,
alternating by department (figures 3-4).
100

10

14

19
19

14
75

47
64

50

80

63
69

65

night
3-shift
2-shift
day

43

25

9
12
10

18

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

100

75

54
before
after

46

50

37
26
25
12

0
day

2-shift

3-shift

night

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

14

3.3.2 Occupational physiological measurements and performance

capacity tests
The physiological well-being and work strain were monitored during for the duration
of two working days and one off-duty day before the intervention. The
measurements were repeated after the lapse of one year. The energetic load and
the balance of the autonomous nervous system were monitored by heart rate
registration (Suunto T6). The results were analyzed with a special software based
on heart rate variability (Hyvinvointianalyysi, Firstbeat Technologies).
From the recordings the periods of mental and/or physical stress can be
differentiated. The energetic load caused by work was expressed in units of MET in
which the energy consumption required by work is compared to the consumption in
rest state. The activity of relaxing part of the autonomous nervous system reflects
the recovery especially during sleep. In addition to physical strain, the activity of
circulatory system increases during mental stress as well. Nurses have been found
to have changes in the balance of their autonomous nervous systems especially as
far as recovery is concerned (Ishii et al. 2005).
Cortisol measurements of saliva samples were performed during the same days
with the heart rate measurements. Especially the morning response (from
awakening to one hour after getting up) is widely used in the stress studies
(Pruessner 1997). The participants took the samples immediately after awakening
and again in thirty minutes and after one hour and again in the evening before going
to sleep. The analysis was performed with the RIA method (Phoenix Laboratories).
A submaximal ergometer test was performed in order to define the functional
profiles of the cardiorespiratory system (Fitware, AinoActive, Finland). The
measurements 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 rate
was also registered during the ergometer test (Polar Electro, Finland). The
measurements were preceded by a medical examination by a physician. The
participants physical activity levels were inquired into and scored in seven
categories (0 = completely inactive - 7 = very active). After the ergometer tests,
lactate samples were collected to define the intensity of muscular work. Even
though the ergometer test was submaximal, it was done under the supervision of a
qualified 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 in
2005. There was a total of 87 participants, 81 women and 6 men. A total of 237
heart rate registrations were entered, 33 of them technically unsatisfactory. The
follow 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. A
total 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 wrist
computer equipped with a belt. In general, it was noted that collecting heart rate
data does not interfere with the normal life. Some participants had difficulties in
starting the measuring. Measuring heart rate was not a familiar activity, and some
participants were apprehensive about the use of the button keys on the watch-like
instrument - for no reason, often. In some cases there was irritation of the skin
because the registration periods were relatively long and there was much
perspiration during the shift. The main factor harming the registrations were the cutoffs in the connection between the data collector band and the wrist computer. The
percentage of successes was, however, satisfactory even in the first phase, and it
improved to a good level with the new Suunto SmartBelt used in the follow-up
phase field measurements.
Before the field measurements were started, the participants attended information
sessions held in their own work places. Detailed information was provided on how
the measurements should be done. In the information sessions, instructions were
distributed to the participants who also had a change to become acquainted with
saliva tubes and the devices that would collect the heart rate data. Only a few of the
participants had the opportunity of attending these information sessions, and it was
up to the work place personnel to transmit the relevant information to the other
participants in the unit.
The difficulty experienced during the first round of field measurements was
reconciling 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 of
the measuring equipment. Therefore, the first round of field measurements took
twice as long as the second one. For the second field measurement round there
were precise times defined for each one of the three registrations. As to the saliva
samples, 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 in
the functioning capability laboratory during the second round. People were
somewhat apprehensive coming in for the measurements, but in general, everyone
was 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 the
repeated 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 first
started, and later on in either department briefings or in the head nurses office. As
far as rota planning was concerned, the project received support in department
meetings and through personal contacts to the head nurses. Information
concerning the measurements was given at the departments several times. After
the follow-up period, every participant got personal feedback on the measurement
results. The one-to-one feedback discussions with the projects physician in charge
were held during autumn 2007.
The departments personnel and line management were informed of the projects
progress on 6 June and 7 September, 2005, in connection of training sessions, and
they had the opportunity of listening to lectures on Healthy working hours (Ms Tarja
Hakola, Senior Specialist) and Physiological measurements (Mr. Harri Lindholm,
Medical Specialist). The supervisors and line managers were briefed as to the
progress of the project and the commitment to it on 15 February, 2006. The
department personnel and line managers had a training session on Ergonomic shift
planning (Ms Tarja Hakola, Senior Specialist) on 10 October, 2006. The internal
bulletins 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 given
information on it. The progress of the project is presented below.

17

1. Preparation phase
Information for users
September '05
- questionnaire

2. Orientation phase
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

October '05
- start of shift plannig

3. Analyzing phase
Case based knowledge base
First version of new shift system
October-November '05
- physiological measurements

4. Design phase
Ergonomic constrains

Areas of increased risks

Listing of priorities
Modified new shift system
November-December '05
- start of intervention

5. Testing phase
Experimental new shift system

6. Evaluation phase
Suggestions for improvement
of new shift system

December '06
- follow-up questionnaire
- physiological measurements

Implemented new shift system

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 were
decreased as were the irregularities of working hours and long periods of
consecutive shifts. The participants felt that the number of single days off was
increased and longer periods of leisure time were decreased.

unfavorable shift sequences

12

irregularity of working hours

80
23

number of consecutive work days

47

17

number of consecutive days off

long work hours

overtime

44
39
34

10

night work

extras

23

11

single days off

20
36

week-end work

20

12

days off on weekdays

11

11

increased
no change
redused

31

25

50

75

100

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

Before the intervention, the participants considered the pros (figure 7) of the shift
system to consist of days off on weekdays, long periods of days off and other
reasons that included various individual working time arrangements contributing to
good coping at work, such as working nights and part time work. Before the
intervention, the participants considered the cons (figure 8) of the system to consist
of going from evening to morning shift, single days off, weekend work and long
periods of work.
After the intervention (figure 9), the participants considered the pros of the shift
system to consist of its regularity, the fulfillment of employees wishes, off-duty
weekdays 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 system
consist of off-duty time starting in the evening, starting duty in the morning after
leisure time and off-duty periods of single day only.

19

days off on weekdays

not evening-to-morning

long periods of days off

daytime work, regular

individual reasons

implementation of personal wishes

regular schedule

days off on weekdays

no night shifts

short periods of work

before

after

rhythm of work and days off

rhythm of work and days off

implementation of personal wishes

long periods of work

extras

mornings and evenings grouped

night shift

days off arrangements

variation

later mornings
0

Figure 7.

10

20

30

40

50

Pros of the shift system before intervention. Percentages

of classified answers to open questions.

Figure 9.

20

30

40

50

Pros of the shift system after intervention. Percentages of

classified answers to open questions.

evening-to-morning

evening shift-to day off

single days off

day off-to morning shift

weekends at work

single days off

long periods of work

consecutive mornings

limits social and family life

10

limits social and family life

before

after

irregular schedule

hourly balancing

individual reasons

other reasons

evening shifts

workload

workload

evening shift

early morning shifts

long periods of work

0

Figure 8.

10

20

30

40

50

Cons of the shift system before intervention. Percentages

of classified answers to open questions.

10

20

30

40

Figure 10. Cons of the shift system after intervention. Percentages of

classified answers to open questions.

50

The implementation of the ergonomic shift planning (figure 11, attachment 1) was
affected by many department internal and external factors such as number of
employees, number of missing employees, the time of year etc. (chapter 6).
50

40

30
evening-to-morning shift (planned)
evening-to-morning shift (actual)
unoccupied shifts
changes to schedule (wishes)
20

10

30

.1
-1
20 9.2
.1
-1
13 2.3
.3
.-1
3. .4.
42
24 3.4
.
.4
-1
4.
5
15
.5 .
.-4
.6
5.
.
6.
-2
26 5.6
.
.6
-1
6
17 .7.
.7
-6
.8
7.
.
8.
-2
7
28
.8
.
.8
.-1
18 7.9
.
.9
.-8
.1
9.
10 0.
-2
9
.1
30
10 0
-1
9
20
1
11 1
-1
11 01
12 2
-3
11
1.
1. 2
-2
22 1.1
.
.1
.-1
12 1.2
.2
.-4
.3
5.
.
3.
-2
5.
3.

Figure 11.

Sample shift planning implementation during the project (number,

department A).

The opportunities of impacting the rota (figure 12) were decreased somewhat
during the intervention, but the change was not statistically significant, and the
personal wishes concerning schedules were implemented, on average, relatively
often.
How often are your
personal wishes noted
when the rota is
planned?
To what extent do you
feel you have control
over the specific shifts
that you work?

after
before

Do you have impact on

solving these problems?

Are there problems

related to the working
time arrangements in
your work?
1
not at all

Figure 12.

3
some

5
a lot

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

21

During the intervention, the start and end times of the shifts were not changed. The
timing of shifts (figure 13) suited the majority of the participants, however, one fifth
considered that the morning shift started too early and a quarter considered that
the evening shift ended too late. A fifth of the respondents thought the night shift
too long. Satisfaction as to the timing and duration of shifts remained the same
during the project.
100

75
before
after

50

25

morning

Figure 13.

evening

too long

duration just right

ends just right

starts just right

duration just right

ends too late

ends just right

starts just right

duration just right

ends just right

starts just right

starts too early

night

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

During the intervention, the shift sequences were shortened (figure 14). The
reduction of morning shifts following evening shifts naturally changed the rhythm of
shifts by increasing the number of consecutive morning and evening shifts. Most of
the respondents considered the number of morning and evening shifts to be
convenient, however, a generous quarter of the respondents thought that there
were too many consecutive morning shifts. Before the intervention, a quarter
thought the number of evening shifts was too small, but however, after the
intervention, one fifth of them thought that there were too many consecutive
evenings. Both before and after the intervention, every second respondent
considered the number of consecutive days off too small.

22

100

75

before
after

50

25

mornings

Figure 14.

evenings

nights

just right

too few

too many

just right

too few

too many

just right

too few

too many

just right

too few

days off

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

The effects of the shift system on the well-being of the personnel in the various
spheres of life (figure 15) clearly improved during the intervention. Sleep and
alertness (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 time
activities were also significantly (p=0.02) facilitated. Family and social life were
facilitated, but the change was not statistically significant. The intervention had no
impact on the working atmosphere.

work climate
leisure time activities
family life
after
before

social life
general health
well-being at work
sleep and alertness
1
disturbs

Figure 15.

5
facilitates

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

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

23

facilitates

the family and social lives of the respondents. Leisure time activities in all groups
were facilitated (p=0.02).
5

4
20-40 years
41-52 years
53-62 years

disturbs

1
before

after

sleep and alertness

facilitates

Figure 16.

before

after

well-being at work

before

after

general health

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

4
20-40 years
41-52 years
53-62 years

disturbs

1
before

after
social life

Figure 17.

before

after
family life

before

after

leisure time
activities

Impacts of the shift system on compatibility of work and life per age
group (average, n=75).

The perceived physical strain (figure 18) decreased significantly in connection of

morning (p=0.0005) and evening (p=0.02) shifts. The physical strain in the night
shift was decreased as well, but not in a significant manner. The perceived mental
strain did not change during the project.

24

heavy

before
after

light

1
morning evening

night

physical

Figure 18.

morning evening

night

mental

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 working
on morning shift, trouble falling asleep when working on evening shift, and heavy
sleepiness at work when working on night shift. These problems were significantly
alleviated during the intervention (p=0.03, p=0.003, and p=0.05, respectively). As to
other problems related to sleep and alertness, the disturbances either remained the
same or were somewhat decreased.

25

alvways

night shift
4

often

often

always

morning shift

How often do you

have trouble waking
up?

Figure 19.

How often do you

have trouble falling
asleep?

How often do you feel

How often do you
How often do you
very sleepy at work? think sleepiness has
have trouble falling
affected your work
back to sleep after
performance?
waking up in the
middle of your sleep?

Problems with sleep and alertness when on morning

shift (average, n=75).

rarely

before
after
2

never

rarely

never

before
after

1
How often do you
have trouble waking
up?

Figure 20.

rarely
never

before
after

1
How often do you
have trouble waking
up?

Figure 21.

How often do you

have trouble falling
asleep?

How often do you feel

How often do you
How often do you
very sleepy at work? think sleepiness has
have trouble falling
affected your work
back to sleep after
performance?
waking up in the
middle of your sleep?

Problems with sleep and alertness when on evening

shift (average, n=75).

always
often

Problems with sleep and alertness when on night shift

(average, n=75).
holiday

before
after
rarely

How often do you feel

How often do you
How often do you
very sleepy at work? think sleepiness has
have trouble falling
affected your work
back to sleep after
performance?
waking up in the
middle of your sleep?

free days

never

often

always

evening shift

How often do you

have trouble falling
asleep?

1
How often do
you have
trouble waking
up?

Figure 22.

How often do
you have
trouble falling
asleep?

How often do
you have
trouble falling
back to sleep
after waking up
in the middle of
your sleep?

How often do
you have
trouble waking
up?

How often do
you have
trouble falling
asleep?

How often do
you have
trouble falling
back to sleep
after waking up
in the middle of
your sleep?

Problems with sleep and alertness while off-duty (average,

n=75).

26

5.2 Physiological impacts of the intervention

saliva cortisol (umol/l)

The changes to the morning response to cortisol on working days were analyzed by
dividing the participants into groups on the basis of the benefits they had experienced
due to the intervention. Before the intervention, there were no statistically significant
differences between the groups regardless of whether the intervention was
experienced 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 on
its upper limit. After the intervention, all groups had an improvement in the morning
response. The change among the participants experiencing the intervention
positively (improved well being) or neutrally (no change) was statistically significant.
Among the nurses experiencing the intervention negatively the improvement of the
morning responses in salivary cortisol was however nearly significant (figure 23).
Those experiencing it negative had the largest divergence.

25
20
15

before

10

after

5
0
positive

unchanged

negative

well-being
Figure 23.

Change ( mol/l) of saliva cortisol morning response before and after

intervention (one year follow-up) in employees experiencing the change
in well-being positive, unchanged, or negative.

On the basis of cortisol, the working time intervention had a beneficial effect on
stress 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 about
the benefits of ergonomic working hour planning to ones own health.
In the analysis of the heart rate variability, on average, there were no changes
detected 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 those
participants who had findings that indicate slow recovery was decreased from 35% to
20% during the intervention, and the portion of those participants who had good
recovery increased from 30% to 52% (figure 24).

27

60
50

40

slow

30

normal
good

20
10
0
before

after
intervention

Figure 24.

Recovery of the autonomous nervous system after working days both

before and after changes to working hours (% of participants).

Very severe cases of overload were not found. Even though the working time
intervention seemed to decrease stress and especially to facilitate recovery, it is
important 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

MET

4
3

average
maximum

2
1
0
p
ee
sl
st
re i se
rc
ce rk
ex wo
e
m
ho s
ie ome
bb
h
ho ute
k
m
or
m
w ines
co t e
ic
u
ed
m
m
m
co . of
rib re
st
di l ca
a
ic
in re
cl
a
rc
he e
ot car
sic
ba
rt
po
re

Figure 25.

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

Nursing work stresses physically more the musculoskeletal system than the cardiorespiratory 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 only
moderate the peaks and the general health of a nurse require the maximal aerobic
fitness more than 5-6 MET's. Because the reduced condition of the respiratory and
blood-vascular systems is connected to the weakening of muscular strength, the
musculo-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 not
exceed ones tolerance level.
About a quarter of the participants had the aerobic fitness below the optimal level of
general health (figure 26). This correlates with the physical exercise taken. A
quarter of the participants performed exercise bouts during the leisure time once a
week or more seldom. Although the physical exercise is only one part of promoting
good health, it is important to guide the risk groups to start a physically active way
of life (Fogelholm et al. 2007).

29

50
40
%

30
20
10
0
<7

7-8

>8

MET
Figure 26.

Cardiovascular performance capacity in the ergometer test. The fitness

below the level 7 MET increases the health risks among the middle-aged
female workers.

Physical activity is important from the point of view of weight control as well. Nursing
presumes sufficient muscular mass. As to weight control, it is important to secure a
balanced body composition. Not only is the body mass index important. The weight
loss should not decrease the muscular strength. Almost a half of the nurses were
found to have a need for weight reduction of less than 5 kg as proportioned to their
muscular mass. One third of them had a need for reduction over 10 kg (figure 27).
50
40
%

30
20
10
0
<5

5-10

>10

kg
Figure 27.

The need for weight reduction proportioned to the measured muscular

mass (% 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 pulmonary
disease related to smoking. Fewer than 10% of the respondents were found to have
an acute change in their health status that required additional examination. These
cases involved mainly the control and balance of treatments of already known
illnesses.

30

6 Experiences of the progress and implementation of

the 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 in
shift planning were so significant that to succeed they required strong commitment on
behalf of those managing the nursing activities. There were a better understanding of
the changes effects to the employees health and a strong commitment to shift
changes created through the process. In order to succeed, the head nurses need both
support and determined guidance in the process. Ergonomic shift planning methods
cannot be directly taken from theory to practice as they require individual application to
each working community before they have a chance to succeed. Wards develop other
functions simultaneously, too, and personnel may change and the totality may be
altered thereby.
In general, the personnel were very committed to the project even though there was
quite significant turnover in the staff in the departments. The director of nursing
services 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 the
departments. There were changes to the substitute positions especially. Some of the
departments suffered from a shortage of personnel all the year 2006. A number of
nurses in certain departments worked shorter hours and some were on long sick
leaves. The situation, as to patients, was quite stable throughout the project.

31

Spring and
summer 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, we
accepted one. All departments are eager to begin. However, the two project training
sessions had few participants only, except for one department.

Autumn 05

Initial survey completed. Started rota planning. Got more careful and eager to defend the
old, unsure of what changes were to be made. Three head nurses and two directors of
nursing services changed. Commitment in these departments got more difficult as
everyone was not involved from the beginning. Physiological measurements started
somewhat floundering.

Spring 06

Agreed to keep numbers of evening-to-morning shift rotations low. This facilitated rota
planning as it is a clear, concrete goal. The plans were monitored by the Titania lists and
their general follow-up throughout the project. Discussed experiences and feelings in the
project team. Commitment seemed difficult to achieve, still, so the steering group held a
pep briefing for the middle management and nearest supervisors in February.
Commitment and stick-to-it-ness both increased. When problems occurred, the head
nurses were contacted and they were positive about this. The steering group work was
vigorous. The project team had discussions and made comparisons. Department-specific
plans were created and they were adhered to until the end of the project, except for one
department. 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 a
shortage of staff throughout the project. They did what they could. Five departments had
relatively permanent staff. Three of the departments stuck to what was agreed once they
had reached it in the spring, and the head nurses explained ergonomic planning to
themselves and others. One had rather individual, varying solutions.

Autumn 06

The department that slunk away in summer got back to the agreed schedule. Gave
feedback as to successes in planning and asked about changes to plans and the reasons
for them. It required lots of support and listening to descriptions of difficulties but I did not
yield because the project duration was limited and the topic was seen as important. In
other words, the planning would have gone off course if it had not been keenly followed up
all the time. If I did not get the compilation lists from the head nurses right away, I asked
for them. Finally, I got them smoothly.
Had the follow-up survey and another training session on ergonomic shift planning for
those wishing it and new employees. Hit the right spot!
I wondered throughout the project how often I should visit the departments, how often I
should call and so on. I phoned the head nurses quite often and visited the departments
with 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 negative
atmosphere 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. Briefings
for 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 how
they were doing:
- The substitutes exhibited poor commitment, they would have preferred to work mornings
only, the temps got to choose and present wishes as to shifts, and a part of the permanent
staff 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, then
extended 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 of
over 6 days, not even for those who do nights only (clear rota planning rules created with
the director of nursing services).
- The department voted about continuing with ergonomic rota planning - the one half was
for, the other half was against - and the continuation is open.

32

The head nurses in the participating departments were sent an electronic survey in
June 2007, inquiring as to the implement ability of the intervention. The pros of
ergonomic rota planning were seen to include the nurses better recovery and the
head nurses opportunity to promote the health of the employees through shift
planning. It was noted that the old gripe about the strenuousness of the eveningto-morning rotations was gone, because sufficient rest was assured. Rota planning
as 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 head
nurses felt that the new rota planning had helped committing to the personal nurse
system because the personal nurse was energetic on all working days. The same
departments improved their communications as well, because the reorganization of
work 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; uninterrupted
stretches of shifts are kept to no more than five shifts, and a part of the head nurses
will plan shorter night shifts. Individual wishes are paid attention on, but the
ergonomic 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. A
part of the head nurses would want to develop participatory rota planning or try
yearly working hours. A part is trying to influence attitudes in their own hospital
environments or to market ergonomic shift planning to their colleagues. All the
respondents have noted that ergonomic shift planning requires a new way of
thinking and some time to digest.
When asked about the need for support and training in enhancing shift planning
methods, the head nurses wished that the personnel be better briefed about shift
planning, and also wished to have common, harmonized policy statements as to
what constitutes good and ergonomic shift planning. Shift planning requires
perceiving the total situation at the department precisely, and there are frequent
discussions held on the topic with the personnel. The shift planning is wished to take
on more flexibility through local agreements and updates to the shift planning
software.

33

7 Conclusions and recommendations

1. This study showed that healthier shift work design is possible in nursing. Ergonomic
shift 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 the
employees and measurable, favorable changes in their systems.
In all age groups, well-being improved both at work and on leisure. The
improvements in shift design made sleep disturbances less common and
improved the quality of sleep, thus improving the total alertness. Well-being at
work improved significantly. In addition, the new shift design created improved
the opportunities to take on leisure time activities.
Along with the longer recovery times, work was felt to be less strenuous
physically in both morning and evening shifts even though the working
processes as such were not changed and the workload remained unchanged.
The shift design intervention decreased the measured stress levels and made
recovery more effective.
3. This study supports the view that nursing primarily stresses, physically, the
musculo-skeletal systems. The load provided by nursing work is not sufficient,
alone, to keep the cardio-respiratory systems healthy. To maintain a good working
condition, 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 had
their cardio-respiratory fitness below the recommended levels. Leisure time
physical activities are needed to maintain the cardio-respiratory performance
capacity. Exhausted worker however do not have resources for these
activities. The total work load must not exceed ones tolerance level.
4. Shift planning is a human resources management tool which, at its best, can be
used to bring well-being into nursing.
Numbers of evening-to-morning rotations that were felt to be stressful were
decreased and long periods of work days were made shorter. This did not
increase the number of single days off, but the rotations of evening shift to day
off to morning shift are experienced as difficult.
Ergonomic shift planning is the basis of modern shift design; information
concerning it must be made available, and people should be trained in it. The
practical implementation of shift planning should be developed together with
the staff concerned. The commitment of the staff can be promoted by
combining ergonomic shift planning with opportunities of influencing shift work
arrangements.

34

5. On the basis of the results of the project, the steering group is ready to recommend
that the branches of the City of Helsinki where shift work is used similarly implement
ergonomic shift planning methods. In practice and primarily, this means giving up
evening-to-morning shift rotations.

35

Sources
Barton J, Costa G, Smith L, Spelten E, Totterdell P, Folkard S: The standard shiftwork index: A
Battery of questionnaires for assessing shiftwork related problems. Work & Stress 1995;9:4-30.
Bost N, Wallis M. The effectiveness of a 15 minute weekly massage in reducing physical and
psychological stress in nurses. Aust J Adv Nurs 2006; 23: 28-33.
Brown D, James G, Mills P. Occupational differences in job strain and physiological stress: female
nurses and school teachers in Hawaii. Psychosom Med 2006; 68: 524- 530.
Cheng Y, Kawachi I, Coakley E, Schwartz J, Colditz G. Association between psychosocial work
characteristics and health functioning in American women : prospective study. BMJ 2000; 320:
1432- 1436.
Davydov D, Shapiro D, Goldstein I, Chicz-Demet A. Moods in everyday situations: effects of
combinations of different arousal- related factors. J Psychosom Res 2007; 62: 321- 329.
Elovainio M, Kivimki M, Puttonen S, Lindholm H, Pohjonen T, Sinervo T. Organisational injustice
and impaired cardiovascular regulation among female employees. Occup Environ Med 2006; 63:
141- 144.
Felton J. Burnout as a clinical entity- its importance in health care workers. Occup Med 1998; 48:
237- 250.
Fogelholm M, Lindholm H, Lusa S, Miilunpalo S, Moilanen J, Paronen O, Saarinen K. Tervett
liikett- terveysliikunnan hyvt kytnnt tyterveyshuollossa. Tyterveyslaitos, Helsinki, 2007.
Forma P, Vnnen J, Saari P. Kuntaty 2010 tutkimus. Esiraportti. Helsinki: Kuntien
elkevakuutus 2003.
Gissel A, Knauth P. Knowledge-based support for the participatory design and implementation of
shift systems. Scand J Work Environ Health 1998, vol 24, suppl 3, 88-95.
Hakola T, Hublin C, Hrm M, Kandolin I, Laitinen J, Sallinen M. Toimivat ja terveet tyajat.
Tyterveyslaitos, Helsinki, 2007.
Hertting A, Theorell T. Physiological changes associated with downsizing of personnel and
reorganisation in the health care sector. Psychother Psychosom 2002; 71: 117-122.
Ishii N, Dakeishi M, Sasaki M, Iwata T, Murata K. Cardiac autonomic imbalance in female nurses
with shift work. Auton Neurosci 2005; 30: 94- 99.
Kivimki M, Virtanen M, Elovainio M, Vnnen A, Keltikangas-Jrvinen L, Vahtera J. Prevalent
cardiovascular disease, risk factors and selection out of shift work. Scand J Work Environ Health
2006; 32: 204- 208.
Knauth P, Hornberger S. Preventive and compensatory measures for shift workers. Occupational
Medicine 2003;53:109-166.
Kunz-Ebrecht S, Kirschbaum C, Steptoe A. Work stress, socioeconomic status and
neuroendocrine activation over the working day. Soc Sci Med 2004; 58: 1523- 1530.
Lindholm H. Miten tystressin fysiologisia vaikutuksia voidaan arvioida? Tyterveiset 2004; 2: 7-9.
Lindholm H, Gockel M. Stressin elinvaikutusten mittaaminen. Duodecim 2000; 116: 2259-65.

36

Pruessner J, Wolf O, Hellhammer D, Buske-Kirschbaum A, von Auer K, Jobst S, Kaspers F.

Kirschbaum C. Free cortisol levels after awakening : a reliable biological marker for the
assessment of adrenocortical activity. Life Sci 1997; 61: 2539- 2549.
Pohjonen T. Perceived work ability of home care workers related to the individual factors and
characteristics of work in different age groups. Occup Med 2001a: 3; 209-217.
Pohjonen T, Liimatainen M, Toikka T, Lindholm H. Tyn kuormitustekijiden hallinnan kehittminen
vanhusten laitoshoidossa. Tysuojelurahaston loppuraportti. Helsinki: Helsingin kaupunki ja
Tyterveyslaitos 2003.
Pohjonen T. Perceived work ability and physical capacity of home care workers. Effects of the
exercise and ergonomic intervention on factors related to work ability. Doctoral dissertation.
Kuopio: Kuopio yliopiston julkaisuja D. Lketiede 260, 2001.
Porges S. Polyvagal theory: phylogenetic contributions to social behaviour. Physiol Behav 2003;
79: 503- 513.
Rauhala A, Kivimki M, Fagerstrm L, Elovainio M, Virtanen M, Vahtera J, Rainio A, Ojaniemi K,
Kinnunen J. What degree of work overload is likely to cause increased sickness absenteeism
among nurses? Evidence from the RAFAELA patient classification system. J Adv Nurs 2007: 57:
286- 295.
Saalasti S. Neural network for heart rate time series analysis. Academic Dissertation, University of
Jyvskyl, Finland, 2003.
Sveinsdottir H, Self- assessed quality of sleep, occupational health, working environment, illness
experience and job satisfaction of female nurses working different combinations of shifts. Scand J
Caring Sci 2006; 20: 229- 237.
Terveystarkastukset tyterveyshuollossa. Tyterveyslaitos, Sosiaali- ja terveysministrei, 2006.
Toivanen H, Lnsimies E, Jokela V, Hnninen O. Impact of regular relaxation training on the
cardiac autonomic nervous system of hospital cleaners and bank employees. Scand J Work
Environ Health 1993; 19: 319-325.

.2
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37

Appendix1. Implementation of shift planning in departments B-F during the project (number).
50

40

30
evening-to-morning shift (planned)
evening-to-morning shift (actual)
unoccupied shifts
changes to schedule (wishes)

20

10

Department B

50

40

30

evening-to-morning shift (planned)

evening-to-morning shift (actual)
unoccupied shifts
changes to schedule (wishes)

20

10

Department C

30
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7

30
.1

38

100

90

80

70

60

50
evening-to-morning shift (planned)
evening-to-morning shift (actual)
unoccupied shifts
changes to schedule (wishes)

40

30

20

10

Department D

100

90

80

70

60

50
evening-to-morning shift (planned)
evening-to-morning shift (actual)
unoccupied shifts
changes to schedule (wishes)

40

30

20

10

Department E

2.
4

24
.4

3.
4
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4.
5
15
.
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.6
5.
.
6.
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26 5.6
.
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6.
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7.
8.
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28 7.8
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18 7.9
.9
.9. 8.1
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10
-2
30 9.1
0
10
.
20 19.
1
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1
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31
1.
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12
120
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.
21 07
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5 . .3
325
.3

-2

.3
-

3.
4.

9.
2

12
.3

-1

.1
-

13

20

30
.1

39

100

90

80

70

60

50
evening-to-morning shift (planned)
evening-to-morning shift (actual)
unoccupied shifts
changes to schedule (wishes)

40

30

20

10

Department F

40

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

Before

After
3,5

2,5

2
before
after
1,5

0,5

0
1

days off

Department B

>7

41

Before

After
3,5

2,5

2
before
after
1,5

0,5

0
1

5
days off

Department C

>7

42

Before

After
3,5

2,5

2
before
after
1,5

0,5

0
1

5
days off

Department D

>7

43

Before

After
3,5

2,5

2
before
after
1,5

0,5

0
1

5
days off

Department E

>7

44

Before

After
3,5

2,5

2
before
after
1,5

0,5

0
1

5
days off

Department F

>7