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11

REVIEWS

The impact of 12-hour shifts on nurses’ health,

wellbeing, and job satisfaction: A systematic review
∗
Maram Banakhar
Faculty of Nursing, King Abdulaziz University, Jeddah, Makkah, Saudi Arabia

Received: April 7, 2017 Accepted: May 30, 2017 Online Published: June 26, 2017
DOI: 10.5430/jnep.v7n11p69 URL: https://doi.org/10.5430/jnep.v7n11p69

A BSTRACT
Objective: This review was conducted to investigate the impact of applying 12-hour shifts in comparison to 8-hour shifts on
nurses’ health wellbeing and job satisfaction.
Methods: MEDLINE, CINHALE, PsycINFO, EMBASE, Web of Science, and SCOPUS databases were searched, covering the
period between 1980 to 2017. Studies were included if they concerned nurses working for 12-hour shifts in comparison to 8-hour
shifts in hospital settings, based on observational/surveys studies.
Results: In the yielded 12 studies, 3 studies reported that 12-hour shifts had an impact on nurses’ health and wellbeing, such as
cognitive anxiety, musculo-skeletal disorders, sleep disturbance, and role stress; however, there was no significant difference
between 12- and 8-hour shifts with digestive and cardiovascular disorders, psychological ill health, and somatic anxiety. Of the 4
studies measuring the impact of 12-hour shifts on fatigue, three studies showed that the nurses experienced more fatigue in the
12-hour shifts in comparison to 8-hour shifts; nevertheless, one study did not find a significant difference in fatigue and critical
thinking performances between 12- and 8-hour shifts. Nine of the 12 studies measured job satisfaction in 12- and 8-hour shifts, 5
studies showed a greater dissatisfaction regarding 12-hour shifts, while 3 studies found that the nurses were more satisfied with
12-hour shifts than with 8-hour shifts; but one study pointed out that there was a difference between the two shifts considering
pay and professional status.
Conclusions: The findings of the review suggest that 12-hour shifts resulted in negative health concerns and job dissatisfaction;
however, there is a need for more empirical evidence to support this.

Key Words: Twelve hour shift, Eight hour shift, Nurses’ health, Nurses’ wellbeing, Nurses’ job satisfaction

1. I NTRODUCTION shifts. This requires the staff to be adaptable to the various

forms of shift work schedules.[1]
In the past two decades, many changes have been imple-
When considering the negative impacts of shift-work on
mented in healthcare working systems. One of these changes
workers’ health, fatigue and sleepiness are the most com-
has been the assimilation of shift-work systems and flexibility
mon complaints among staff. Job performances, lack of
in work schedules. The need for 24 hours care makes health-
psychosocial well-being, and job dissatisfaction have also
care professions work with different shift systems, such as
been well reported in the literature.[2, 3] Community based
8 h, 9 h, 10 h or 12 hour shifts. However, the common shift-
studies of fatigue demonstrate the prevalence of fatigue in
work systems divided a 24 h day in two (12 h) or three (8 h)
∗ Correspondence: Maram Banakhar; Email: [email protected]; Address: Faculty of Nursing, King Abdulaziz University, Jeddah, Makkah,

Saudi Arabia.

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primary care studies, which is defined as loss of energy and thermore, few hours of sleep impact on hormone levels such
tiredness among workers ranging from 10% to 45%.[2, 4] This as leptin, cortisone, and thyrotropin all dependent on sleep
prevalence is associated with lack of physical activity and duration.[22]
psychosocial variables such as depression and anxiety, and
The Maastricht Cohort study on fatigue at work demonstrated
psychological problems. The data of NHANES (National
that increasing the hours of work per day resulted in a greater
Health and Nutrition Examination Survey), indicates that
need for recovery from work.[9] This study also indicated that
female respondents suffered from fatigue at 20.4%, which
working for six or fewer hours per day lowered the need for
is higher than that suffered by male respondents at 14.3%.
recovery time. Overtime, extended work shifts, and working
This finding points to a higher risk among women than men
for more than 8-hours can have an adverse effect on health,
at 1.5 times more risk.[5] Therefore, fatigue is considered
such as the risk of musculoskeletal disorders, cardiovascular
as a symptom resulting from shift work, which has an im-
symptoms, hypertension, injury, and the risk of diabetes, as
pact on health. It has a significant effect on the levels of
well as increased mortality and morbidity rates, and a higher
alertness, concentration, judgment, mood, and performance
rate of accidents.[8, 23–27] Fatigue has been found to increase
which might also be a reason for the increased risk of in-
over the length of the duration of shifts among the healthcare
jury and medical errors.[6, 7] Moreover, fatigue also impairs
professions, such as in 12-hour shifts.[3] Moreover, the qual-
memory, problem solving, and decision making-abilities.[8, 9]
ity of nurses’ work suffered with long working hours (9 h
Fatigue problems are believed to cost the United States about
and 12 h).[28]
18 billion dollars in accidents and lost productivity, while
76,000 injuries among shift workers were reported.[6, 10] However, while systematic reviews have been conducted to
examine the impact of working hours on health, it is notice-
With regard to sleepiness, several studies have indicated that
able that no review has examined the impact of 12-hour shifts
the average of sleep duration from the 1910 to 2002 has
compared to 8-hour shifts on nurses’ health and wellbeing,
decreased from 9 to 6 hours on workdays.[11, 12] A survey
and job satisfaction. For example, a review was conducted to
study showed that American nurses have an average of 84
investigate the effect of residents’ working hours on patients’
minutes more sleep on non-workdays.[13] Thus, shift work is
safety, including mortality rates, medication errors, and ad-
suggested as a cause of sleep disorders among nurses, where
verse events,[29] whereas a further review which examined
they feel sleepy during a shift. When considering the con-
the differences between 8 and 12-hour shifts considering
tributing factors of sleepiness, the literature identifies that
the worker’s outcomes and safety in the industrial sector.[30]
long working hours and rotating shifts as the main causes for
Despite the fact that nurses work different shift work sys-
sleeping disorders. In the night and with rotating shifts, the
tems which are similar to industrial workers, they cannot
nurses rarely obtain an adequate amount of sleep. In fact, the
be compared to industrial shift workers for various reasons.
nurses experienced less sleeping hours (1 to 4 hour) than in
The nurses’ work environment is different from that of the
normal sleeping situation.[14, 15] More studies have revealed
industrial worker, and nurses deal often with life and death
that long shift hours and overtime are strongly linked to the
situations.
difficulties of being awake through a shift which leads to the
increased risk of making an error.[13, 16]
2. M ETHODS OF THE REVIEW
Despite the fact that the exact amount of sleep required for The objective of this review is to investigate whether 12-hour
healthy adults has not been determined, the impact of sleepi- shift has an impact on nurses’ health, wellbeing and job sat-
ness is well documented. Relevant literature indicates that isfaction in comparison to 8-hour shifts. Thus, a three-step
insufficient sleep has an adverse effect on adult’s health. Al- search strategy was used in this review to identify published
though literature demonstrates relevant studies with different and unpublished studies reported in English from 1980-2017.
methodologies, the findings report the same results. It is Starting the search from 1980 was selected because most
found that an inadequate amount of sleep has an impact on studies were conducted when the 12-hour shift was intro-
mood, job performance, motivation, cognitive skills, and duced in healthcare systems that is crucial to find out if there
safety.[17, 18] Moreover, depression and irritability signifi- is any issues or changes in the evidence from 1980 until 2017.
cantly increased, plus the feelings of stress with low hours of Initially, limited searches of MEDLINE and CINAHL were
sleep. Furthermore, a growing body of literature concludes undertaken to identify keywords contained in the titles or
that lack of sleep is connected with the metabolism and ap- abstracts and the index terms used to describe relevant arti-
petite problems with, increasing the risk of obesity.[19, 20] In cles. A second extensive search using identified keywords
addition, insufficient sleep can alter glucose tolerance levels was then undertaken across all included databases which
and increases the risk of development of diabetes.[21] Fur- are MIDLINE, CINHAL, PsychINFO, EMBASE, Web of
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Science, and SCOPUS (Elsevier). The third step included a Journal, and Online dissertation abstract.
hand-search of the references lists and bibliographies of all
potential studies to identify relevant articles, this hand-search 2.1 Search terms
has accessed several journals such as the Nursing Times Jour- The search started by dividing the research question into
nal, Nursing Management Journal, Nursing Administration parts for an easier and accurate search process. The results
of the search terms are shown in the Table 1.

Table 1. Search terms used in the databases

Electronic databases used Key component Keywords
“12 hour shift” “8 hour shift” “twelve hour shift” “long hour$” “shift length”
Shift work
“shift schedule” “working shift” “12 hour shift$” “shift work” “shift pattern”
MEDLINE
CINHAL Nurses’ health-
“physical health” “health” “mental health” “exhaustion” “psychological stress”
EMBASE wellbeing
Web of Science Fatigue “Chronic fatigue” “muscle fatigue” “tiredness” “mental fatigue”
SCOPUS (Elsevier) Sleep “sleep disturbance” “sleep deprivation” “sleep apnea” “sleep disorder”
Job satisfaction “Job satisfaction” “Attitude of health personnel” “Job performance” “burnout”

The search was established with each keyword, and then 2.5 Types of outcome measures
by grouping, and combining terms together using boolean Working hours among nurses have been assessed by various
technique to achieve the best literature. methods. However, the most common ways of assessing
the impact of 12-hour shifts are to measure nurses’ health
2.2 Types of studies and their satisfaction. Thus, for this systematic review, the
primary outcome of interest is the impact on nurses’ health
This review considers any Randomized Controlled Trials
and wellbeing: including physical psychological health dis-
(RCTs) published after 1980 that evaluate the effect of 12-
orders, fatigue, alertness, critical thinking, sleep disturbance
hour shifts on nurses’ health, wellbeing, and job satisfaction.
and stress. The secondary outcome is job satisfaction which
In the absence of RCTs, other research designs such as non-
is measured by nurses’ behaviour, nurses’ attitude, burnout,
randomized controlled trials, cohort studies, experimental
and emotional exhaustion.
and non-experimental studies, observational studies, and be-
fore and after studies were also considered for inclusion 2.6 Retrieval of references and handling
in a narrative review to enable the identification of current In this review, in order to identify more studies, checking
approaches and possible outcome measures. and hand-searching of bibliographies were used. At first,
all the studies written in the English language from 1980
2.3 Types of participants to 2017 which met the inclusion criteria and matched the
The review examined studies that included all nurses (male key terms were included. Secondly, in quantitative stud-
and female). Studies that evaluate the effects of working ies, all the abstracts were reviewed according to the review
hours on patients and other health care providers were ex- objective. After that, the full texts were obtained, and ap-
cluded from this review. Also, studies that have a combina- propriate references were identified. In addition, the list of
tion of nurses, doctors, and technicians in their sample were included and excluded studies was decided and confirmed
excluded. after examination.

2.7 Assessment of methodological quality

2.4 Types of interventions After the comprehensive search, all the primary studies cho-
This review included the studies that evaluated the impact sen were examined with regard to the quality of study design.
of 12-hour shifts in comparison to 8-hour shifts on nurses’ In order to avoid bias, two reviewers assessed the quality of
health, wellbeing, and job satisfaction by comparing these the studies included within the review, and identified whether
two types of shift schedule. Moreover, studies that included or not they were of high quality on selection, performance,
an evaluation of the 12-hour shift on nurses, and studies that measurement and attrition thus minimising bias.[31] The
combined the 12-hour shift with working hours per week quantitative papers were assessed for methodological va-
were also included. lidity prior to inclusion, by using standardised critical ap-
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praisal instruments from the Joanna Briggs Institute Meta tracted data included specific details on the study design,
Analysis of Statistics Assessment and Review Instrument sample, setting, shift examination, measurement tool, out-
(JBI-MAStARI). The methodological quality of the 13 fi- come measures, key findings, and statistical analysis.
nal studies included in this review was examined. Of the
13 final studies, all used observational designs; 6 used de- 2.9 Data analysis
scriptive cross-sectional studies, and 5 used a survey. One
In this review, the extracted data from the included studies
used a before and after design, and the final one used a
was synthesised and presented in narrative form instead of
quasi-experimental design. After the assessment, 12 stud-
meta-analysis, as a result of a lack of concurrence in method-
ies were included in this review and one descriptive study
ology within the relevant studies. The lack of homogeneity
was excluded due to the low methodological quality. Both
in data means meta-analysis may not be undertaken, as the
reviewers decided to exclude the study as a result of unclear
pooling of data may not be feasible.[32, 33] In order to make it
criteria of sample inclusions, confounding factors and how
clear, the studies were grouped together for analyses within
they were dealt with, also outcome assessment measures,
three categories, such as fatigue, physical, psychological
in addition to insufficient descriptions between both groups,
health, wellbeing, and job satisfaction.
and the follow-up was also not conducted.

2.8 Data collection 2.10 Literature search result

Data from primary studies were extracted and gathered by The results of the identified studies in each database are
using data extraction tools based on JBI-MAStARI. The ex- shown in Table 2.

Table 2. Results of search strategy

Database Dates searched Total references Total potential identified studies
CINHAL 1982-2017 2703 187
MIDLINE 1980-2017 1896 230
Psycho INFO 1982-2017 1290 94
Scopus 1980-2017 1945 87
Web of Science 1980-2017 82 43
Manual research 17
Total 7916 658

The databases and manual search yielded 658 studies. Of 2.11 Data synthesis
these 658 studies, 194 were identified as being potentially The data was synthesized and grouped under three main out-
relevant after reviewing the titles and abstracts. Reviews, let- come measures which were physical, psychological health,
ters, conference papers and comment studies were excluded, wellbeing, fatigue, and job satisfaction. Summaries of the
leaving 159 studies to be formally analyzed by using an in- outcome measure are clarified in Tables 3 and 4.
clusion and exclusion criteria which was developed by the
researcher for this review. From the 159 studies, 135 studies 3. R ESULT
did not meet the inclusion criteria, such as studies including
3.1 The impact of 12-hour shifts on nurses’ physical and
nurses and other healthcare providers as participants, com-
psychological health and wellbeing
paring rotating shifts among nurses, comparing 8- vs. 9-hour
Three studies have examined the effects on nurses’ health
shifts or measuring the impact of 12-hour shifts on patients’
and wellbeing. Iskra-Golec et al. (1996) conducted a study
outcomes and medication administration errors. Of the 24
to find out the impact of working hours (12 h day/night shifts
studies left, 7 studies were not accessible (7 articles were not
vs. 8 h day/afternoon shifts) on nurses’ health and wellbeing
accessible on the university databases). Of the 18 studies, 4
by comparing two groups of ICUs nurses working for either
studies were published with foreign languages. This resulted
12 (n = 96) or 8 (n = 30) hour shifts.[34] The findings demon-
in the selection and analysis of 13 studies. One study was
strated that the total mean score of the 12-hour shift group
excluded because of the low methodological quality, result-
reported (15.42) digestive problems compared to the 8-hour
ing in a final sample of 12 studies. Figure 1 presents a visual
shift group (15.68). The mean score of the 12-hour shift and
representation of the overall search process.
8-hour shift groups revealed that both groups experienced
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cardiovascular symptoms (15.29, 16 respectively). 12.36 whereas in the 8-hour shift it was 16.33. However, a signifi-
mean score of psychological ill-health was found with the cant difference in the mean score between both groups was
12-hour shift group, while it was 11.08 with the 8-hour shift found in cognitive anxiety (aggravated by mental concern)
group. Mean of health measures of somatic anxiety (aggra- where the 12-hour shift group reported (16.16) higher than
vated by bodily symptoms) of tension, such as butterflies in the 8 hour shift group (13.48).
the stomach[35] among the 12-hour shift group shows (17.38),

Figure 1. Search and retrieval process

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Table 3. Studies included in the review

Outcome Shift
No Authors Study title Study design Sample size Measurement tool Settings
measure analysed
Critical thinking and
Field and Critical Subjective Symptoms of Fatigue Critical care unit,
fatigue: How do nurses Quasi-experime 102 registered 8 and 12 hour
1. Loverid- thinking and (Yoshitake, 1978) and Three-Minute Acute-care Hospital,
on 8 and 12 hour shifts ntal design nurses shifts
ge (1988) fatigue Reasoning Test (Beddeley, 1968) Southern California
compare?
Nurses working
Standard Shift work Index (Barton et
Iskra- Health, well-being and 12 hour (n = Health, Intensive care units,
Descriptive al.,1990), and Maslach Burnout 8 and 12 hour
2. Golec et burnout of ICU nurses 96), and nurses wellbeing, and Cracovian hospital,
study Inventory (Maslach and Jackson, shifts
al. (1996) on 12- and 8-h shifts working 8 hour burnout Wales, UK
1981)
(n = 30)
Estimation of the
psychological load
Szczurak Japanese scale (Subjective
In the performance of Descriptive Psychological Cardiology and 8 and 12 hour
3. et al. 108 of nurses Symptoms of Fatigue (Yoshitake,
nurses’ work based on study fatigue surgical units, Poland shifts
(2007) 1978)
subjective fatigue
symptoms
Work schedule Musculoskeleta Nordic Questionnaire of ≤8 and ≥12
Two states in the
Lipscomb characteristics and Descriptive l disorders of Musculoskeletal Symptoms Combined
1163 registered United States (Illinois
4. et al. reported musculoskeletal cross-sectional the neck, (Kuorinka et al., 1987), and Job with working
nurses and New York)
(2002) disorder of registered design shoulder, and Control Questionnaire (Karasek, hours per
registered nurses
nurses back 1985) week
Michigan registered
Role stress and career nurses working in
Hoffman Descriptive Role stress, and Nursing Stress Scale, and Index of
satisfaction among 500 registered critical care, 8 and 12 hour
5. and Scott cross-sectional career Work Satisfaction (Hoffman and
registered nurses by nurses medical-surgical, shifts
(2003) design satisfaction Scott, 2003)
work shift patterns mental health, and
paediatric units, US
Critical care,
emergency, and
40% random
perinatal,
sample of Developed questionnaire including
Eight- and 12- hour medical-surgical,
Palmer Descriptive registered and Nurses job performance, attendance, 8 and 12 hour
6. shifts: comparing nurses’ paediatric and
(1991) study licensed behaviour continuing education, and general shift
behaviour patterns diabetes units in
vocational job satisfaction (Palmer, 1991)
Foothill Presbyterian
nurse
Hospital, Glendora,
California
10 wards of a country
Todd et 12-hour shifts: job Before and after Job satisfaction 8 and 12 hour
7. 320 nurses Likert Scale (Clark, 1975) hospital in North
al. (1993) satisfaction study design of nurses shift
Ireland, UK
Attitudes of nurses 9 hospital in the US,
Kundi et Descriptive Attitude of Developed questionnaire including 8 and 12 hour
8. towards 8-h and 12-h 1,124 nurses Vienna city and 3
al. (1995) study nurses shift schedule and shift preference shift
shift systems private hospitals
Comparison of nurse,
Maslach Burnout Inventory (MBI)
system and quality Descriptive Job satisfaction 99 direct care units in
Stone et (Maslach and Jackson, 1981), and 8 and 12 hour
9. patient care outcomes in cross-sectional 805 nurses and emotional Fourteen hospitals in
al. (2006) Job Enjoyment Scale (Taunton et al. shift nurses
8-hour and 12-hour design exhaustion New York city
2004)
shifts
The survey included a total of 118
questions organised in five sections:
investigating work environment,
Association of 12 h 31627 burnout and job satisfaction, ‘About
shifts and nurses’ job registered your most recent shift at work in this
Dall’Ora satisfaction, burnout and nurses in 2170 Job satisfaction hospital’, which had the purpose to
Cross-sectional 12 European ≤8 and ≥12
10. et al. intention to leave: general and emotional measure shift length and nurse
survey countries. hour shifts
(2017) findings from a medical/surgica exhaustion staffing levels. The ‘About you’
cross-sectional study of l units within section aimed to investigate
12 European countries 488 hospitals demographic details such as age,
gender and education. Maslach
Burnout Inventory (MBI) was used
to assess emotional exhaustion.
Satisfaction with workschedules for
well-being and for family life (single
Effects of extended work questions), and extent of
Estryn-Bé ≤8 day/night
shifts on employee Work-family conflict (W/FC) hospitals (N = 147),
hara and 25,924 Nurses’ health, shifts and
fatigue, health, Secondary (five-item scale) Netemeyer et al. nursing homes (N =
11. Van der European wellness and ≥12 hour
satisfaction, work/family analysis (1996). 185), and home care
Heijden nurses job satisfaction day/night
balance, and patient health problems we used several institutions (N = 76).
(2012) shifts
safety indicators, Burnout Kristensen and
Borritz (2001), Work-ability index
IIlmarinen et al. (1997).
Job satisfaction was assessed by
The Longer The Shifts
A secondary using point Likertscale. 577 hospitals
Stimpfel For Hospital Nurses, The 22,275 Job satisfaction 8-9 hours,
analysis of Burnout was measured using the In California, New
12. et al. Higher The Levels Of registered Burnout 10-11 hours,
cross-sectional nine-item emotional exhaustion Jersey, Pennsylvania,
(2012) Burnout And Patient nurses 12-13 hours
data subscale of the Maslach Burnout and Florida
Dissatisfaction
Inventory.

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Table 4. Summary of study outcome measures

Staff preferred
Main category Authors Specific outcome Shift analyzed
shift (8h/12h)
Working hours Health and wellbeing (digestive and
Iskra-Golec et al. (1996)
and physical and cardiovascular disorders, cognitive and √ 8 and 12 h
psychological somatic anxiety, and sleep)
health and Lipscomb et al. (2002) Health complaints (neck, shoulder, and back) √ ≤8h and ≥12h
wellbeing Hoffman and Scott (2003) Stress √ 8h and 12h
Field and Loveridge (1988) Fatigue - 8h and 12h
Working hours Iskra-Golec et al. (1996) Fatigue √ 8h and 12h
and fatigue Szczurak et al. (2007) Fatigue - 8h and 12h
Estryn-Béhara et al. (2012) Fatigue √
Palmer (1991) Nurse’s behavior √ 8h and 12h
Todd et al. (1993) Job satisfaction √ 8h and 12h
Kundi et al. (1995) Job satisfaction √ 8h and 12h
Hoffman and Scott (2003) Job satisfaction - 8h and 12h
Working hours
Stone et al. (2006) Job satisfaction √ 8h and 12h
and job
satisfaction Iskra-Golec et al. (1996) Job satisfaction with free time √ 8h and 12h
Dall’Ora et al. (2017) Job satisfaction, burnout and intention to leave √ 8h and 12h
Stimpfel et al. (2012) Job satisfaction, burnout and intention to leave √ 8h and 12h
Estryn-Béhara and Van der
Job satisfaction, burnout and intention to leave √ 8h and 12h
Heijden (2012)

Sleep disorder was one of the outcome measures studied by back (OR 2.67, 95% CI 1.26-5.66). However, the authors
Iskra-Golec et al. (1996).[34] The results showed that nurses indicated that neither working for 12-hours per day or more,
working longer shifts reported significant general sleep dis- or 40 hours per week or more itself increased the risk of
turbances compared to the 8-hour shift group (F = 10.35). reported musculoskeletal disorders.
Moreover, the 12-hour shift group were more tired after sleep
Hoffman and Scott (2003) conducted a descriptive cross-
than the 8 hour shift group, despite the fact that they slept
sectional study among 500 registered nurses working 8 and
longer and had a higher ratio of average sleep length, to the
12-hours (12 h day/night shifts, 8 h day/evening/night shifts)
length of sleep declared as sufficient (0.84) in the 8-hour
in the United States in order to investigate role stress by
shift group (0.62).
shift length.[36] The results indicated that nurses working
Lipscomb et al. (2002) carried out a study to examine the for 12-hour shifts experienced higher levels of stress than
relationship between work schedule characteristics such as those with 8-hour shifts. The significant level of stress was
working for 12-hour shifts or more per week (day shift), displayed through caring for dying patients (M = 15.7; p =
and 8-hour shifts or more per week (day shift), and the re- .6) and when managing workload situations (M = 16.3; p
ported musculoskeletal disorders of the neck, shoulders, and = .05) compared to those working 8-hour shifts caring for
back.[25] This cross-sectional study had a sample of 1,163 dying patients and managing workload situations (M = 14.4;
nurses selected randomly from the list of actively licensed M = 15.1 respectively).
nurses residing in two states, Illinois and New York, United
States.
3.2 The impact of the 12-hour shift on fatigue
The results demonstrated that long working hours per day
Fatigue was evaluated and tested in four included studies.
together with a combination of working-hours per week were
Field and Loveridge (1988) carried out a quasi-experimental
associated with musculoskeletal disorders. Thus, they found
design study to compare fatigue and the ability to undertake
that working 12-hour shifts or more per day, and working
critical thinking performance in the first and last hours of the
for 40 hours or more per week elevated the odds ratio for
shift between 12 and 8-hour shifts in Southern California.[37]
musculoskeletal disorders of the neck (OR 2.30, 95% CI
This study includes two experimental groups of critical care
1.03-5.11) shoulder (OR 2.48, 95% CI 1.07-5.77), and the
nurses (n = 102) working for either 12 or 8-hour day shifts.
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Each nurse in both groups undertook two tests. The first test Estryn-Béhara and Van der Heijden (2012) conducted a study
was the Three Minute Reasoning Test[38] which consisted of to examine the impact of extended work shifts on employee
64 index cards each containing a short phrase followed by a fatigue and health in ten European countries.[42] The data
pair of letters. The participant evaluated the phrase and the or- were collected from three different health care settings: hos-
der of the two letters to determine if the two items described pitals (N = 147), home care institutions (N = 76) and nursing
the same condition. This test was carried out to evaluate homes (N = 185). The data were obtained from a total of
staff’s ability for critical thinking performance. The nurses 25,924 nurses. In analyzing the data, the results showed that
were also tested with the Subjective Symptoms of Fatigue nurses working 12-hour shifts feel more often tired.[42]
Test[39] that included 30 items (yes-no) to obtain subjective
symptoms of fatigue. The symptom checklist was found to 3.3 The impact of the 12-hour shifts on nurses’ job sat-
be a valid indicator of three broad areas of fatigue: drowsi- isfaction
ness, difficulty in concentration, and projection of physical
Job satisfaction and burnout were examined within nine stud-
impairment. The data of this study was analyzed with a
ies by measuring nurses’ attitude, behaviour, burnout, and sat-
multiple analysis of variance. The nonsignificant levels of
isfaction. Palmer (1991) carried out a study over one full year
fatigue were determined by p > .05.
in Foothill Presbyterian Hospital in California among RNs
The results demonstrated that the levels of the fatigue score (registered nurses) and LVNs (licensed vocational nurse).[43]
were significantly higher at the end rather than the start of The sample was divided into two groups, one group was
the shift. However, by dividing the sample into 12 and 8- scheduled to work 12-hour day/night shifts in critical care,
hour shifts, the findings reported that there was no significant emergency, and perinatal departments, and the other group
difference between the 12 and 8-hour shift groups in feel- 8-hour day/evening/night shifts in medical, surgical, paedi-
ings of fatigue or any of the subcategories. Moreover, the atric, and diabetes departments. The data was collected from
results of the ability for the critical thinking performance in personal files, attendance records, and continuing education
both groups showed that there was no significant difference class records. Moreover, a developed questionnaire was dis-
between 8 and 12-hour shifts. Thus, these findings would tributed between the participants that aimed at determining
suggest that the level of fatigue at the end of the shift reported their levels of satisfaction. The records revealed a signif-
a significant increase; however, nurses in the 12-hour shift icant difference between the two shift systems in clinical
were no more fatigued than nurses with the 8-hour shift. performance, including team leadership and personal devel-
Iskra-Golec et al. (1996) conducted a study by comparing opment, where the 8-hour shift nurses had a higher score
two groups of nurses, one group worked a 12-hour shift than the 12-hour shift nurses. In the area of attendance, the
(n = 96), and the other group worked an 8-hour shift (n = data showed a significant difference between 12 and 8-hour
30).[34] Both groups individually completed the Standard shifts. It found that more days missed were reported among
Shift Work Index (SSI)[40] questionnaire during work. The 8 hour shift nurses. Furthermore, for both types of shifts,
authors found that the group of nurses working the 12-hour the nurses pointed out that personal illness was the major
shift experienced more chronic fatigue than the 8-hour shift cause of absence from work (8 h = 12; 12 h = 12). The
nurses group (Mean score: 26.97, 23.75 respectively).[34] results of the continuing education class attendance which
was provided by the hospital to increase their knowledge
Szczurak et al. (2007) performed a study to examine the showed that 8-hour shift nurses attended more classes (4.8)
psychological fatigue of nursing personnel by conducting a than those on 12-hour shifts (4.3). A rating scale to identify
questionnaire among 108 nurses in a private medical care participant levels of satisfaction revealed a significant differ-
centre in Poland.[41] The authors used a Japanese scale in ence between both groups, it found that 12-hour shift nurses
the questionnaire which enabled the analysis of the psycho- had a total score of (8.90) which was more than the 8-hours
logical load based on Subjective Fatigue Symptoms.[39] The shift nurses (8.06).
study included two types of shift systems (12 and 8-hour
day shifts). The results demonstrated that the total activity Todd et al. (1993) carried out a before and after study to in-
decrease among nurses working for 12-hour shifts in the vestigate the impact of the shift system (12 h day/night shifts
cardiology unit was 29.34%, while it was 34.77% in surgical and 8 h day/evening/night shifts) on job satisfaction in 10
unit. On the other hand, the results showed that the total wards in two hospitals in Northern Ireland, UK.[44] A survey
activity decrease among nurses working 8-hour shifts in the among 320 nurses was conducted with a follow-up within
cardiology unit was 24.58%, whereas it was 17.36% in the two phases. The first phase was conducted for one month
surgical unit.[41] prior to the introduction of 12-hour shifts, while the second
phase was undertaken after 6 months of introducing 12-hour
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shifts. The Likert scale[45] which measures job satisfaction city of Vienna, United States.[47] The survey was delivered
includes 12 items within two factors: intrinsic (ambition, to 1,124 staff nurses in 103 hospital departments. For the
content, exciting, opportunity, initiative, and creative) and nurses who worked for 12-hour shifts and the data revealed
extrinsic (pay, pride, colleague, hours, conditions, and secu- that 26% of the nurses were satisfied with this shift schedule;
rity) job satisfaction. In addition to the 12 Likert scale items, however, their desire to change the shift was reported at 25%
7 shift specific items (13-19) were designed for this study in- as a result of the adverse effect on their social and leisure
cluding vacations, family, housework, child minders, mental time (23%), and participant health (26%). On the other hand,
and physical fatigue. The data of this study demonstrated 8-hour shift nurses demonstrated 38% schedule satisfaction,
highly significant differences between 12 and 8-hour shifts as a result of the low adverse effects of this shift system on
on six of the 12 job satisfaction items. These differences social and leisure time (9%) and health (2%). Thus, 11% of
pointed to the greater dissatisfaction with work under the 12- nurses desired to change shift.
hour shift system. Thus, the nurses indicated that they were
Hoffman and Scott (2003) carried out a descriptive cross-
less satisfied in their occupations as ambitious people. The
sectional design study to examine the career satisfaction
system was poorly paid, there were long working hours, less
among registered nurses by shift length.[36] The survey of
excitement, and poor working conditions. However, there
this study was conducted among 500 registered nurses who
were no differences between the shift systems regarding the
worked 8 or 12-hour shifts in critical care, medical-surgical,
opportunity of promotion, chances of showing initiative, cre-
mental health, and paediatric units, Michigan, United States.
ativity and the security of nursing as a career. Furthermore,
The data of career satisfaction was collected by developing
the nurses reported a high level of dissatisfaction under the
the Index of Work Satisfaction (IWS). The findings of career
12-hour shift. This was reflected in the nurses’ levels of
satisfaction among registered nurses identified a similar level
fatigue, their perception of other people’s views on the pro-
of satisfaction between 8 and 12-hour shifts. Both groups of
fession, and their personal lives. Nurses felt that they had less
registered nurses demonstrated that they obtained the same
time with their families, their personal life more often came
levels of satisfaction from the interaction between nurses and
as second priority, and for the married nurses the 12-hour
physicians, also the ability to work autonomously. However,
shift was a problem because they had to arrange for child
registered nurses working for 12-hour shifts reported a higher
minders. The study concluded that there were significant
level of satisfaction from their professional status (M = 38.4;
differences between intrinsic and extrinsic job satisfaction
SD = 5.2) than those working 8-hour shifts. In contrast, the 8-
among nurses working for a 12-hour shift as compared to an
hour shift nurses were significantly more satisfied with their
8-hour shift, and therefore, the nurses were more dissatisfied
pay (M = 22.3; SD = 9.4). The IWS mean score of registered
with their work on both factors.
nurses working 12-hour shifts reported (M = 12.96; SD =
Iskra-Golec et al. (1996) compared two groups of nurses (8- 2.2). Similarly, registered nurses who worked 8-hour shifts
hour day/afternoon shifts n = 30, and 12-hour day/night shifts had mean scores of 13.17 (SD = 2.2).
n = 96) considering their job satisfaction working in ICUs by
In addition, the authors examined the relationship between
using a questionnaire including (SSI)[34, 40] which incorpo-
role stress and career satisfaction by using Pearson’s Product-
rates job satisfaction, and burnout. The burnout in this study
Moment correlation test with NSS and IWS scores. The
was assessed by means of the Maslach Burnout Inventory,[46]
findings indicated that high levels of stress decrease the level
it was measured by emotional exhaustion, depersonalization,
of career satisfaction, therefore, a crucial relationship be-
and personal accomplishment. The authors found that sat-
tween level of stress and career satisfaction was identified.
isfaction with the free amount of time allowed by the shift
system for social and domestic activities was higher among Stone et al. (2006) performed a cross-sectional study by
nurses with 12-hour shifts rather than 8-hour shifts (M = making a comparison of nurse, system and quality patient
55.45; M = 39,77 respectively) (F = 12.89). However, no care outcomes in 8 and 12-hour shifts in fourteen hospitals in
[48]
significant difference was found between both groups in over- New York City. This design was developed and the data
all job satisfaction. Moreover, emotional exhaustion among collected by survey from adult general inpatient units. The
12-hour shift nurses was significantly higher (M = 21.37) authors identified study variables which were nursing out-
than the 8-hour shift group (M = 16.80) (F = 4.02). comes, while the independent variable was identified based
on the type of shift length (12 or 8-hour shifts). Job satisfac-
Kundi et al. (1995) performed a descriptive study to ex-
tion in this survey was measured by using a Job Enjoyment
plore the nurses’ attitudes, and their priorities towards 8-hour
Scale, where the respondents were asked to rate job satisfac-
day/evening/night shifts and 12-hour day/night shifts by de-
tion on a 5-point Likert-type Scale.[45] The results showed
veloping a survey and conducted it in twelve hospitals in the
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that thirteen hospitals were eligible in this study. A total of scale–type question, ‘How satisfied are you with your job?’.
99 units were analyzed, the majority of the nurses worked Furthermore, Burnout was assessed by using the the Maslach
8-hour shifts 63%, while 36% of the nurses worked 12-hour Burnout Inventory.[46] The study results demonstrated that
shifts. By comparing 8 and 12-hour shifts on nurses’ out- the increase in the shift length is associated with a signifi-
comes, the authors found that those working 12-hour shifts cant increase in the odds of burnout, job dissatisfaction, and
were more satisfied with their jobs (M = 21.2; SD = 4.3), intention to leave the job. The odds of burnout and job dis-
and experienced less emotional exhaustion (M = 21.4; SD satisfaction were up to two and a half times higher for nurses
= 12.4) than those with 8 hour shifts (M = 20.3, SD = 4.3; who worked longer shifts than for nurses who worked shifts
M = 25.9, SD = 12.7 respectively). Furthermore, the nurses of 8 hours.
with 12-hour shifts were 10 times more satisfied with their
Estryn-Béhara and Van der Heijden (2012) examined the
schedules (77.11%). Considering the missing shifts, the find-
effect of extended work shifts on employee fatigue, health
ings demonstrated that nurses working 8-hour shifts reported
and satisfaction in ten European countries.[42] Nurses in this
missing shifts more than those with 12-hour shifts. Thus,
study were recruited from three different health care settings:
the study indicated that the nurses were more satisfied with
hospitals (N = 147), home care institutions (N = 76) and nurs-
12-hour shifts than with 8-hour shifts.
ing homes (N = 185). The data were obtained from a total of
Dall’Ora et al. carried out a cross-sectional study in 12 25,924 nurses. In analyzing the data, the results showed that
European countries to examine the relationship between 12 nurses working for long shifts (12-hour shifts) encountered
working shifts and nurses’ job satisfaction, burnout and inten- more interruptions in their job. In addition, nurses working
tion to leave the job.[49] The surveys were distributed among for 12-hour shifts are dissatisfied with their working time
31,627 registered nurses in 488 hospitals in the following relative to their well being and have more frequently a high
countries: England, Belgium, Finland, Germany, Greece, burnout score.
Ireland, Netherlands, Norway, Poland, Spain, Switzerland
and Sweden. A total of 30 hospitals (medical and surgical
4. D ISCUSSION
units) were included in each country. Job satisfaction was
measured by asking ‘How satisfied are you with your job?’ According to this review findings, there is little evidence
Responses were reported on a 4-point scale, ranging from of significant effects of 12-hour shifts on physical and psy-
‘very dissatisfied’ to ‘very satisfied’. The burnout was as- chological health and wellbeing. Adverse effects on health
sessed by using the Maslach Burnout Inventory (MBI).[46] and wellbeing, such as cognitive anxiety, poor sleep quality,
The results reported that a total of 8,666 nurses (27%) en- musculoskeletal disorders, and stress were more associated
countered high emotional exhaustion. Moreover, a total of with the 12-hour shift system; therefore, staff sometimes
8,268 nurses demonstrated that they being very dissatisfied preferred 8-hour shifts to avoid these symptoms. However,
with their job (26%), whereas 8,016 nurses (25%) were dis- the findings for the effect of 12-hour shifts on specifically,
satisfied with the flexibility of work schedule and a total fatigue and job satisfaction were inconclusive.
of 10,440 nurses (33%) reported their intention to leave the This review has insufficient evidence to determine these ef-
current job. Nurses working long shifts (12 hours) were ex- fects in comparison to 8-hour shifts and. Therefore, a particu-
perienced higher burnout in a comparison to nurses working lar shift system for hospitals, is not recommended, this is due
8 hours. to several reasons. Firstly, the included studies had variable
The relationship between nurses’ shift length, burnout, job strengths, weaknesses, and different study designs; however,
dissatisfaction, and intention to leave the job was also exam- none of these studies was a clinical trial which is rated as
ined in a further study conducted by Stimpfel et al. (2012).[50] the highest type of evidence. Moreover, the variability of the
This study involved a secondary analysis of cross-sectional scores is due to two major weaknesses, which are the follow-
data from three sources: the Multi-State Nursing Care and ing up and outcome of people who withdrew from the study.
Patient Safety Study, the Hospital Consumer Assessment of Secondly, the outcome measuring tools used differed among
Healthcare Providers and Systems and from the American the studies in different settings and countries, especially with
Hospital Association Annual Survey of Hospitals. The study reference to fatigue and job satisfaction. Therefore, the re-
sample were registered nurses (n = 22,275) from the Multi- sults of the individual studies are conflicting, indicating that
State Nursing Care and Patient Safety Study. The nurses this evidence is insufficient to generalise the results.
were working in 577 hospitals in four states: California, However, the negative effects of 12-hour shifts have been
New Jersey, Pennsylvania, and Florida. In this study, the well documented in literature such as stress, sleep distur-
Job satisfaction was measured by using a four-point Likert bances, musculoskeletal disorders, fatigue, and job satisfac-
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tion. When considering cognitive anxiety and stress which chological work demands lead to musculoskeletal disorders
are related to each other, these adverse effects could result of the shoulders, lower back, neck and upper back among
from longer daily exposures to the stress of the nurses’ work nurses.[62] Some studies found that musculoskeletal disor-
characteristics, such as the nurse’s involvement in life and ders have been consistently associated with patient-handling
death situations, and the high level of responsibility in crit- among nurses.[63, 64] The highest rates of non-fatal occupa-
ical situations.[51, 52] Moreover, it seems possible that these tional musculoskeletal disorders have been reported among
results are due to the nurses’ experiences and fatigue as an nurses than in any other healthcare professionals.[65] How-
adverse effect. These results are consistent with those of ever, it is recommended that healthcare organizations should
other studies which suggest that higher levels of stress are provide a healthful working schedule that is required to pre-
found in inexperienced younger nurses.[53, 54] Furthermore, vent the risk of musculoskeletal disorders among nurses, they
the studies indicated that working conditions together with also should provide educational programs which consider
shift schedules were accountable for the development of Good Body Mechanics by an informal policy. These pro-
burnout especially among female shift-working nurses.[55, 56] grams should provide an understanding of basic body move-
Therefore, the development of a stress reduction policy in the ments that will help to prevent work-related musculoskeletal
healthcare organizations that aims to identify work related injuries.[66]
stress and to prevent it by providing an educational strategy
With regard to fatigue, two studies in the review identified
is a crucial issue. Stress management strategies are effective
significant differences of fatigue between 12-hour and 8-hour
in reducing personal levels of stress and improving nurses’
shift groups of nurses, while the third study concluded that
physical health and wellbeing.[57]
there were no significant differences between both groups.
The incidence of sleep disturbance was in proportion to the However, shift workers are subjected to fatigue as a result of
duration of the night shift.[16] Such result is consistent with long hours of mental or physical activity.[14] This result is
the findings of this review, where it was found that nurses in accordance with studies reporting that an accumulation of
working for 12-hour shifts reported significant poor general fatigue is associated with extended working days (12-hour
sleep qualities, and felt more tired after sleep. It could be shift).[18, 67] However, when considering critical care units,
suggested that higher indices of chronic fatigue, anxiety, and fatigue is the most common complaint among emergency
emotional exhaustion among nurses working for 12-hour nurses, as a result of long working hours of physical activ-
shifts are associated with poor general sleep qualities.[58, 59] ity.[68] While in the ICU, the ICU nurses working for 12
Thus, to improve the circadian rhythm, good sleep habits hour shifts were more exposed to a psychological workload
and a comfortable environment are important to improve the than nurses who worked for 8-hour shifts.[69] Thus, physical
quality of sleep. This could be explained to staff so that they activity, emotional and mental workloads which result in fa-
are better able to manage sleep disturbance.[58, 60] tigue could be an explanation for the findings of this review.
A further explanation of chronic fatigue is that consecutive
Musculoskeletal disorders were found to be related to 12-
12-hour shifts lead to an accumulation of fatigue that result
hour shifts in this review, despite the fact that this finding had
in a chronic stage. According to these findings, it should be
not previously been described in the literature. Although[25]
assumed that the quality of care and work performance on
produced the only study that recognized the relationship
8-hour shifts is higher than on 12-hour shifts with a decrease
between work schedule characteristics and musculoskeletal
in the risk of errors.[70] Surprisingly, this review found that
disorders in day shifts; this finding is supported by another
there was no significant difference between 12- and 8-hour
study identifying that long working hours are one of the
shift systems, which is consistent with findings.[71] Different
risk factors of back pain; however, it should be noticed that
findings were shown in Szczurak et al.’s (2007) study, even
this study did not define long hours as being of 12-hour or
though the same measurement tool was used in both studies
more.[61]
to examine the fatigue at the beginning and end of 12- and
The work schedule characteristics which included days of 8-hour day shifts among nurses.[41] This inconsistency may
work, length of day, work breaks, and psychological de- be due to differences with regard to personal and work char-
mands were significantly associated with musculoskeletal acteristics in both studies, where fatigue was measured in
disorders in the current finding. Therefore, it is suggested that different units (critical care, cardiology and surgical units).
demanding work schedules play an important role in muscu-
However, it should be noticed that night shifts are more as-
loskeletal disorders through exposure to physical or psycho-
sociated with fatigue and low critical thinking performance.
logical demands or both. This corroborates with the results
Both cognitive performance and alertness in night shifts are
of a further study which demonstrated that physical and psy-
reduced; while it is well known that in day shifts, alertness
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and cognitive thinking are at their highest level.[72] Between characterized by having more days off, with 3 days off and
the hours of 3 p.m. and 5 p.m. the shift worker’s alertness more free weekends than with the 8-hour shifts.[34] Thus, the
may decrease. Thus, shift workers become more fatigued in evidence is inconclusive, but nurses’ experiences must surely
addition to the impairment of mental and physical health on be mediated by the social and cultural context in which they
night shifts, while having a high ability for critical-thinking live.
performances in day shifts. To manage this negative effect,
Although 12-hour shifts result in greater dissatisfaction
the program and system management should be considered
among nurses in some aspects, it is a popular and preferred
for fatigue management. Nurses must be able to recognize
shift system in educational and private healthcare organiza-
signs of fatigue and be willing to institute appropriate inter-
tions. The 12-hour shift has the advantage of being cost effec-
ventions. However, studies have identified that healthcare
tive, this shift system has been praised in terms of enhancing
professionals have difficulty in assessing their own levels of
recruitment, continuity of care, and morale while at the same
fatigue.[73, 74] Thus, interventions should be introduced in
time decreasing sick time, personal cost, and turnover. It is,
healthcare organizations which include educational program
therefore, sometimes described as the best option for the ad-
such as Fatigue Countermeasure,[75] and schedule alterations
ministrators if they are concerned about retaining staff.[30, 43]
which allow for information regarding the symptoms of fa-
It should be noted that these reported adverse effects of
tigue, sleep hygiene measures, shift work and its adverse
12-hour shifts (fatigue, sleepiness, and musculoskeletal dis-
effects to be implemented. Furthermore, the hospital process
orders) have not been investigated in Saudi Arabia or other
could help in preventing fatigue among nurses by careful
Middle Eastern/Arabic contexts. This reflects a general lack
scheduling.[76]
of nursing research and the use of evidence based practice.
Job satisfaction is a complex and multifaceted concept, which Thus, examining the impact of working hours among Saudi
can mean different things to different people. It is, therefore, hospitals by comparing the two shift systems is a crucial
difficult to measure objectively. This review demonstrated issue to explore. The job satisfaction of Saudi nurses could
differing results which were explained by the different mea- be measured as an outcome by using intrinsic and extrinsic
surement tools used, consequently, different aspects of job factors of job satisfaction, including family responsibilities
satisfaction were measured. In this review job satisfaction as a significant issue in Saudi culture. General job satisfac-
was measured by intrinsic and extrinsic factors including the tion is critical, where a positive relationship has been found
level of workload and chronic fatigue. They also measured between these factors of job satisfaction and organisational
the home and work-life balance, such as family responsibili- commitment.[78] This is consistent to a study which revealed
ties and social life, and the amount of free time, for example a strong positive relationship between job satisfaction and
in social and domestic activities. Nurses’ behaviour was also organizational commitment in Saudi Arabia within a sample
measured by clinical performance, attendance, reasons for of registered nurses.[79] The means and standard deviations
absence, and continuing education classes, satisfaction with demonstrated that nurses were satisfied with their jobs, and
scheduling, schedule preference, and intention to stay. It therefore, they were committed to their hospital’s organisa-
was also measured by the interaction between nurses and tions. This finding is in agreement with study results which
physicians, working autonomously and satisfaction from the showed a close positive correlation between job satisfaction
professional status obtained and their position on the pay and organizational commitment.[80]
scale. Thus, different aspects of job satisfaction gave con-
In addition to job satisfaction, safety issues such as investi-
flicting results.
gating the relationship between working hours and patient
Working conditions are crucial especially when they are safety (medication errors), or staff injury by observing the
associated with job satisfaction among nurses in different staff while administering medications at flexible times is an
hospital settings.[77] The twelve-hour shift is found to be identified gap which should be filled by scientific research.
an onerous obligation. This is indicated by similar findings However, it is important to notice that fatigue and sleepiness
of two studies in the review.[44, 47] However, free time and could be risk factors leading to medication errors, thus ex-
family responsibilities are considered sources of satisfaction amining the relationship of these factors is significant also
for nurses who have a family. For example, the enhancement in terms of the quality of care given. Furthermore, it would
of the family relationships, social activities and involvement be interesting to consider the quality of life of 12- and 8-
are the advantages provided by 12-hour shifts.[30] This is hour shift nurses, this is a new outcome measure that has
in agreement with one finding of this review, where lower not been investigated before. All of these outcome measures
social and domestic disruption among nurses with 12-hour can be examined by validated measurement tools. Thus,
shifts may be due to the fact that the 12-hour shift system is well-designed studies that examine the association between
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working hours and nurses’ outcomes are needed to build a 5. C ONCLUSION

consistent body of knowledge on the impact of the 12-hour Nurses in this review reported a variety of health and well-
shift on nurses’ health and job satisfaction. Such studies being concerns in relation to the impact of the 12-hour com-
should take into account the cultural and social environment pared to 8-hour shifts such as sleep disturbance, stress, tired-
and expectations. ness, fatigue and anxiety. Furthermore, nurses in the recent
Publication bias is a limitation of this review as only pub- studies highlighted that they were dissatisfied with 12-hour
lished articles were identified by the search strategy; however, shifts and reported high emotional exhaustion and intention
6 studies were not found in the university databases which to leave their job. However, it should be noted that the con-
could have added more strength to the review by the inclusion clusion of this review is affected by the insufficient of recent
of more studies. Furthermore, this review includes studies evidence, different culture and social environment. Thus,
from 1980; however, this is because 12-hour shifts were intro- further high-quality studies are required to be conducted in
duced in this period and therefore, the majority of the studies this area of research with experimental and non-experimental
conducted to examine this type of shift originated from this research designs.
time. It is well known that systematic reviews are limited by
ACKNOWLEDGEMENTS
the availability and quality of evidence; thus, another poten-
Special thanks to my supervisor Dr. Linda East and Dr. Mai
tial limitation is the inclusion of observational studies which
Banakhar for their guidance and encouragement in making
indicate a source of bias in addition to the quality variability
this review possible.
of these studies. Moreover, this review limits working hours
to 12- vs. 8-hour shifts, the author views this as appropriate, C ONFLICTS OF I NTEREST D ISCLOSURE
as limiting inclusion criteria to the typical work shifts. The author declares that there is no conflict of interest state-
ment.

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