A new typology of work schedules: Evidence from a cross-sectional study among nurses working in residential elder care

Abstract

BACKGROUND: Work schedules contribute substantially to the health and well-being of nurses. Too broad typologies are used in research that do not meet the current variety in work schedules.

OBJECTIVE: To develop a new typology for nurses’ work schedules based on five requirements and to validate the typology.

METHODS: This study is based on a questionnaire returned by 498 nurses (response 51%) including questions regarding nurses’ work schedule, socio-demographic, and family characteristics and their appraisal of the work schedule. Frequencies of the different schedules were computed to determine the typology. To validate the typology, differences between the types were tested with ANOVAs, Chi² and Kruskal-Wallis tests.

RESULTS: Five main types can be distinguished based on predetermined requirements and frequencies, namely: (1) fixed early shift, (2) rotating two shift pattern without night shift, (3) rotating three shift pattern, (4) fixed and rotating two shift pattern including night shift, and (5) fixed normal day or afternoon shifts. Nurses in these types of work schedule differed significantly with respect to hours worked, days off between shifts, age, education, years in the job, commuting time, contribution to household income, satisfaction with work schedule and work schedule control. Especially nurses with type 3 schedules differed from other types.

CONCLUSIONS: A typology of five main types of work schedules is proposed. Content validity of the typology is sufficient and the new typology seems useful for research on work-related aspects of nursing.

Keywords

Work schedule typology shiftwork satisfaction with irregular work times socio-demographic family

1 Introduction

Shiftwork is high on the list of factors that contribute to leaving health care and decreasing quality of care in the Netherlands and globally as well [1 –4]. In research, shiftwork is often broadly defined as working outside the normal daytime hours [5 –7]. Research on shiftwork is hampered by broad and indistinct operationalizations of work schedules [6, 8] which do not meet the current variety of work schedules. Merkus et al. [6] showed in their extensive systematic review that especially in health care, the influence of shiftwork on outcomes might be schedule and population (female) specific. Even high quality studies used in their review did not specify or differentiate between work schedule characteristics. It is difficult to interpret and compare research on work schedules because of the lack of detailed information [6]. It thus seems important to develop a typology of work schedules that meets the above-mentionedproblems.

Although ‘nurse’ indicates normally the qualification level of a registered nurse, the current research uses this term for nurses working in residential elder care in the Netherlands. This includes registered nurses, enrolled nurses, licensed vocational or practical nurses and nurse care helpers. In the Netherlands nurses working in residental elder care are comparable with respect of qualification level to Dutch nurses working in hospitals, home care, care for disabled people and mental health care but do have different psychosocial and physical demands [9]. The proportion in Europe of registered nurses, enrolled nurses, licensed vocational or practical nurses is the highest in hospital care followed by residential elder [10]. The proportion of registered nurses working in residential elder care varies between European countries with the Netherlands as a leadingcountry [11].

Nurses are among the workers who work in different work schedules. Work schedules are changing [2, 12] and the work schedule a nurse works in usually changes during her career. Although irregular working hours are mandatory, the choice for the type of schedule is, to some extent, up to the nurses themselves and to their supervisors [13]. Choice options are expected to increase [3, 12] due to nursing shortages and increasing numbers of freelance nurses. This leads to an increasing variety of types of work schedules [2 , 14]. The variety of work schedules is probably greater now than it has everbeen [15].

There seems to be no scientific agreement on what the best work schedule typology is [7 , 16]. Therefore, the influence of specific work schedules cannot be fully studied and research that focuses on, for example, the effects of shiftwork on well-being and employability will consequently be hampered.

1.1 Background

A meaningful typology for the large diversity in contemporary work schedules should reflect the degree to which a schedule disturbs the biological rhythm, sleep, family life and social life [17]. Evidence seems to be indicating [18, 19] that it is important for research to distinguish between different types of fixed and rotational shifts, in order to detect differences between the types of schedules besides the usual distinction between fixed and rotational work schedules. Often the two shift and three shift are combined. Other research showed significant differences between these shift schedules with respect to stress, health and job related attitudes, in disadvantage of the three shift schedule [20 –22]. Moreover, reviews on shiftwork show that nurses working in fixed shifts show fewer problems with respect to health and social and domestic problems than nurses working in rotating shifts [23, 24].

Especially for a dominantly female working population which most of the time has to combine work with duties at home [25, 26], sleep quality seems of great importance [27, 28]. Night and early shifts affect, among other things, quality of sleep. Also the number of hours of night sleep before the early morning shifts and hours of day sleep after night shifts seems to be disturbed, which diminishes the possibility to recover [29 –33]. Nurses with fixed schedules without nightshifts might be better able to combine work and care at home than nurses with a combination of rotating shifts. Early and evening shifts seem to cause conflict with other social and family activities, e.g. school timetables of children. Commuting time to work can interrupt sleep before going to an early shift [8 , 33–36].

When defining the new types, the following requirements thus have to be met:

a distinction has to be made between fixed shift pattern versus rotating shifts [19];

a distinction has to be made between nightshifts versus no nightshift [18, 37]; and

a distinction has to be made between early shifts versus day shift because of the combination with commuting time, which could affect sleep [25, 30].

Furthermore, for research purposes the typology has to be concise but also has to cover the variety of work schedules. Therefore, the following criteria have also to be considered:

it has to represent the most prevalent types of work schedules in separate types; and

it has to classify not more than five types of schedules, in order to use the new typology in statistical analyses.

In addition, work schedule characteristics and nurse characteristics should differ across the types of work schedule according to the new typology to show sufficient construct validity. It can be expected that the work schedule types differ regarding work schedule characteristics, such as working part-time, working overtime and having days off [16 , 38–40]. Further, the nurses working in the different types might differ regarding socio-demographic characteristics and family characteristics [3 , 41], but also regarding their appraisal, in terms of satisfaction with work schedule [42] and work schedule control.

Differences between the work schedule types can also be expected in the way the nurses appraise their work schedule. Employees will be more satisfied when they work the type of work schedule that fit their needs [43, 44]. Female nurses might prefer non-standard working hours as a conscious choice to arrange work around childcare and their partners’ job [45, 46]. Decisions and choices around scheduling are influenced by family considerations and most often not by their own health and well-being, especially for workers with more extensive family responsibilities [26]. Other studies show that the appraisal of the work schedule adds to the explanation of outcomes. Authors argue that employees’ appraisals of ‘objective’ conditions [47], such as the work schedule, need to be included to fully take work schedules into consideration [48, 49]. Peters et al. [42] found satisfaction with the work schedule (measured with the SIW scale), for example, to be strongly linked to health characteristics. Van Rijswijk [50] found that female employees, who work the schedule that fitted with their other responsibilities, experienced less work-home interference, in addition to objective characteristics such as the number of work hours and flextime. Furthermore, perceived control over work time has been a major concern in recent research and seems to be an independent predictor of health, job attitudes and work-life conflict for women in particular [51, 52].

1.2 Objectives

The objectives of this study are to define a contemporary typology of work schedules in nursing and to study differences between these types in terms of work schedule characteristics, socio-demographic characteristics, family characteristics, and the nurses’ appraisal of the work schedule.

The research questions are therefore as follow:

What is a useful typology of nowadays work schedules among nursing populations for both research and management purposes?

What are the work schedule characteristics of the types and what are the differences?

a) What are the nurses’ socio-demographicand family characteristics and what is theappraisal of the work schedule by nursesin the different types of work schedule and,

b) What are these differences between nurses inthe different types of work schedule?

2 Methods

2.1 Design

A cross-sectional study was performed to answer the research questions. With the questionnaire, information was gathered in October 2009 regarding work schedule descriptives and characteristics, socio-demographic and family characteristics and the appraisal of the work schedule. The questionnaire was sent to the home addresses of all nursing employees working shifts in three residential elder care facilities in the Netherlands. Nurses were asked to return the questionnaires within two weeks. Reminder letters were sent to all participants two and three weeks after the initial distribution of the questionnaires.

2.2 Sample

The study involved nurses working shifts in three residential elder care facilities in the Netherlands. The educational level of these nurses can be distinguished by five levels: level one, two and three refer to care helper providing basic care. Level four nurse implies secondary vocational education and is comparable with an enrolled nurse, licensed vocational or practical nurse, and level five implies higher vocational education with a bachelor degree and is comparable with a registered nurse (RN). The three homes for elder care that participated accommodate clients with psycho-geriatric disorders and physical frailties. The organizations were included because the nurses’ work schedules were representative because they seem to reflect the diversity of work schedules of nurses working in both acute or short-term aged care and long-term aged care settings in theNetherlands.

2.3 Inclusion criteria

Nurses were only included if they reported their type of work schedule and worked with – mostly – elderly clients with psycho-geriatric disorders and physical frailties. Of all nurses invited in this study (N = 1009), 974 met the inclusion criteria. Of these 974 nurses, 498 returned the questionnaire (response rate of 51%). Exclusion criteria were being on sick leave for over twelve months and being younger than 18 years or older than 65 years of age.

2.4 Measures

The questionnaire assessed work schedule descriptives and characteristics, socio-demographic and family characteristics and the appraisal of the work schedule.

2.4.1 Work schedule descriptives

To collect data on the descriptives of the work schedules needed for developing the new typology, respondents were asked when their working days began and ended and which shifts they worked (morning, afternoon and night shifts). They were also asked whether they worked other shifts besides the standard morning, late and night shifts. Early shifts (start of work day between 6.00 a.m. and 7.30 a.m. and ending before 3.30 p.m.), ‘normal’ day shifts (start of work day between 7.00–8.00 and ending between 4.00–5.00 p.m.), late shifts (start of work day between 3.00–5.00 p.m. and ending between 8.00–11.00 p.m.) and night shifts (start of work day between 11.00 p.m. and ending around 7.00 a.m.). By asking when their shifts started and ended instead of using only predefined shift categories, we tried to prevent for misclassification of type of shift.

2.4.2 Work schedule characteristics

To test differences between work schedule types, the following work schedule characteristics were measured.

Average number of hours each week and average number of overtime hours each week were included in the questionnaire. Days off between two series of shifts was used to measure the ability to recover or take rest using a single item concerning the number of days off between two series of shifts. Prior knowledge of work schedule was operationalized by asking participants how many weeks in advance they were informed of their work schedules on a ordinal scale ranging from 1 ‘one week’ to 5 ‘more than four weeks’. This was dichotomized into 0 ‘knowledge of schedule at least 2 weeks in advance’ or 1 ‘less than two weeks in advance’, because two weeks is mandatory according to the collective labour agreement.

2.4.3 Socio-demographics and family characteristics

Data regarding socio-demographic and family factors include sex, age, educational level, job status, marital status, partner’s job status, partner’s shiftwork, partner’s average number of working hours per week, number of children <12 years, number of days children spent in day care per week, number of hours spent on care for family members per week, commuting time per workday and contribution to the total household income.

2.4.4 Appraisal of the work schedules

Satisfaction with work schedules was measured using the Satisfaction with Irregular Working times (SIW) scale [42]. SIW refers to the extent to which nurses are satisfied with their irregular work schedules, particularly in the context of their leisure time, family situation, social circumstances, sleep and work–leisure time balance. The scale consists of fourteen items that are scored on a 5-point response scale ranging from 1 ‘entirely dissatisfied’ to 5 ‘entirely satisfied’.

Work schedule control was measured by 10 items. This scale measures the perceptions of having a choice in and influence on the scheduling of work regarding starting and ending times, days off, the taking of breaks during the workday, swapping shifts and taking unpaid leave. It consists of six items scored with either 1 ‘yes’ or 0 ‘no’ derived from the work scheduling autonomy scale [53], two items from the flexibility scale representing flexibility in terms of time [54] and two items based on the measure used in the Nurses Early Exit Study (NEXT) [11]: “Does your roster have a fixed pattern?” and “Is it easy to swap shifts?”. The latter four items were scored on a 5-point response scale and were dichotomized by median split so that the higher scores reflected 1 ‘yes’ and the lower scores reflected 0 ‘no’. Factor analysis showed a three factor structure: control over work pace, control over starting and ending times and control over amount of days off. Because two of the subscales showed a low internal consistency and deleting items did not increase the reliability, it was decided to treat the items as belonging to one scale.

2.5 Ethical considerations

The study was not submitted to an ethical committee because according to Dutch law (Wet Medisch-Wetenschappelijk Onderzoek met Mensen/Medical Research Involving Human Subjects Act), surveys only have to submitted to an ethical committee in a limited number of situations which do not apply to the current study. The study was approved by the management board of the nursing homes involved. The participants were informed by individual letter and an institutional newsletter, they were free to refuse to participate and welcomed to ask questions and express concerns about the study any time. Return of a completed questionnaire was taken to imply consent. Data were stored anonymously, treated confidentially and the participants’ privacy was sufficiently guaranteed.

2.6 Data analysis

Data were analysed using IBM SPSS version 20. A frequency distribution of all different work patterns, and means and standard deviations of starting and ending times were computed. In order to develop a new typology, based on the five criteria mentioned in the introduction, the following contrasts were inspected: fixed shift pattern versus rotating shifts, nightshifts versus no nightshifts, and early shifts versus day shifts. The internal consistency of the scales was determined by Cronbach’s alpha reliabilities. Descriptive statistics were computed for the independent and dependent variables. One-way ANOVAs with post-hoc analyses (Tukey), Chi-square and Kruskal-Wallis tests were used to test for significant differences in the study variables between the new work schedule types. Where ANOVAs were used, post-hoc analyses (Tukey) were performed to test the differences. Where the Kruskal-Wallis test was used (e.g. level of education), post-hoc Mann-Whitney tests with Bonferroni correction (0.05/10 tests: 0.005 level of significance) were performed to test differences between work schedule types.

3 Results

The demographics of the nurses are shown in Table 1.

The final sample comprised mainly women, the mean age was 42.2 years (range 18–65), and 5.7% had full-time contracts (that is, 36 hours per week). The most common educational level was level 3 with qualification level 1 (care helper level 1) as the lowest and qualification level 5 (registered nurse) as the highest educational level. About half of the nurses had children living at home and one-third of the nurses had children under the age of twelve. A quarter of the nurses’ partners worked in shifts.

The average number of shifts in the weekends of the 95% of nurses who worked weekends was 3.8 per month. The average number of night shifts of the 41.1% of nurses who worked nights was 3.8 per month. Noticeable are the large standard deviations of the starting times and ending times of the morning and the afternoon shifts, ranging from 50 until 91 minutes.

The socio-demographics of non-respondents (n = 476; 49%) were not significantly different from those of the participants (e.g. average number of hours and average number of overtime hours each week, income, type of position and sickness absence duration), except that the non-respondents were younger; 37.5 years (SD = 11.83 years) (p < 0.01) versus 42.2 years (SD = 12.04 years) of the respondents conducted with organizations’ reports.

3.1 New typology

On the basis of our five criteria, a first draft typology was developed, consisting of eight types: Fixed shifts (frequency):

fixed early shifts (9.2%),

fixed ‘normal’ day shifts (1%),

fixed afternoon shifts (5.8%), and

fixed night shifts (4.4%).

Rotating shifts (frequency):

h)
early in combination with afternoon shift (42.6%),

early in combination with night shift (1.2%),

afternoon in combination with night shift (2.6%), and

rotating three shift pattern (33.1%).

The (b), (c), (d) (f) and (g) types of work schedules were reported by five, twenty-nine, twenty-one, six and fourteen respondents respectively and therefore did not fulfil the fourth requirement formulated in the background. We finally distinguished five types that fulfilled all five requirements: Type 5.
fixed early shift (a)

rotating two shift pattern (early and afternoon shifts) (e)

rotating three shift pattern (early, afternoon and night shifts) (h)

fixed and rotating two shift pattern including night shift (d, f, g)

fixed normal day or afternoon shifts (b, c).

Because almost all nurses worked weekends, no distinction was made between working weekends or weekdays. As can be seen in Table 2, the most prevalent type of work schedule was the type 2 schedule (early and afternoon two shift schedule) followed by the type 3 schedule (rotating three shift schedule).
3.2 Differences between the five types

As can be seen in Table 2, there were noticeable differences between the types of work schedules. The average number of hours worked per week differed significantly between nurses working in the different types of schedules. Nurses with type 3 schedules worked on average substantially more hours than nurses with the type 2, 4 and 5 schedules. Overtime hours per week did not differ among nurses with different types of work schedules. Days off between two series of shifts as an indicator of the possibility to recover or to take a rest differed significantly between nurses in the five types of work schedules; nurses with type 3 schedules had fewer days off than those with type 4 and 5 schedules. No differences between the five types of work schedules were found regarding the moment nurses were informed about their work schedules.

As can be seen in Table 3, there were a number of significant differences with respect to the socio-demographic and family characteristics. The amount of women working in the types of work schedule and the age of nurses working in the different types of schedules differed. Nurses with type 3 schedules were significantly younger than nurses with other types of work schedules, except for nurses with type 2 schedules. Educational level differed significantly. Nurses with type 1 and type 2 schedules had lower educational levels than nurses in type 3 schedules. The average years that nurses worked in the current job differed between the nurses; nurses with type 3 schedules worked considerably less years in the current job than nurses in the other type of schedules. Living with a partner, having an employed partner or not, the average number of their partners’ work hours per week, having a partner with shiftwork or not, taking care of children under the age of twelve, number of days children spent in day care per week, number of hours spent on care for family members per week did not differ between the types. Commuting time per workday differed significantly. Nurses with type 3 schedules had more commuting minutes per workday than nurses with type 1 schedules. Nurses with type 3 contributed more to the total household income than nurses with type 2.

With respect to the appraisal of the work schedule, it can be seen in Table 4 that satisfaction with the work schedule differed significantly. Nurses with type 3 were less satisfied with their work schedule than nurses with type 4 schedules. Finally, the work schedule control differed. The nurses with type 3 schedules experienced considerable less control over their work schedule than all other nurses except for nurses with type 4 schedules.

4 Discussion

This paper presents a new typology of work schedules based on data of 498 nurses working in elderly care institutions in the Netherlands. This new typology could improve research on work schedules. Based on predetermined criteria and frequencies of all possible working schedules found in this sample (n = 24) a new typology of work schedules consisting of five types is proposed. Next, the differences between the five types in terms of schedule characteristics, nurses’ characteristics (socio-demographics and family characteristics) and appraisal of the work schedule were studied. A considerable amount of differences between the types of schedules was found regarding work schedule characteristics, the nurses’ socio-demographic characteristics and nurses’ appraisal of the work schedule.

4.1 The new typology of nursing work schedules

There is a need for a more sophisticated typology [6] which also better represents the increasing diversity in work schedules over time [2 , 29]. We think that the new typology found in this study, is an improvement because it takes into account the most frequently reported types of work schedules and moreover, these types differ regarding work schedule characteristics, nurse characteristics and appraisal of the work schedule. The new typology of schedules introduced in this study is based, as a starting point, on the most prevalent and more traditional two and three rotating schedules. Next, fixed shifts are distinguished. The new typology is meaningful for practice, because it seems to also represent differences regarding the nurses who work in the different types and their appraisals of the work schedules. Besides the distinction between weekends and non-weekends, which is not used in our typology, Our typology parallels the frequencies of different types reported in other research [18, 19, 37].

4.2 Differences between the five types

Using this new typology, important differences were detected between the nurses working in the five types of schedules, which further validates the new typology. The work of nurses with type 3 schedules (with a rotating three shift pattern) was – in agreement with other research – characterized by more negative features than the work of nurses in other schedules [11 , 55]. These nurses were least satisfied with their work schedule as was also found in other research [11], and they were even less satisfied than a comparable group of nurses in another study [42]. It seems that in the experience of the nurses, the three shift schedule has more disadvantages than a two shift schedule. Furthermore, they indicated to have the least control over their work schedule. This is probably due to the rotating pattern which makes it more difficult to swap shifts and to schedule starting and ending times. These findings confirm the importance of including the appraisal of the work schedule in this study and in futureresearch.

Nurses with the type 3 schedules worked the most hours on average, commuted the most minutes per workday and had the fewest days off in between shifts. Having days off is normally seen as an opportunity to recover from work [29 , 57] and more commuting hours could limit the available time to recover. Furthermore, these nurses were on average the youngest group and worked on average the least years in the current job which, in line with the conclusion of Winwood et al. [55], could indicate (Winwood et al., 2006) that younger, inexperienced nurses working in type 3 schedules may require greater support from their organization, even though in our case their mean age was already 37 years. Nurses working in type 1, 4 and 5 schedules were on average about 10 years older.

Nurses with other types of work schedules than type 3 also have some noticeable characteristics. Nurses working in type 1 schedules appeared to have lower commuting time per workday than nurses working in type 2 schedules and they experienced higher work schedule control than nurses working in a type 3 schedule. Nurses working in type 2 schedule differed from nurses working in type 1 schedule because they work fewer hours on average per week. Possibly, the type 2 schedule offers more room for nurses to adjust the schedule to their preferences [58]. The main difference between nurses in these types of schedule and nurses working in type 4 schedules was that the work of nurses in type 4 schedules was characterised by higher satisfaction with work schedule and more days off between shifts. Nurses with type 4 and 5 schedules were comparable except for the latter being characterized by experiencing higher work schedule control. Type 4 schedule was characterized by fixed nightshifts and obviously these nurses had less room to adjust their work schedule than nurses working in type 5 shifts with fixed normal day of afternoonshifts.

4.3 Different career stages?

Taking the above results into further consideration, the current findings regarding age differences across the different types of work schedule is striking and do not seem to reflect the variety in family responsibilities between life stages. They might represent a specific career pattern. It might be that younger nurses prefer to start their careers with type 3 schedules, either because of primary or self-selection [15, 59], their organization’s advice, or because of the higher wages, which could be preferable in this stage of life. With increasing age, they probably want to change to a less demanding type of schedule [60], because they might have trouble tolerating shiftwork [29, 61]. This might explain why the type 5 schedule is characterized by a higher prevalence of older, level 5 nurses who work less hours compared to nurses with type 3 schedules.

4.4 Limitations

The criteria for the new typology were sufficient to construct a typology, which reveals differences between nurses working in different types of shifts. Response was moderate to high (51%) and the respondents were comparable with Dutch elderly care nurses in general regarding age, sex, average work week and number of years at the current job [3]. The respondents were thus representative for the residential elder care population they came from, except that non-respondents were slightly younger than respondents were. It can thus be concluded that selective dropout is not a serious problem in the present study. The nurses included in this research are representative for nurses working in residential elder care in the Netherlands who work largely across 8 hour shifts. Countries vary in their shift length. Although twelve-hour shifts are increasingly used across Europe [36], they are not common in the Netherlands, Belgium, Germany, Greece, Norway, and Sweden [62]. Our typology could therefore be generalizable to those countries. Generalizations of our typology to countries with nurses working in twelve-hour shifts (e.g. England, Ireland, and Poland) should be made with care. The possibility exists that using the same method could produce a altered typology of workschedule.

Because we limited the number of different types of work schedules for reasons of feasibility, employees with slightly different work schedules might have been classified in the same type. In practice, one should not forget that for an individual employee, a one hour difference in starting times could be a meaningful difference in relation to bringing children to school or allowing for more sleep [63]. Type 4 work schedules contained both fixed and rotating shifts, including nightshifts. These were combined because they all contained night shifts. Research by Demerouti et al. [64] showed that employees with rotating shifts reported less job satisfaction than employees working in fixed shifts. This might have led to a slight underestimation of the differences between type 4 and the other types.

Considering the scales used, the Cronbach’s alpha reliability of the Satisfaction with Irregular Working times was good (Cronbach’s alpha 0.92) and of the work schedule control scale was sufficient (Cronbach’s alpha 0.65) [65]. For ANOVA’s with five groups, power should be sufficient in the present study [66, 67].

5 Conclusion

All in all, it is possible to distinguish five main types of work schedules among nurses working in residential elder care in the Netherlands. A considerable amount of differences was found between the types of schedules regarding work schedule characteristics, the nurses’ socio-demographic characteristics and the nurses’ appraisal of the work schedule. This indicates sufficient construct validity of the new typology. The new typology seems useful to classify shifts on a more detailed level, which is of utmost importance for research and might be useful for employers as well.

5.1 Practical and scientific implications

The present typology of nurses’ work schedules is based on empirical research and seems a promising typology for research regarding work-related health and employability. To get an even more precise picture, research focusing on the health-related characteristics of the nurses working in the different types might be useful.

It would be valuable to validate the typology in other health care professions with shift work and to develop a new typology for nurses working twelve-hour shifts.

The new typology may not only be useful for researchers because of its conciseness, but also for employers and nursing managers for monitoring nurses’ employability. However further longitudinal research is warranted to elucidate whether, how and why nurses change work schedule types during their careers and if so, what the consequences are.

Conflict of interest

The authors declare that they have no competing interests.

Footnotes

Acknowledgments

We would like to acknowledge the participating nursing homes for their collaboration and to thank all the nurses who participated in this study.

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