nurse retention: moderating the ill-effects of shiftwork

This article explores ¯ exible working arrangements for nurses in the National Health

Service (NHS) within the context of government family-friendly rhetoric and nurse

shortage. More specifically it examines issues influencing the implementation of

shiftwork with specific consideration of the interplay between flexibility, from the

organisational perspective, and choice, or denial of choice, from the nurse perspective. It

recognises that time at work is part of an often strained relationship between ® nancial, social

and health dimensions of life. The article is based on a meta-analysis of empirical research

drawn from the ® elds of occupational psychology, ergonomics, management and medicine.

New insights are offered by adopting this multi-disciplinary approach providing a link

between hitherto largely separate discourses and agendas. By examining the detrimental

effects of shiftwork and focusing on the moderate in¯ uence of nurse choice on those ills, we

gain insight that can inform the ¯ exible working debate and HR practice and which may

facilitate reduced nurse turnover and increased return to work. Hence, this article focuses on

one of the many complex, controversial and unresolved HR issues within healthcare, that of

the implementation of working arrangements and its impact on organisational and

individual effectiveness.

There is growing evidence that employers, not least the NHS, are looking for greater

¯ exibility in the use of the workforce as part-time, short-term, ` exible’ and annualised hours

contracts and other non-standard employment practices are increasing (Atkinson and Meager,

1986; Curson, 1986; Cumings, 1993; IRS, 1994; Pollert, 1988; Watson, 1994). These flexible

working practices have been viewed as new forms of management control and labour

exploitation (Hakim, 1990; Pollert, 1988) and as an outcome of post-war consumerism where

women could `satisfy their desire to work, while also augmenting their family income’

(Cuming, 1993: 181). This has been seen as the result of intensi® ed international competition

and the requirement to reduce costs of production (Curson, 1986; Lyons, 1990; Syrett, 1983) of

supply, as methods to promote ef® ciency and effectiveness (Atkinson and Meager, 1986).

The issue of ¯ exible working has always proven salient within nursing, particularly in

ward-based areas requiring 24-hour patient care. Not surprisingly, work schedules have been

shown to have an impact on many aspects of nurse’s working and domestic lives and on their

retention in the workplace (Burton and Burton, 1982; Duxbury and Armstrong, 1982;

Edwardson and Anderson, 1983). However, shiftwork is not necessarily a drawback, on the

contrary the opportunity to work shifts bene® ts some nurses and for them, it is argued, many

of the problems of shiftwork may be alleviated. It is hardly surprising, therefore, that studies

have suggested that nurse retention is related to aspects of control or choice over working

lives and conditions (Choi, et al, 1989; Meeuwsen and Pool, 1996; Weisman, et al, 1981) while

the rigidity of nurse rostering could result in increased nurse turnover (Brown, 1988). Despite

awareness of this, just 53 per cent of nurses in the NHS work their preferred shift pattern

(Smith and Seccombe, 1998). Some nurses prefer, and if empowered choose, permanent night

work, for example, while others prefer ¯ exible rather than regular shifts.

16 HUMAN RESOURCE MANAGEMENT JOURNAL ± VOL 10 NO 4

Nurse retention: moderating the ill-effects of shiftwork

Ian Brooks, University College Northampton

The fastest growing and least popular shift (increased from 23 per cent in 1994 to 30 per

cent in 1999) is internal rotation, a system where nurses rotate between days and nights

usually within each month (Robinson et al, 1999). What is more, among the most popular

shift arrangement for those who have chosen them, permanent earlies/lates and permanent

nights, are in decline. The proportion of nurses working earlies (eg 07.30 to 15.00) and lates

(eg 12.30 to 20.00) declined from 26 to 17 percent, while those working permanent nights

decreased from 14 to 7 per cent between 1994 and 1999. It is also worth noting that those

working 12-hour shifts rose rapidly from just two to six per cent between 1994 and 1999.

Although the numbers on some `popular’ shifts, for example nine to ® ve days and twilight

hours, have increased slightly, substantial and consistent evidence of improved nurse choice

of shifts is not apparent (Robinson et al, 1999). Clearly, there is an issue of ¯ exibility for the

organisation and choice or control for nurses and this dilemma will be further examined.

The paradox

A paradox created by the pursuit of practices which reduce nurse choice, personal reward

and accessibility to employment within a climate of nurse shortage and government family-

friendly rhetoric, could be considered evidence of the irrational nature of management and

decision making in the NHS. Striving for ¯ exibility in organising creates a discriminatory

scenario which exacerbates nurse shortage and potentially lowers struggling morale.

Flexibility for those doing the organising appears to be at odds with flexibility for the

individuals being organised, raising the question for whom is ¯ exible working, working’? It

is also acting in apparent contradiction to recent government HR initiatives and its caring,

family-friendly rhetoric.

Anecdotal evidence indicates that healthcare managers have re¯ ected more closely on the

in¯ uence of working time arrangements on nurse wellbeing, retention and recruitment in

recent years yet, as the trends indicated above illustrate, permanent day and night shifts are

in decline and rotating shifts increasing. Nurse choice of shift remains a distant objective in

most units. In fact it is widely believed within healthcare that in the absence of an acute

nurse shortage, moves towards further employee-friendly rostering would receive scant

attention. This may be explained by the pressure nurse managers are under to maintain

quality of service within a declining resource base. The emphasis on cost effectiveness has

led to a focus on reducing overlapping shifts, identif ication of workload patterns,

minimising staf® ng levels and the pursuit of ¯ exible staf® ng and scheduling. In other words

operational imperatives, together with organisational and professional inertia, encourage

managers to deny nurse choice and, only when necessary, to accommodate it. What is more,

ward managers, who are generally responsible for nurse rostering, view nurse shortage as a

national problem outside of their control. Quite understandably, unit cost effectiveness,

quality of service provision and control over rostering are more immediate concerns.

The issue is further enriched by the stance adopted with regard to permanent night

nursing. In many units permanent night shift nursing has been actively discouraged

re¯ ecting the antipathy many managers and nurses have to dedicated night work. Night

work is often regarded as divisive, attracting higher pay for `babysitting’ (Brooks, 1999). It

also is seen as acting as a barrier to the provision of statutory training and other professional

nurse development. Night nurses are regarded as remote, less involved with institutional

and professional activities and less accessible to managerial control (Brooks, 1999).

Necessity is encouraging some units to reconsider their stance in this regard although

nurse choice of shifts appears of secondary importance when compared to the managerial

need to provide 24-hour provision, with appropriate staf® ng levels and skill mix, within

Ian Brooks, University College, Northampton

17HUMAN RESOURCE MANAGEMENT JOURNAL ± VOL 10 NO 4

tight budgetary constraints. The real or perceived need for organisational flexibility

appears to outweigh the desire for flexibility or choice from individual nurses. Power

traditionally lies with the employer, although acute nurse shortage and greater societal

and political recognition of the importance of quality of work life and the consequent need

for employee- friendly ¯ exibility, is beginning to have an impact on institutional inertia

and managerial practices.

Nurse choice

It is important to clarify what is understood by nurse choice while at the same time

acknowledging that the relationship between in¯ uence’, `choice’ and `control’ is complex

and justi® es further elaboration than can be afforded here. In both the NHS and private

sector some nurses have an imposed, often inflexible, shift pattern, while many have a

degree of in¯ uence over their temporal pattern of work. For example, it is usual for ward

managers to consider `off-duty’ requests, recorded in a ward-based diary, when rostering.

However, it is reported that only about a half of nurses work their preferred shift pattern or,

more signi® cantly, 47 per cent do not (Smith and Seccombe, 1998).

Nurse choice can be regarded as being at one end of a continuum with institutional or

managerial imposed allocation at the other. A degree of choice is acknowledged when

nurses have some influence on their working hours. Such influence may include, for

example, the right of proposal, power of veto or team/self-rostering. Having choice should

increase the likelihood of perceived (or real) individual control being recognised by

individual nurses. Hence, control is the perceived degree of choice and in¯ uence in the

decision-making process that directly affects an individual’ s working time patterns.

This article argues that significant benefits will ensue if pereived or real choice is

practiced by individual nurses. Conversely, if nurses perceive a lack of choice over this

crucial aspect of their lives, then the detrimental effects of shiftwork outlined below are

more likely to adversely effect individual and organisational outcomes. There is now a

considerable literature which emphasises the significance of workplace control and its

capacity to positively in¯ uence performance, health, including coronary heart disease and

morbidity (Frankenhaeuser and Gardell, 1976; Karasek, 1990), stress levels, job satisfaction

and intention to leave one’s job (Astrand et al, 1989; Bussing, 1988; Bussing, 1996; DeJonge,

1995; Jackson, 1983; Karasek, 1979; Spector, 1988; Wall and Davids, 1991). What is more,

control does not have to be `real’ but merely perceived for it to have the same effect

(Lefcourt, 1973; Thompson, 1981).

It appears that control over working times is more relevant for speci® c subgroups who

have a high degree of stressors and demands, for example nurses with young children or

other caring responsibilities or single parents (Bussing, 1996). This is particularly pertinent

when one considers a recent large scale survey of nurses on the UKCC register (1998) which

revealed that the majority had caring responsibility for children (40 per cent; half of these

nurses cared for pre-school age children) or dependent adults (14 per cent) or both (four per

cent). Working arrangements and shift patterns do have an impact on nurses’ ability to

combine active work with their domestic and social responsibilities as indicated in a survey

of nurses who had left the NHS in 1997/8 (Smith and Seccombe, 1998). When asked to

indicate the single most important factor which would have reduced the likelihood of their

leaving, the availability of ¯ exible working hours (eight per cent) came third after better

resources to do the job and better pay, followed in order by creche or day care facilities

(seven per cent), career breaks (six per cent), greater availability of job share (three per cent),

more part-time working (two per cent) and after school child care (one per cent).



The importance of shiftwork research in HRM should not be underestimated, particularly

as a proliferation of activity has highlighted many of the detrimental effects of non-standard

working arrangements, while there has been a significant increase in the proportion of

employees enduring shiftwork in recent times. For example, around 20 per cent of

employees in the European Union work some form of shift or non-standard work schedule

(BEST, 1993), while in North America about 17 per cent of full-time and almost 50 per cent of

part-time employees are engaged in shiftwork (Flain, 1986; US Congress, 1991).

Shiftwork research focuses on a variety of issues, such as the disturbance of circadian

rhythms (Monk and Folkard, 1985; Akerstedt, 1990; Czeisler et al, 1980), sleep problems

(Verhaegen et al, 1987), fatigue (Alward, 1986), physical and psychological health (Akerstedt,

1988, 1990; Bohle and Tilley, 1989), social and domestic disruption (Walker, 1985; Colligan

and Rosa, 1990), performance (Lavie, 1991; Monk, 1990; Waterhouse et al, 1992), absenteeism

(Dalton and Mesch, 1990; Tasto et al, 1978) and safety (Smith et al, 1979; Waterhouse et al,

1992; Williamson and Feyer, 1995).

We will brie¯ y examine some of the key issues while recognising that this meta-analysis

cannot embrace the full complexity of inter-relationships between factors nor engage in all

the key debates in the field. It aims to synthes ise, interpret and make accessible a

considerable literature and it will, by focussing on nurse choice as a crucial moderating

influence, emphasise clear ways forward for the management of flexible working

arrangements in the NHS and contribute both to academic understanding and HR practice.

Circadian rhythms

There is extensive evidence that shiftwork disrupts the human biological, or circadian,

rhythms (Akerstedt, 1990; Harrington, 1978; Mahan et al, 1990; Waterhouse et al, 1992).

Nevertheless, there is debate concerning the extent to which shift workers’ circadian rhythms

adjust to night work routines, with general agreement that lack of adjustment is a causal

factor encouraging a higher incidence of health problems, sleep disorder, dissatisfaction at

work and reduced job performance. No evidence is reported of a total adjustment of the

circadian rhythms of temperature, `alertness’ and `wellbeing’ even over many successive

night shifts, where full adjustment of the circadian system remains incomplete (Knauth and

Rutenfranz, 1982). Despite this, Folkard et al (1978) conclude that long-term adjustment can

occur in permanent full-time night nurses, manifesting itself in a developed capacity for

short-term adjustment rather than a permanent ¯ attening of the rhythm.

Of particular signi® cance to the argument presented in this article is that it is generally

agreed that circadian rhythms differ between individuals, particularly in the rhythm rate of

adjustment, its size and peak. For example, research has indicated `morning’ and `evening’

types (Horne and Ostberg, 1976; Smith et al, 1989; Torsval and Akerstedt, 1980); it is argued

that the latter category adjust better to night work, suggesting that individual physiological

differences may predict tolerance to shiftwork (Andlauer, 1987; Moog, 1987). Other research

indicates that individuals differ in their ability to overcome drowsiness, referred to as

`vigorousness’, and to sleep at different times of the day and night, termed `¯ exibility’ (Costa

et al, 1989; Folkard et al, 1979) while others argue that a commitment to night work appears

to better ensure such productive adjustment (Barton, 1994; Brooks, 1997; Wilkinson, 1992). In

support of this argument, it is apparent that some individual shiftworkers including those

on permanent nights do not suffer adverse effects to the extent that is normally attributed to

non-standard working times (Alward and Monk, 1990; Barton and Folkard, 1991). In search

of an explanation, Adams et al (1986), using an interview based methodology, found that

many night nurses organise their lives around their nocturnal worklife as a coping



mechanism aimed at better ensuring adjustment. In conclusion, it is argued that choice of

permanent night work, for example, may indicate a self-selection process by those better

disposed, physiologically and psychologically to night work.

Sleep

Sleep disturbance associated with shiftwork is extensively researched (Akerstedt and

Kecklund, 1991; Dahlgren, 1981; Torsvall et al, 1989). It is argued that sleep quality and

duration is a causal factor influencing workplace performance, absenteeism and stress,

while sleep deprivation can lead to both physical and psychological ill-health. Although

an individual’ s preferred amount of sleep differs (Mullaney et al, 1977), the quality and

quantity of sleep achieved is likely to give some indication of the appropriateness of any

shift system (Wilkinson, 1992). An extensive review of 44 published research works

measuring shift worker ’ s sleep duration found that those on permanent shifts, even

nights, sleep longer than on either rapidly or weekly rotating shifts (Wilkinson, 1992).

Wilkinson also cautions that for some individual’ s `work, safety and general wellbeing are

substantially impaired (due to sleep deprivation) even on permanent night shift and these

must be persuaded away from it’ (1992: 1433).

The problem is, as noted above, that full circadian rhythm adjustment does not occur, so

that nurses on night shifts tend to accumulate a chronic sleep de® cit which may result in

disruption of physiological adjustment, sleep, fatigue or alertness (Knauth, 1993). It is not

surprising, therefore, that Rutenfranz et al (1985) reported that about two-thirds of

shiftworkers complained of sleep disruption. What is more, the problems are also age

related. In numerous studies it was found that among older shiftworkers the `normal’

reduction in sleep quality and quantity experienced by over 40 year olds was exacerbated

(Foret et al, 1981; Matsumoto and Morita, 1987; Reilly, 1997; Tepas et al, 1993), while Butat et

al (1999) found that sleep disorders were, in fact, more frequent for all age groups of

shiftworker compared with day workers. These ® ndings are of particular concern given the

ageing of the workforce in general and of nurses speci® cally (20 per cent of nurses are over

50 years old, just 16 per cent are under 30: average age is 40) ± UKCC Register, 1998.

Of particular signi® cance to the argument presented in this article are the ® ndings that

permanent night shift nurses (the vast majority of whom choose that shift) when compared

with rotating shift nurses (the least popular shift system), were more ¯ exible in their sleeping

habits (Verhaegen et al, 1987), reported a higher day sleep quality, exhibited a greater

preference for evening and night activities (Verhaegen et al, 1987; Barton, 1994) and greater

ability to overcome drowsiness (Barton, 1994). These support and strengthen earlier research

which found that permanent night nurses were more adaptable and less fatigued by night

work than staff on rotating shifts (Alward, 1986) and provide further evidence that an element

of self-selection (choice) appears to moderate the detrimental effects of shiftwork.

Physical and mental health

Considerable research has focused on the adverse health implications of shiftwork (Akerstedt,

1988, 1990; Bohle and Tilley, 1989; Costa et al, 1990; Haider et al, 1986; Knutsson et al, 1986;

Reinberg et al, 1981; Rutenfranz et al, 1985; Segawa, 1987; Thierry and Meijman, 1994; Wallace

et al, 1995; Wedderburn and Smith, 1984; Walker, 1985). An increased incidence of many

illnesses have been recorded among shift workers, including sleep/wake disorders (Martens

et al, 1999), neuroticism (Bohle and Tilley, 1989; Knuttson, 1989, Rutenfranz et al, 1985),

cardiovascular diseases (Gordon et al, 1986; Knutsson, 1989; Moore-Ede and Richardson, 1985;

Siegrist et al, 1988) and gastrointestinal problems (Costa et al, 1981; Singer, 1982; Waterhouse et



al, 1992). For example, Costa et al (1981) found that the time between starting a particular

working arrangement and the onset of gastrodenitis was on average just over four and a half

years for permanent night workers, a little over seven years for other shiftworkers and 12

years for day workers, which is hardly surprising given that the frequency and pattern of meal

taking is disrupted by shiftwork and lowered during night work (Cervinka, et al, 1984), not

least in the NHS because many staff canteens are closed at night.

Although a clear link between choice of various aspects of work and both stress and

general health levels has been established (Bussing, 1996) limited research has speci® cally

examined the effects of choice in the rostering of healthcare workers. That said, there is

literature which supports the contention that personal control has moderating effects on health

and occupational stress (Astrand et al, 1989; Karasek, 1979; Payne and Flectcher, 1983).

Domestic and social life

Shiftwork is not only at odds with an individual’s natural biological cycles, it also contravenes

society’s established social rhythm. As a consequence, shiftwork has an adverse in¯ uence on

relationships in life partnerships and participation in social life often leading to isolation or

marginalisation (Colligan and Rosa, 1990; Hoskins, 1981; Raymond, 1988; Volger et al, 1988;

Wedderburn, 1993; Walker, 1985). In addition the complex relationships between work time,

family arrangements and leisure has encouraged a proliferation of research which indicates

that work schedules which lead to notable complications in family and social life `are more

likely to have a negative in¯ uence on wellbeing and health’ (Bussing, 1996: 240).

Tasto et al (1978) found that nurse shiftworkers were reported to be dissatis® ed with the

amount of time available to spend with children and saw themselves less involved in

childbearing responsibilities. Clearly, issues of gender discrimination are potentially acute in

this regard for while few studies have revealed different health related experiences for male

and female shiftworkers, tolerance of shiftwork is likely to be influenced by social and

domestic pressures (Gadbois, 1981) and, as a consequence, may have a different impact on

women and men. An important issue in this regard is the predictability and regularity of

shiftwork. It is suggested that regular hours, even night work, enables employees to plan

and ful® l family responsibilities, participate in social activities and cope with mental and

physical fatigue better than if they are working rotational shifts (Jamal and Jamal, 1982),

particularly where shift patterns are not predictable in advance.

It is also important to note that not only do individuals ’ domestic and social

circumstances differ, so do their ability to cope with resultant pressures. A significant

element of choice in shifts worked may enable nurses to exercise their creative powers to

achieve best ® t between their working and non-working lives (Hall and Parker, 1993). Self-

selection would also reduce the number of shiftworkers who ® nd it dif® cult to cope with

shiftwork because of their, often unique, family and social relationships and arrangements.

Not surprisingly, Staines and Pleck (1984, 1986) found that shiftwork is associated with less

time in family roles, higher levels of con¯ ict between work and family life and lower levels

of family adjustment and that flexibility of work schedules moderates the negative

association between quality of family life and non-standard working times.

Performance

Performance tends to parallel the circadian rhythm of body temperature, although it can

peak early or later according to the type of task being conducted, arousal phenomena (such

as lighting conditions), time spent awake and individual motivation. Hardly surprising then

that consensus suggests that performance is reduced during night work (Lavie, 1991; Monk,



1990; Waterhouse, et al, 1992), largely because of increased sleepiness and changes in EEG

ultradian rhythms (Akerstedt et al, 1991), but that adverse effects are tempered by the

existence of individual choice or control over working arrangements (Barton, 1994).

From the evidence presented above, it can be hypothesised that in¯ exible shift systems

which disallow nurse choice are likely, other things being equal, to hamper nurses’ attempts to

balance work and home life responsibilities leading to increased absenteeism. Dalton and

Mesch (1990) noted that rigidity and lack of employee autonomy may also demotivate staff

and potentially increase absenteeism and turnover. It has been found that nurses on rotating

shifts record higher absence levels than those on regular or permanent shifts while rotating

nurses make more worksite health centre visits for a broader range of complaints than those

on ® xed shifts (Tasto et al, 1978). Despite expectations, permanent night nurses record no

higher absence rates that those on day shifts (Barton and Folkard, 1991). It is suggested that as

most permanent night staff have chosen to work that shift that this has a moderating effect on

absence levels. The extent of nurse in¯ uence over working time arrangements appears to be

positively correlated to reduced absenteeism and turnover. Dalton and Mesch (1990) found

that absenteeism and turnover rates were reduced where a system of flexible rostering

operated which is consistent with the ® nding that nurses’ sense of control in their working

lives effects their decision to continue or leave their jobs (Weisman et al, 1981; Choi et al, 1989).

Smith et al (1979) found that injury rates were similar for permanent night and day shift

employees but higher for those working rotating shifts, while Williamson and Feyer (1995)

have shown a higher incidence of errors and accidents in many areas of work for night

shifts. Gold et al (1992) found that nurses on shiftwork had twice the chance of nodding off

while driving to and from work and increased chances of having work related accidents or

making medication errors than their day shift colleagues. Waterhouse et al (1992) noted that

safety appears to be reduced during the night shift, although generally research ® ndings are

equivocal and vary according to sector, shift patterns and other contextual factors. It may be

nothing more than coincidence that the disasters at Bhopal, Chernobyl and Three-Mile

Island all occurred at night!

Clearly, an explanation for likely increases in safety problems at night is that employees’

circadian rhythms are at their lowest ebb often leading to drowsiness. Again, individual

choice of shifts may encourage those who have particularly poor coping mechanisms and

suffer from drowsiness and fatigue to avoid working nights ± denial of choice may have

detrimental consequences in this regard.

DISCUSSION

Evidence suggests that the creation of an organisational climate where involvement in

shiftwork rostering leads to perceived or real control and the effective exercise of individual

choice of shifts worked, appears to relieve many of the reported detrimental effects of non-

standard working. Conversely compulsion, especially to work nights, to rotate shifts or to

work irregular hours, will lead to increased reported health problems, reduced sleep (quality

and duration), increased turnover and possibly increased absenteeism, workplace injury,

lapses in safety and reduced performance. Since nursing will remain a 24-hour service, it

appears imperative to acknowledge and incorporate further autonomy in this regard in

order to design and operate more socially tolerant arrangements.

This position is increasingly supported by research ® ndings. Barton (1994) and others

(Skipper et al, 1990) have stressed the signi® cance of individual circumstances in in¯ uencing

choice of shifts. Some individuals prefer night work, for example, as this enables them to



share childcare responsibilities (Robson and Wedderburn, 1990) and elicit domestic

commitments (Barton, 1994) while allowing them time at home with their young children

(Gadbois, 1981) and, due to night enhancements, enjoy the added financial incentive

(Barton, 1994). Verhaegen et al (1987) found that permanent night nurses consistently rated

various aspects of their work more highly than rotating shift nurses, largely they argued, as

the night staff had chosen that particular shift system, whereas the majority of rotating

nurses had that pattern of work imposed on them. These results are consistent with those

presented in this article, further illustrating the signi® cance of choice.

It is quite plausible that an individual’s choice of shift may be influenced by both the

perceived or realised ability to adjust their circadian rhythms or cope with the consequences of

incomplete adjustment. This position is supported by Barton and Folkard (1991) who argue

that commitment to night working will better ensure adaptation of circadian rhythms. As

intimated above, research has clearly indicated a signi® cant correlation between individuals`

¯ exibility of sleeping, their ability to overcome drowsiness and their tolerance to shiftwork

(Vidacek, 1990). Bussing (1996: 241) suggests that autonomy in work scheduling appears to act

as a coping mechanism `alleviating the detrimental effects of non-standard working’.

That tolerance to shiftwork differs between individuals is beyond dispute. However,

somewhat more contentious is the powerful argument that intolerance may be considered a

chronic disease. Such intolerance is de® ned by the intensity of a set of medical complaints

including sleep dif® culties, persistent fatigue, behavioural changes, digestive troubles and

reliance on sleep inducing drugs (Andlauer et al, 1979; Reinberg and Smolensky, 1992;

Reinberg, 1996) and may be predicted by examination of the amplitude of circadian rhythm.

In the light of this contention, and the likelihood that 20-25 per cent of shift workers are

known to reject and leave shiftwork at an early stage because of serious disturbances (Costa,

1996; Harrington, 1978), indiscriminate rostering for all active members of an occupational

group will ensure the occurrence of these genetically related chronic symptoms in some

employees resulting in negative individual and organisational outcomes.

FIGURE 1 Nurse choice and individual difference as input and output criteria

Figure 1 models the in¯ uence of shift systems on individual and organisational outcomes.

Nurse choice, and individual differences, acts as both an input and output ® lter. It affects the

circadian, social and domestic rhythm resulting from any particular shift system (input) and

modi® es the individual and organisational outcomes created by rhythm disruption (output).



Shiftsystemfeatures

Nurse choice and

individualdifferences

(input)

Circadian rhythms

Domestic rhythms

Social rhythms

+ or -Physical andmental health+ or -Performance+ or -Absenteeism+ or -Satisfaction and

motivation+ or -Safety+ or -Retention and return

Nurse choice and

individualdifferences

(output)

CONCLUSION

The ills of shiftwork clearly have an impact on both individuals and organisations. For

example, Harrington (1978) found that about 10 per cent of shiftworkers enjoyed shiftwork

while around a quarter found it suf® ciently unpleasant to have to leave the workplace. The

rest merely tolerate it. A series of intervening variables of which choice appears paramount

appear to in¯ uence levels of tolerance to shiftwork and to moderate certain adverse effects

of otherwise deleterious working arrangements. Drawing on the work of Seifert (1989), who

identi® ed six socio-economic criteria in¯ uencing tolerance to working time design, and on

Bussing (1996), Barton et al (1995) and Smith and Barton (1994), who focused on personal

control, together with the findings of this research exercise, we identify a series of

moderating variables as illustrated in Figure 2 and listed below:

· choice (real or perceived) in the implementation of shiftwork practices;

· predictability and regularity of working time arrangements;

· social and domestic relationships, arrangements and preferences;

· individual’ s physiological and psychological tolerance including gender and age

variables, nature of and adaptation to circadian rhythms, personality type, ¯ exibility

of sleep habits, capacity to overcome drowsiness, effectiveness of other coping

strategies; morningness/eveningness characteristics and learned resourcefulness

(Rosenbaum, 1989);

· extrinsic reward eg income, job security and access to labour markets as compensation

for Á unsociable’ hours.

FIGURE 2 Moderating variables: choice as a meta-criteria



Choice(meta-criteria)

Predictabilityand regularity

of shifts

Physiological andpsychological

tolerance

Extrinsicreward

Social anddomestic

preferences

These five categories embrace fundamental shiftwork design and implementation

practices, including the degree of participative management practised together with socio-

economic, psychological and physiological components. Clearly there are complex inter-

relationships between the moderating variables; choice is viewed as a meta-criterion.

The increased demand for ¯ exibility from the organisation, this article argues, is often at

odds with choice for the individual, yet it is perceived choice in the implementation of

working arrangements which serves as the ultimate moderating or tolerance inducing

variable. Flexibility for the organisation versus autonomy for the individual creates an

omnipresent organisational dilemma: recognising this is an important step towards

managing and coping within that ambiguity.

The rapid growth of ¯ exible working in the NHS coincides with a protracted period of

acute nurse shortage. Nurse supply is contracting, although numbers now entering training

have recently increased, while the average age of qualified professionals on the UKCC

register is rising (Smith and Seccombe, 1998). Most NHS Trust hospitals are holding nurse

vacancies, reportedly as much as 30 per cent in some urban areas. The government have

attempted to arrest the decline in numbers entering the profession by offering signi® cant

pay rises to newly qualified nurses and providing further nurse training places.

Additionally, they have launched a national HR strategy, `working together: securing a

quality workforce for the NHS’ (DoH, 1999), with a strategic objectives to improve the

quality of working life. Meanwhile, despite technological, managerial and professional

changes which have led to signi® cant productivity increases for nursing staff, the demand

for quali® ed nurses remains highly buoyant. Understandably, considerable attention has

been focused on the retention of nurses by NHS Trusts, health authorities, the NHS

executive and government. This has led to a resurgence of interest and concern around a

variety of HRM issues.

Finally, it is recognised that there is no single most appropriate shift system and that

working time arrangements have to seek synergies between the unequivocal prescriptions of

empirical research, the operational and strategic objectives of organisations and the needs of

individuals and groups of employees. The diversity of organisational contexts has ensured

that a multiplicity of working arrangement and shift systems exist not only within any one

country or sector of activity but often within one organisation, such as the NHS. What is

more, systems based on differing strategic and operational imperatives often exist in any one

NHS Trust hospital: between one ward and its neighbour. Faced with such variability and

complexity, an ad hoc system prevails and does little to ensure, in any coherent or concerted

manner, that either the needs of the individual nurse, the requirements of the unit or the

prescription from the literature are accommodated.

There is a requirement for more context sensitive research to establish both the nature of

the `mechanisms’ acting to reduce the detrimental effects of shiftwork and the extent to

which such moderation occurs. What is more, as the ill effects of shiftwork are many and

varied, and do not apply equally to all shiftworkers, further research efforts may highlight

explanatory factors accounting for the observed differential effects.

However, the arguments presented in this article have practical, as well as academic

value, not least for the process of staff scheduling in a wide array of organisations and

among a range of occupational groups. Non-standard working times are becoming more

commonplace (BEST, 1993; US Congress, 1991) giving greater significance to measures

which may serve to facilitate the effective implementation of such flexible employment

practices. Generally, the allocation of work, including its temporal distribution, is widely



considered a managerial task while enabling participant choice implies the need for greater

employee involvement in this process. The use of off-duty request mechanisms are

commonplace, however, the emphasis remains on direct managerial control.

It is argued that a top-down, directive approach needs, as part of a carefully managed

change process, to give way to a more inclusive process which accommodates greater

choice. This represents second order change (Watzlawick et al, 1974) involving double loop

learning (Argyris and Schon, 1974), altering, as it will, the nature of the employment

relationship. Such change might promote the value of team-based self-rostering processes.

Clearly, a prerequisite for this is the development of a climate of involvement and

consultation and, more speci® cally, a need to establish the `ground rules’ and differentiated

and changing roles of individuals, teams and managers. Self-rostering embraces choice and

team-based, ’ground level’ decision making. Its successful implementation, with clear

checks in place to ensure adequate consideration of the service need, will bring a myriad of

actual and potential bene® ts and lesson the detrimental effects of shiftwork.

This article has suggested that organisation-driven flexibility appears unable to

accommodate the evolving personal and social needs of nurses, and so contributes to the not

inconsiderable retention and return concerns within the NHS. If we add to this

consideration of the current acute nurse shortage, an ageing nurse population and an

increasing demand for healthcare services, the NHS is facing a chronic HR problem which

welcomed, but potentially `cosmetic’, remedies, such as pay rises for newly quali® ed nurses,

may only marginally forestall. Flexible working appears to be used as a mechanism aimed at

addressing environmental complexity and dynamism so better enabling an organisation to

operate ef® ciently and effectively. The emphasis is placed on the organisation, as opposed to

the individual or group: it is the latter which is required, for example, to be temporally or

numerically, `¯ exible’ . This article has highlighted a serious concern with the mechanical,

operationally driven search for ever greater employee temporal flexibility. Longer term

organisational, team and individual wellbeing may better be served by a more sensitive and

considered implementation of, in this case, shiftwork.

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nurse retention: moderating the ill-effects of shiftwork

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