The impact of work time control on physicians' sleep and well-being

Highlights

• We report a cross-sectional survey of hospital physicians in Sweden.

• More work time control predicted less fatigue after work.

• Work time control buffered some of the negative effects of night work.

Abstract

Physicians' work schedules are an important determinant of their own wellbeing and that of their patients. This study considers whether allowing physicians control over their work hours ameliorates the effects of demanding work schedules. A questionnaire was completed by hospital physicians regarding their work hours (exposure to long shifts, short inter-shift intervals, weekend duties, night duties, unpaid overtime; and work time control), sleep (quantity and disturbance) and wellbeing (burnout, stress and fatigue). Work time control moderated the negative impact that frequent night working had upon sleep quantity and sleep disturbance. For participants who never worked long shifts, work time control was associated with fewer short sleeps, but this was not the case for those who did work long shifts. Optimizing the balance between schedule flexibility and patient needs could enhance physicians’ sleep when working the night shift, thereby reducing their levels of fatigue and enhancing patient care.

Introduction

Physicians working in industrialised countries have traditionally worked long hours, particularly during the early stages of their career, with their schedules often featuring frequent overnight and on-call duties. Moreover, physicians face a particularly demanding combination of workplace stressors including high workload, demanding work hours, having to make critical judgements (including at times of heightened fatigue), emotional interactions, high cognitive demands and restricted autonomy (Wallace et al., 2009). Consequently, physicians tend to report higher levels of stress and emotional exhaustion and are more likely to report getting insufficient sleep, when compared to the general working population (Tucker et al., 2013).

Following concerns regarding the long hours worked by physicians and the potentially negative affects on both their own wellbeing and that of their patients, the last decade has seen moves towards the standardisation of physicians' working conditions (e.g. ACGME, 2011, European Parliament, 1993, Philibert et al., 2002). These regulations stipulate limits such as maximum weekly work hours, maximum shift duration, maximum quantity of night work and minimum amount of rest opportunities (e.g. between shifts and days off per week). They reflect, at least in part, research findings that demonstrate the importance of appropriate work schedule design for the management of physicians' fatigue and wellbeing.

A recent systematic review reported that the reduction of shifts over 16 h was associated with improvements in patient safety, as well as physicians' quality of life, in most studies (Levine et al., 2010). For example, an intervention involving the total elimination of extended shifts (>24 h) resulted not only in physicians getting more sleep, but also experiencing fewer attentional failures (i.e. microsleeps) and committing fewer medical errors (Landrigan et al., 2004, Lockley et al., 2004). Another intervention study involved redesigning physicians' work schedules with shorter shifts, fewer consecutive night shifts, and a sequence of morning, evening and night shifts designed to facilitate circadian adaptation to night work. The intervention brought about a 33% reduction in medical errors (Cappuccio et al., 2009). Survey studies have also highlighted a range of factors, in addition to length of work hours, which are crucial to the management of physicians' fatigue, sleep and health. These include the prevalence of night work, the number of consecutive night shifts worked in a row, the number of rest days after working nights, the length of the interval between successive shifts, the regularity of the work schedule and being able to sleep during duty hours (Baldwin and Daugherty, 2004, Brown et al., 2010, Ferguson et al., 2010, Gander et al., 2007, Tucker et al., 2010). Physicians' work schedules can also impact on their health, with high levels of on-call work and working several consecutive nights both having been linked to impaired psychological wellbeing (Brown et al., 2010, Heponiemi et al., 2008, Smith et al., 2006, Tucker et al., 2010). High levels of on-call were also found to predict greater intention to quit (Heponiemi et al., 2008).

Control over work hours and schedule flexibility are important predictors of physicians' work-life balance, burnout (Keeton et al., 2007) and career satisfaction (Clem et al., 2008). These outcomes have, in turn, been linked to lower quality of care (Gundersen, 2001, Spickard et al., 2002) and are also likely to negatively impact on recruitment and retention. Our research has indicated that the proportion of shift working physicians (in Sweden) who lack any influence over their work hours is substantially higher than the equivalent statistic for all (Swedish) shift workers (Tucker et al., 2013). When comparing physicians in different medical specialties, we found physicians working in specialities where influence of work hours was low (ear, nose & throat, orthopaedics, cardiology, surgery and anaesthesia) tended to report the most negative attitudes towards their work hours in general.

The importance of work time control for employees is underlined by the findings of a recent systematic review which identified it as a predictor of several job related outcomes (i.e. attitudes, performance and turnover), work-nonwork balance and some indices of health, including burnout and sleep (Nijp et al., 2012). Work time control has also been shown to ameliorate some of the negative impacts of demanding work schedules. It has been shown to buffer the effects of long work hours on sickness absence (Ala-Mursula et al., 2006), physical ill-health symptom frequency (Tucker and Rutherford, 2005) and work-family interference (Geurts et al., 2009, Hughes and Parkes, 2007, Kandolin et al., 2001, Valcour, 2007). These beneficial effects may due in part to the alleviation of stress and fatigue, as follows.

Job autonomy – of which work time control is a specific sub dimension – has been identified in several influential occupational health theories as an important determinant of employee health (e.g. job characteristics model: Hackman and Oldham, 1975; demand-control model: Karasek and Theorell, 1990). Nijp et al. (2012) proposed two regulatory mechanisms that can explain favourable associations between work time control and indices of health. The first was a time-regulation mechanism, such that workers who have work time control are better able to align their work hours with their non-work commitments (c.f. Barnett et al., 1999). Hence work time control may help reduce work-home interference, which is a potential source of psychological strain among doctors (Tucker et al., 2010). The second was a recovery-regulation mechanism, and was based on effort-recovery theory (Meijman and Mulder, 1998). Workers who have work time control are better able to maintain a balance between effort and recovery, as they can stop working before they become too fatigued (Beckers et al., 2008) e.g. by taking rest pauses during work; having control over when they start and finish work; and by having control over leave days. Conversely, a lack of work time control is likely to result in insufficient recovery, which is a key factor underlying the association between stressful work and poor health (Geurts and Sonnentag, 2006).

Workers with higher work time control not only report better health but also fewer sleep problems and less fatigue (e.g. Takahashi et al., 2011, Takahashi et al., 2012). By enhancing time-regulation, work time control can help individuals to match their work hours with their own circadian rhythms (Baltes et al., 1999). Moreover, sleep may also be improved by the reduction of stressors (e.g. work-home interference; Geurts et al., 1999) and by enhanced opportunities for unwinding after work (c.f. Fritz and Sonnentag, 2006).

In summary, physicians' work schedules are an important determinant of their health, fatigue and sleep. While the majority of research in this area has focussed on the impact of particular work schedule parameters (e.g. the timing, duration and sequencing of shifts, and the distribution of rest opportunities), there is some limited evidence indicating the importance of providing physicians with control over their work hours. This accords with evidence from other occupational sectors showing that work time control is associated with enhancements of health, fatigue and sleep. A number of studies have also shown that work time control buffers (i.e. moderates) the impact of long work hours on health and wellbeing. However, it remains to be determined whether work time control can buffer the effects of other work schedule parameters, other than length of work hours, which are known to impact on fatigue, sleep and health. The current study addresses this gap in the literature by examining how the impacts of five key working time parameters (frequency of long shifts, frequency of short inter-shift intervals – “quick returns”, frequency of weekend days that are worked, frequency of night duties and number hours of overtime worked per week) were moderated by work time control.

Our predictions were based on the premise that work time control buffers the negative effects of demanding work schedules. Hence we hypothesized that demanding work schedules (defined in terms of the five working time parameters listed above) would be less commonly associated with greater fatigue, impaired sleep and poorer health among physicians with work time control, as compared to physicians who lacked work time control.