N U RS I NG A N D HEA L T H C AR E M AN A G EM E N T AN D P OLI C Y

Work-related fatigue and recovery: the contribution of age, domestic

responsibilities and shiftwork
Peter C. Winwood BDS BPsych
Senior Research Fellow, Department of Applied Psychological Research, University of South Australia, Adelaide, Australia

Antony H. Winefield PhD

Director, Centre for Applied Psychological Research, University of South Australia, Adelaide, Australia

Kurt Lushington PhD

Senior Lecturer, Department of Applied Psychological Research, University of South Australia, Adelaide, Australia

Accepted for publication 24 March 2006

Correspondence: & L U S H I N G T O N K . ( 2 0 0 6 ) Journal

Peter C. Winwood,
Department of Applied Psychological
Research,
University of South Australia,
Adelaide,
Australia.
E-mail: pwinwood@internode.on.net or
peter.winwood@unisa.edu.au
doi: 10.1111/j.1365-2648.2006.04011.x
W I N W O O D P . C . , W I N E F IE L D A. H.
of
Advanced Nursing 56(4), 438449
Work-related fatigue and recovery: the contribution of age, domestic responsibilities
and shiftwork
Aim. This paper reports a study of the relationship between age, domestic respon-
sibilities (being partnered and having dependents), recovery from shiftwork-related
fatigue and the evolution of maladaptive health outcomes among full-time working
female nurses.
Background. Several studies have suggested that full-time working women with
family responsibilities are at greater risk of developing work-related fatigue prob-
lems than single women without these responsibilities.
Method. A questionnaire was distributed in 2004 to 2400 nurses at two hospitals in
Australia, and 1280 responses were obtained (response rate 54%). The data from a
purposive sample of 846 full-time working nurses are reported here.
Findings. Domestic responsibilities were not related to differences in fatigue and
recovery. Our results suggested that for full-time shiftworking nurses, being part of
a family structure, may actually be protective against the development of
maladaptive fatigue. The most important factor determining maladaptive fatigue
outcome was shift pattern worked, particularly rotation including night duty. The
effect of age was equivocal. The youngest age group reported the highest fatigue and
poorest recovery compared to the oldest group, who reported the best characteris-
tics. However, this latter group may represent a particularly well-adapted survivor
cohort. The relationship between age and fatigue was partly confounded by older,
experienced, nurses with greater job responsibilities, working fewer multiple shifts
including night duty. In general, increasing age was not associated with poorer
recovery or higher maladaptive fatigue.
Conclusions. Unpredictable internal shift rotations, including night duty, which are
traditional and typical in nursing, are inimical to maintaining nurses health. More
creative approaches to rostering for nurses working multiple shifts are a necessary
step towards reducing wastage from the profession due to chronic work-related
fatigue. Younger nurses in particular, may need more support than is currently
recognized if they are to be retained within the profession.

182 2006 The Authors. Journal compilation 2006 Blackwell Publishing Ltd
Nursing and healthcare management and policy
Keywords: burnout, empirical research report, family, nurses, questionnaire,
shiftwork, stress
Introduction
Despite many social changes in the 21st century, women
continue to undertake the majority of unpaid domestic work
in the home (Charles 1981, Castles 1994, Artazcoz et al.
2001). As a result of this combined paid and unpaid
workload, it is commonly assumed that partnered women
who work full-time, particularly those with dependents, have
less opportunity to recover from acute, work-related fatigue.
As a consequence, they are more likely to develop maladap-
tive chronic fatigue, particularly when they do shiftwork.
This assumption is supported by some evidence of a corre-
lation between full-time work and health problems among
married mothers (McGovern & Matter 1992, Oginska et al.
1993, Chan 1994, Gardu o Md & Marquez 1995, Mikhail &
Ragheb 1996, Edell-Gustafsson et al. 2002).
The nursing profession is staffed predominantly by women,
despite an increasing recruitment of men during the past
decade. Nursing is a work environment that is notable for its
high work demands, high work stress and high levels of
fatigue (Estryn-Behar et al. 1990, Kandolin 1993, Iskra-Golec
et al. 1996, Piko 1999, Demerouti et al. 2000, Chen &
McMurray 2001, Edell-Gustafsson et al. 2002, Zboril-
Benson 2002, Ruggiero 2003, Hughes & Rogers 2004,
Noriega et al. 2004). For example, up to 50% of Australian
nurses who leave, or are considering leaving, the profession
cite overwork, fatigue and stress as major factors in their
decision (Buchanan & Considine 2002, Zboril-Benson 2002).
The fatigue and recovery problems associated with shift-
work are well recognized and exist independent of partner-
ship or family status (Hardman et al. 1991, Spelten et al.
1993, Iskra-Golec et al. 1996, Lushington et al. 1997,
Nicholson & DAuria 1999, Ahsberg et al. 2000, Ranjarat-
nam & Arendt 2001, Jansen et al. 2003, Muecke 2005). In
addition, a particular difficulty faced by many nurses is the
occupational demand of internal rotation shiftwork (Leart-
hart 2000, Buchanan & Considine 2002). The traditional
pattern of shiftwork in nursing involves working different
shifts at different times of the day and night according to a
pattern that is frequently unpredictable. Internal rotation
shiftwork-related problems (Baker 1980, Harrington 1994,
Cruz et al. 2000) may be more difficult to resolve for
partnered nurses with dependents. This is related to the work/
home interference effect of shiftwork on their domestic
responsibilities (Cooper et al. 1989, Jansen et al. 2004, van
Hooff et al. 2005).
Recovery from work-related fatigue
In contrast, however, there is also a body of literature
suggesting that workers who are partnered have an advantage
in resolving work-related stress (including fatigue) because of
the positive value of companionship, allowing the sponta-
neous sharing of work tensions and concerns (Boey 1998,
Burnard et al. 2000, Newey & Hood 2004, Rocha & Debert-
Ribeiro 2004, Tomasson et al. 2004). In addition, it might be
expected that partnered nurses are more likely to benefit from
the anxiolytic effects of physical contact, including intimacy.
Such contacts release neuro-hormones such as oxytocin,
dopamine and serotonin into the central nervous system
(Wikstrom et al. 2003, Motzer & Hertig 2004, Debiec 2005,
Esch & Stefano 2005), offsetting the effects of stress
hormones such as cortisol, adrenaline and noradrenaline
which may be stimulated during a work shift.
There are good theoretical reasons for the notion that the
transition from acute fatigue states to chronic fatigue traits is
associated with persistent failure to recover adequately
during the non-work time between shifts (McEwen & Stellar
1993, McEwen 1998, McEwen & Seeman 1999, Winwood
et al. 2005). Full-time working nurses with dependents might
be expected to spend a variable period of their time after
work, normally associated with recovery, engaged in further
domestic work activity. As a consequence, they may be less
likely to achieve the same level of stress/fatigue recovery
compared with unpartnered nurses without dependents, who
are not subject to these additional domestic demands.
Persistent failure to recover from acute end-of-shift fatigue
can be expected to be associated with the evolution of
maladaptive chronic fatigue traits (Winwood et al. 2006a,b).
Hence, if partner and dependent status are important risk
factors for chronic fatigue evolution, partnered nurses with
dependents would be expected to manifest lower levels of
recovery than unpartnered peers without dependents and
higher levels of chronic maladaptive fatigue.
The evidence for age being a correlate of fatigue is mixed
(David et al. 1990, Wessely 2001, Schnorpfeil et al. 2002,
Akerstedt et al. 2004, Huibers et al. 2004) and subject to a
number of confounding variables, for example financial
security, general health status and support from previously
dependent offspring. However, if among full-time working
nurses acute work-related fatigue is correlated with age, and
if higher levels of acute work-related fatigue are associated
with reduced intershift fatigue recovery, then older nurses
might be expected to report greater levels of maladaptive
fatigue (Niedhammer et al. 1995).
 With regard to the definition of dependents and partner,
these descriptors are commonly associated with healthy
children under the age of 16 and healthy functioning
partners. However, some working women care for aged
and/or frail parents, whose care demands may be very high.
Also, some working mothers care for dependent children who
have chronic disabilities and limitations of varying kinds that
are particularly demanding. Similarly, some womens part-
ners may have chronic health and/or dependency problems
resulting in higher than normal care demands.
The study
Aim
The aim of the study was to identify the relationship between
age, domestic responsibilities (being partnered and having
dependents), recovery from shiftwork-related fatigue and the
evolution of maladaptive health outcomes among full-time
working female nurses.
We hypothesized that:
Among full-time working nurses older, partnered nurses
with dependents would report lower levels of recovery
between shifts and higher fatigue compared with younger
nurses without dependents.
Regularly working a rotation of different shifts, partic-
ularly including night duty, would be associated with
lower recovery and higher maladaptive fatigue (independ-
ently of age and domestic responsibilities) compared with
regularly working a single predictable day shift.
Design
The data reported here form part of a questionnaire study
with a sample of Australian nurses.
We made no attempt to differentiate between average and
special needs categories of dependents or partner (which
might be the task of a more specialized study) as we were
more concerned to explore the broad concept of the effects of
domestic responsibility and shiftwork on fatigue and
recovery.
Participants
In the main study, 1280 nurses from 2400 surveyed at two
South Australian hospitals provided their demographic
details and fully completed several self-report questionnaires
on their fatigue and recovery during the same period. The
overall gross response rate was 54%; however, this figure
may be unrepresentatively low. The pay offices of the
respective hospitals report that, in any given pay period,
1015% of nurses are absent due to sickness or some other
form of leave, so that a proportion of these may not have
received the questionnaire.
From these respondents, 846 female nurses working full-
time were selected, part-time workers and men being exclu-
ded by definition. Mean (standard deviation) participant age
was 396 (106) years, 439(51%) were partnered and 284
(336%) had dependents. The overwhelming majority (812,
96%) worked 8-hour shifts. A rotating pattern of shifts was
regularly worked by 635 (741%) participants, of whom 521
(82%) reported that their shift rotations were irregular and
unpredictable. Mean (SD ) length of experience as a nurse was
103 (85) years, age and length of experience being highly
correlated. Among the participants 198 (234%) were
enrolled nurses (EN) [mean (SD ) age 427 (93) years],
485 (573%) were Registered Nurses (RN) [371 (110)
years], 142 (168%) were clinical nurses/clinical nurse con-
sultants (CN/CNCs) [406(100) years] and 21 (25%) were
clinical nurse managers/nurse managers (CNM/NMs) [466
(88) years].
Examination of the full sample demographics indicated
that the distributions of mean age, length of experience,
gender, full-time/part-time working and job category were
broadly consistent with the wider population of nurses
working in Australia as reported in national statistics (AIHW
2003, 2005).
Power analysis
G-power calculations (Erdfelder et al. 1996) indicated that
the sample size (n 846) ensured statistical power of 095 to
detect a medium effect size (015) with significance of
P 005 in the analyses undertaken, i.e. the size of the
sample was such that there was only a 5% probability than
any medium size effect, which was found to be statistically
significant (P 005), had occurred by chance.
Questionnaire
In addition to providing demographic details, participants
completed the Occupational Fatigue Exhaustion Recovery
scale (OFER). This new instrument was particularly appro-
priate for measuring fatigue and recovery among participants
in the study. Its 15 items form three subscales: chronic fatigue
(OFER-CF), acute fatigue (OFER-AF) and recovery between
shifts (OFER-IR). The OFER-IR subscale is unique among
reported fatigue measurement scales (Winwood et al. 2005,
Winwood et al. 2006a,b). The OFER-IR subscale includes
items such as Recovering from work fatigue between shifts
isnt a problem for me, I often feel tired from one work shift
by the time I have to start the next shift, I rarely have
enough time to recover my energy between shifts. Likert
response scales between 0 and 6 (Strongly Disagree to
Strongly Agree) are used for all items.
The OFER scale has been reported to possess robust
psychometric characteristics of construct and convergent
validity, with internal reliability of the subscales (Cronbachs
alpha coefficient) ranging from 080 to 085. It has been
validated as a gender bias-free measure of fatigue/recovery
among several populations, including nurses.
Ethical considerations
Approval for the study was granted by the ethics committees
of the University of South Australia (P243-02) and of the
respective hospitals gave approval for the study. Each of
2400 nurses at the two hospitals were invited to take part in
the study via a pack attached to their pay slips in January
2004. Anonymity was assured and return of completed
questionnaires facilitated by including a reply-paid envelope.
Because the survey was anonymous as a condition of ethics
approval being granted, non-response analysis was preclu-
ded.
Data analysis
All statistical analyses were undertaken using SPSS v. 12
software (SPSS Inc., Chicago, IL, USA).
Histograms (with normal curve overlay) of the three OFER
subscales data, age in years and length of experience were
generated and checked for normality of distribution. The
presence of confounding outliers was checked using the
Explore function of Descriptive Statistics within the software.
Both tests indicated that the data were suitable for the
analyses undertaken without modification.
Pearsons r bivariate correlations (two tailed) between
Age, Length of Service, Fatigue and Recovery were calcu-
lated. Construct validity of the composite variable Shift
Table 1 Correlations between age, length of experience and OFER subscales
Age in years Length of experience
Age in years 100
Length of experience 072** 100
OFER-CF 009** 004
OFER-IR 022** 020**
OFER-AF 005 013**
OFER, Occupational Fatigue Exhaustion Recovery; -CF, Chronic Fatigue; -AF, Acute Fatigue; -IR, Intershift Recovery.
**P <001.
Pattern was checked using separate one-way AN O VA ana-
lyses of Chronic Fatigue and Recovery mean scores accord-
ing to Shift Pattern, with Bonferroni post hoc comparisons.
Variations in OFER-CF and OFER-IR scores according to
age were investigated using General Linear Model Multiva-
riate Analysis (M A N OV A ) in which Age was entered as
a fixed factor and OFER-CF and OFER-IR scores as
depend- ent variables. Wilks lambda statistic was used
as the criterion for F-test significance. Relationships
between Age, Job Category and Shift Pattern were
investigated by one- way AN OV A , with Bonferroni post hoc
comparison, and chi- square analysis. Main effects of
Partner and Dependent Status and Shift Pattern on Fatigue
and Recovery were investigated using M AN O VA analysis in
which OFER-CF and OFER-IR scores were entered as
dependent variables, Partner, Dependent Status and Shift
Pattern were fixed factors, and Age was entered as a
covariant to partial out the effect of age.
Results
Correlations between age and length of service; chronic
and acute fatigue and recovery scores
Pearsons r correlations between scores on the instrument
subscales and other continuous variables are reported in
Table 1. The strength and direction of some these correla-
tions are noteworthy.
The strongly negative and statistically significant correla-
tion between recovery (OFER-IR), with both acute and
chronic fatigue scores was expected as recovery and fatigue
can be considered as reciprocal.
The correlation between age and length of experience was
strong and statistically significant (071), as expected, indi-
cating that older nurses had longer experience. However, the
statistically significant positive correlation of age with
OFER-IR (recovery) suggests a tendency towards better
recovery with greater age, which was the reverse of what
had been hypothesized.
OFER-CF OFER-IR OFER-AF
100
053** 100
053** 047** 100
Dummy coded and other variables created for analyses
Married participants, including those in stable co-habiting
relationships, were classified as partnered; all others,
including single, widowed and divorced/separated partici-
pants, were classified as unpartnered to produce the
dichotomous variable Partner Status. Similarly, those report-
ing having dependents (including aged dependents) were
categorized as Dependents; all others were categorized as
NO Dependents to produce the dichotomous variable
Dependent Status. To facilitate A NO VA post hoc compari-
sons, the continuous variable Age in Years was transformed
into Age Group, with five levels: 1824, 2534, 3544, 45
54 and 55 years.
The literature indicates that regular shiftworkers who work
at night face particular difficulties with sleeping, which is an
important source of psycho-physiological work-related
strain. This is particularly high if night work is for short
periods only, i.e. only one or two contiguous shifts, and/or in
an irregular and unpredictable pattern interspersed with day
work (Gold et al. 1992, Cruz et al. 2000, Learthart 2000,
Akerstedt et al. 2002).
Participants provided details of the shift pattern they
worked regularly, for example, early/day shift only, night
duty only, early and late shift only, early and night duty only,
and all three shifts. To determine the significance of variations
in shift pattern worked, a four-level ordinal variable Shift
Pattern was created. This was a composite of single/multiple
shift and night duty/no night duty shift patterns. Participants
were grouped according to a theoretically increasing (stress)
demand of shift pattern regularly worked. Level 1 included all
participants regularly working a single shift during the day
only (lowest stress). Level 2 included those regularly working
a single shift including night duty, i.e. permanent night duty
(higher stress than day duty only, but less than unpredictable
shift rotation). Level 3 comprised nurses regularly working a
rotation of different shifts, but not including night duty
(higher stress than working fixed shifts, but lower than
rotating shifts including night duty). Finally, level 4 included
those regularly working a rotation of all shifts, including night
duty (the highest level of shift work stress).
To test the construct validity of the variable, Shift Pattern,
a one-way AN OVA analysis of OFER-CF (fatigue) scores
according to Shift Pattern was undertaken. This analysis was
significant: [F (3,841) 721, P <0001]. The means plot
of this analysis is shown in Figure 1. A similar analysis of
Recovery indicated an equally significant linear variation in
recovery according to Shift Pattern. Taken together, these
results confirmed the theoretical association between shift
pattern and increased work strain outcomes in the Shift
5400
OFER - chronic fatigue mean score
5200
5000
4800
4600
Single no Single with Multiple no Multiple with
nights nights nights nights
Shift pattern worked
Figure 1 Chronic fatigue mean score according to shift pattern
worked.
Pattern variable structure, and justified its further use in
analysis.
Multivariate analyses
We sought to identify differences between fatigue and
recovery according to age. The dependent variables of OFER
chronic and acute fatigue and recovery were entered as
dependent variables in a General Linear Model Multivariate
analysis with Age Group as a fixed factor to generate
Bonferroni post hoc comparisons according to age level,
which are reported in Table 2. This analysis indicated
significant differences in all of the dependent variables
according to Age Group [Wilks k 0951; F (12,
2196) 499, P <0001]. The OFER-CF (chronic fatigue)
scores of the >55 group were significantly lower than
for all other groups except the 3544 years group
[F (4,832) 379, P 0005]. Similarly, the OFER-AF
(acute fatigue) scores of the >55 group were significantly
lower than for all other age groups except the 3544 year
group [F (4,832) 375, P 0005]. Lastly, the >55 group
OFER-IR (recovery) scores were significantly higher than all
other groups [F (4,832) 1314, P <0001].
Taken together, these observations suggest that increasing
age was associated with decreased chronic fatigue and
increased recovery outcomes. This was the opposite of what
had been predicted. Accordingly, the possibility of confound-
ing interactions between age and other factors were investi-
gated.
Table 2 Analysis of fatigue/recovery scores according to age

Age group

Mean (SD ) Mean (S D ) Mean (S D ) Mean (SD ) Mean (SD ) Bonferroni

Dependent a 1824 years b 2534 years c 3544 years d 4554 years e 55 years post hoc
variable (n 84) (n 211) (n 224) (n 262) (n 56) F test comparisons

OFER-CF 573 (203) 522 (228) 512 (243) 527 (247) 417 (253) 379** (a b d)>c(*>e)
OFER-IR 265 (172) 333 (227) 388 (233) 388 (231 525 (250) 1314*** (a b c d)*<e
OFER-AF 619 (192) 594 (196) 577 (212) 604 (206) 499 (223) 373** (a b d)>c(*>e)

OFER, Occupational Fatigue Exhaustion Recovery; -CF, Chronic Fatigue; -AF, Acute Fatigue; -IR, Intershift Recovery; n, number of cases in
subgroup; S D , standard deviation; Bonferroni post hoc comparisons: , no significant difference; >, higher; <, lower; *>, significantly
higher; *<, significantly lower.

Relationships between age, job category and shift pattern Table 3 Distribution of shifts worked by job category and age level

A one-way A NO VA with Age as a dependent variable Shift pattern

according to Shift Pattern was undertaken, with Bonferroni Single Single Multiple Multiple
post hoc analysis. This result was statistically significant NO WITH NO WITH
[F (3, 833) 2817, P <0001], indicating that older nights, nights, nights, nights,
Job category Age level count count count count
participants tended to work fewer high-stress shift patterns.
The relationship between Job Category and Shift Pattern was EN 1824 0 0 1 7
also investigated by chi-square analysis, which was also 2534 0 4 2 22
2 3544 9 5 8 46
statistically significant [v 18975, d.f. 3, P <0001].
4554 12 7 12 45
This indicates that more nurses with greater work responsi-
>55 4 3 2 8
bilities tended to work fewer of the high-stress shift patterns RN, RGN 1824 0 1 4 69
(see Table 3). 2534 12 3 12 103
These observations are best explained by the common 3544 23 6 14 75
practice of senior (older and more experienced) nurses with 4554 17 11 16 88
>55 9 4 1 10
greater job responsibility, acquiring progressively more lati-
CN, CNC 1824 1 0 0 1
tude over the shifts they work, and for more administrative 2534 22 0 2 25
work functions to be undertaken during the day rather than 3544 17 2 5 11
at night. However, both factors clearly confound the simple 4554 31 0 7 4
association between age and nursing work-strain, as senior >55 11 0 0 1
job category nurses also tended to be older. CNM/NM 1824 0 0 0 0
2534 1 0 1 2
3544 1 0 0 1
Effects of partner and dependent status 4554 11 0 0 1
>55 3 0 0 0
We examined the simultaneous effect of partnership, depend-
Count, number of participants in cell; EN, enrolled nurse; RN/RGN,
ent status and shift pattern on fatigue and recovery using
Registered Nurse/Registered General Nurse; CN/CNC, clinical nurse/
General Linear Model M A NO V A analysis. In view of clinical nurse consultant; CNM/NM, clinical nurse manager/nurse
the relationship between age and shift pattern that had manager.
been determined, Age was entered into the equation as a
covariate to partial out its effect. The means (SD s) of maladaptive chronic fatigue levels to be higher where the
subgroup scores for fatigue and recovery according to work pattern is one of multiple rather than single shifts
Partnership and Dependents status and Shift Pattern are (particularly when night duty is part of the rotation), i.e.
shown in Table 4 and a summary of both multivariate and higher stress shift patterns. An explanation for this is
univariate analyses of variance in Table 5. suggested when recovery scores are examined. Here, the
Several patterns of relationship between the factors are consistent pattern is of reduced levels of recovery between
clear. For example, the effect of shift pattern regularly shifts when the work pattern is a rotation of shifts rather than
worked is evident. A consistent trend is indicated for single shift, and worst when night duty is included.
Table 4 Analysis of fatigue and recovery scores according to partner and dependent status and shift pattern

Independent variable

Dependent variable Partner status Dependents status Shift pattern Mean SD n

OFER-CF Not partnered NO dependents Single NO nights 4830 2387 45

Single WITH nights 5396 2814 14
Multiple NO nights 5378 1908 28
Multiple WITH nights 5626 2300 187
Dependents Single NO nights 4402 2109 17
Single WITH nights 4417 2866 5
Multiple NO nights 6646 2402 6
Multiple WITH nights 5732 2351 41
Partnered NO dependents Single NO nights 4289 2652 68
Single WITH nights 3578 2681 8
Multiple NO nights 5519 2200 27
Multiple WITH nights 5432 2391 175
Dependents Single NO nights 4517 2348 53
Single WITH nights 5285 1923 19
Multiple NO nights 4413 2331 25
Multiple WITH nights 5050 2420 114
OFER-AF Not partnered NO dependents Single NO nights 4961 1852 45
Single WITH nights 5714 2519 14
Multiple NO nights 6015 1830 28
Multiple WITH nights 5911 2051 187
Dependents Single NO nights 5583 2614 17
Single WITH nights 6667 2684 5
Multiple NO nights 8097 1207 6
Multiple WITH nights 6465 1844 41
Partnered NO dependents Single NO nights 5097 2267 68
Single WITH nights 5385 3297 8
Multiple NO nights 6225 1542 27
Multiple WITH nights 6052 1999 175
Dependents Single NO nights 5561 2020 53
Single WITH nights 6566 1932 19
Multiple NO nights 5607 1799 25
Multiple WITH nights 6120 2065 114
OFER-IR Not partnered NO dependents Single NO nights 5563 2276 45
Single WITH nights 5063 2686 14
Multiple NO nights 4044 2476 28
Multiple WITH nights 3163 2079 187
Dependents Single NO nights 4863 1912 17
Single WITH nights 5000 2913 5
Multiple NO nights 4296 1847 6
Multiple WITH nights 2740 1819 41
Partnered NO dependents Single NO nights 5508 2367 68
Single WITH nights 5083 2579 8
Multiple NO nights 3288 1920 27
Multiple WITH nights 2936 1948 175
Dependents Single NO nights 5101 2154 53
Single WITH nights 3743 1944 19
Multiple NO nights 4347 2230 25
Multiple WITH nights 3153 2278 114

OFER, Occupational Fatigue Exhaustion Recovery; -CF, Chronic Fatigue; -AF, Acute Fatigue; -IR, Intershift Recovery; n, number in subgroup;
S D , standard deviation.
Table 5 Relationship between partnership, dependents and shift maladaptive fatigue among nurses with additional domestic
pattern effects on fatigue, recovery and quality of life measure
responsibilities that we had expected.
A NOVA

M AN O VA OFER-CF OFER-AF OFER-IR Discussion

Variable F (3, 813) F (1,815) F (1,815) F (1,815)

Partnership (P) 313* 378* 215 ns 006 ns Study limitat ions

Dependents (D) 331* 006 ns 781* 076 ns
The results ar e subject to the limitations of all correlational,
Shift Pattern (S) 2479*** 54** 65*** 341***
self-report study designs, and thus causality cannot be
9IU inferred from them.
The overall effective response rate (estimated at approxi-
Consistently low recovery between shifts mediates the evo-
mately 60%) compares with a figure of 50% regarded by
lution of chronic fatigue symptoms (Winwood et al. 2005,
several authorities as adequate for survey studies (Barbie
Winwood et al. 2006a,b).
1990). In addition, the high study number, derived from two
Among participants working permanent night duty, the
separate institutions, ensured strong statistical power (095)
mean scores for chronic fatigue and recovery were consis-
for the analyses undertaken. Finally, demographic distribu-
tently poorer than for those working a single shift during the
tions within the overall sample were very similar to Austra-
day. This suggests that, although individual nurses tend to
lian national figures. Therefore, we are confident that the
adapt to permanent night work, it is at a stress cost which
trends identified are statistically valid. We acknowledge,
may be difficult to sustain in the long term (Edell-Gustafsson
however, that no attempt was made to distinguish the effects
2002, Muecke 2005).
that special needs categories of dependent and partner may
A more surprising pattern is that according to partner and
have in individual cases. This might be the subject of a more
dependent status. We had expected partnered nurses with
specialized study.
dependents to report higher fatigue and lower recovery than
unpartnered nurses without dependents. However, this pat-
tern was not evident. Table 4 indicates a pattern of lower Significance of results
maladaptive fatigue associated with better recovery among
Taken together, our results failed to demonstrate that full-
partnered nurses with dependents. Within this subgroup,
time working nurses with domestic and dependent responsi-
working multiple shifts without night work, fatigue mean
bilities are more at risk of low recovery from acute work
scores were significantly lower than reported by unpartnered
fatigue between shifts, and consequently developing mal-
nurses without dependents working the same shift [OFER-CF
adaptive fatigue symptomology, compared with unpartnered
score difference 95: t (25) 212, P 004.].
nurses without dependents. In contrast, our results suggest
Another surprising observation was that the fatigue and
that being part of a family has potential benefits in moder-
recovery mean scores of partnered nurses without dependents
ating work strain in nursing. Overall, the value of being part
were not notably better than those of partnered nurses with
of a family in buffering the evolution of work strain into
dependents; in fact they tend to be worse. This suggests that
maladaptive chronic fatigue would appear to outweigh its
having dependents is not a significant determinant of chronic
(undoubted) additional demands.
fatigue score when a nurse is partnered. By comparison, the
The observation that partnered/with dependents nurses
mean fatigue and recovery scores of unpartnered nurses who
also reported better recovery between shifts suggests a
have dependents tended to be the worst of any of the
possible mechanism behind such a process. Family (including
subgroups. This may reflect the many difficulties faced by
its many responsibilities) could be argued to constitute a
women who support families unaided, regardless of their job
prime purpose in working to live. The daily observation of
type (Chandola et al. 2004).
this purpose being enacted within a family setting may
Overall, the differences in maladaptive fatigue and inter-
provide essential meaning and personal fulfilment within a
shift recovery between subgroups were small, few being
positive psychology perspective (Csikszentmihalyi & LeFevre
statistically significant. However, importantly, we found no
1989, Csikszentmihalyi 2000), which is less readily available
evidence of the pattern of reduced recovery and more
to nurses without partners or dependents.
Such an explanation would fit well within the job demands/
resources (JD/R) model of work strain proposed by Demer-
outi et al. (2001). The value of family could be argued to

What is already known about this topic
Despite many changes in gender roles within marriage
in the 20th century, women continue to do most of the
domestic work in the home, including childcare, whe-
ther or not they work.
There are reports that full-time working mothers suffer
greater health problems than mothers who do not work.
Shiftwork places special burdens on workers, partic-
ularly when it involves working at night, and in short-
term and/or unpredictable rotations.
What this paper adds
Among full-time working nurses, being partnered,
having dependents or being in an older age group are
not associated with reduced recovery from work strain
between shifts and consequent greater maladaptive
stress/fatigue outcomes.
Shift pattern worked, particularly rotations including
night duty, is the most important cause of long-term
stress/fatigue among nurses, particularly younger, less
experienced nurses.
Being partnered and having children may be protective
against the maladaptive effects of nursing work strain.
constitute an important part of the personal resources
through which individual nurses may restore vital motivation
and enjoy emotional support outside the work environment
which is sustaining within their work environment.
Our findings are contrary to those of other studies of family
strain, domestic pressures, work fatigue and health outcomes
(Wedderburn & Robson 1990, Sprusinska-E 1992, Romito
et al. 1994, Wohl et al. 1995). However, it is notable that these
latter reports fail to make a clear distinction between acute
end-of-shift work-related fatigue and maladaptive chronic
work-related fatigue. In addition, they include the effects of
other sociocultural variables such as difficulties with accom-
modation and spousal dependency (Sprusinska-E 1992).
However, our observations are consistent with reports of
no connection between family responsibilities and burnout
symptoms among nurses (Kandolin 1993) and that social
support (including family) is an important factor in the
management of work strain by nurses (Boey 1998, Petterson
1998, Burnard et al. 2000, Tully 2004). In addition, our
results are consistent with those of Waldron et al. (1998),
who found that working and married mothers experienced
better physical health than unemployed women and working
single people without children (Waldron et al. 1998).
We had expected that age would be correlated with
increased fatigue and poorer recovery between shifts. Instead,
we found that the oldest age group in the study sample
(55 years) reported the least chronic fatigue and acute
fatigue and best recovery. However, these findings are
confounded by a correlation between age and shift pattern
worked. Across the entire sample, the proportion of more
demanding shift patterns regularly worked decreased pro-
gressively with age (length of experience) and job responsi-
bility. The better recovery and lower fatigue among the oldest
age group may also be explained by them forming a survivor
cohort which is particularly well adapted to the nursing
profession, and in addition manifesting healthy worker
attributes (Sterling & Weinkam 1985, Portela et al. 2004).
By comparison, those in the youngest age group (18
24 years) reported the highest chronic fatigue and acute
fatigue scores and the lowest recovery. The poor results of
this group are consistent with reports that nurses face
significant challenges in the first years after graduation in
adapting to the work demands of nursing whilst overcoming
inexperience and developing practical nursing and life skills,
including time management (McNeese-Smith & van Servellen
2000, McNeese-Smith 2000). In addition, they must begin to
adapt to work with rotating shift patterns (including night
duty) which, in this sample, they work in the highest
proportion compared with all other age groups. All our
analyses confirmed that working multiple shifts which
include night work was associated with higher acute work-
related fatigue, poorer intershift recovery and higher mala-
daptive chronic fatigue. These observations are consistent
with many other reports of the relationship between shift-
work and work strain (Tasto et al. 1978, Baker 1980,
Kandolin 1993, Harrington 1994, Cruz et al. 2000, Akerstedt
et al. 2002, Folkard & Tucker 2003).
Conclusions
There are consistent reports of severe and chronic nursing
shortages in many English-speaking countries (Davidhizar
2004, Gelinas & Loh 2004, Stubbings & Scott 2004, Oxtoby
2005, Ross et al. 2005, Sheward et al. 2005).
Our results suggest that an unpredictable internal rotation
of shifts (including night work) is inimical to the long-term
health of nurses. We would argue that of all the factors which
contribute to the high stress of healthcare work, the tradi-
tional pattern of shiftwork practiced in nursing is the one
which breaks the camels back. More creative approaches to
rostering seem to be needed. Such rosters need to take into
account the well-documented effects of irregular and
unpredictable circadian rhythm disturbance. In general,
nurses tend to be a highly dedicated workforce. However,
such dedication cannot be expected to offset the limits of
human psycho-physiology indefinitely.
The particular difficulties experienced by younger nurses
suggest that they may require greater support during their
early years than is commonly recognized. Although possibly
difficult to implement, such support, associated with roster-
ing practice improvements, might have a long-term value
which far outweighs these difficulties.
For the majority of full-time working nurses, it is evident
that the effects of shiftwork, in addition to other nursing
stressors, far outweigh any of the stresses attributable to their
family commitments. Indeed, the supportive benefits of their
domestic circumstances may be the crucial factor that enables
many nurses to maintain their nursing careers.
Author contributions
PCW was responsible for the study conception and design
and drafting of the manuscript; performed the data collection
and data analysis and made critical revisions to the paper. KL
obtained funding and provided administrative support and
provided statistical expertise. AHW supervised the study.
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