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. 2023 Sep 11;9(9):CD010639.
doi: 10.1002/14651858.CD010639.pub2.

Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers

Gerben Hulsegge  1 , Pieter Coenen  2 , Gregg M Gascon  3   4 , Manisha Pahwa  5   6 , Birgit Greiner  7 , Ciarán Bohane  8 , Imelda S Wong  9 , Juha Liira  10 , Rachel Riera  11   12   13 , Daniela V Pachito  14
Affiliations

Adapting shift work schedules for sleep quality, sleep duration, and sleepiness in shift workers

Gerben Hulsegge et al. Cochrane Database Syst Rev. .

Abstract

Background: Shift work is associated with insufficient sleep, which can compromise worker alertness with ultimate effects on occupational health and safety. Adapting shift work schedules may reduce adverse occupational outcomes.

Objectives: To assess the effects of shift schedule adaptation on sleep quality, sleep duration, and sleepiness among shift workers.

Search methods: We searched CENTRAL, PubMed, Embase, and eight other databases on 13 December 2020, and again on 20 April 2022, applying no language restrictions.

Selection criteria: We included randomised controlled trials (RCTs) and non-RCTs, including controlled before-after (CBA) trials, interrupted time series, and cross-over trials. Eligible trials evaluated any of the following shift schedule components. • Permanency of shifts • Regularity of shift changes • Direction of shift rotation • Speed of rotation • Shift duration • Timing of start of shifts • Distribution of shift schedule • Time off between shifts • Split shifts • Protected sleep • Worker participation We included studies that assessed sleep quality off-shift, sleep duration off-shift, or sleepiness during shifts.

Data collection and analysis: Two review authors independently screened the titles and abstracts of the records recovered by the search, read through the full-text articles of potentially eligible studies, and extracted data. We assessed the risk of bias of included studies using the Cochrane risk of bias tool, with specific additional domains for non-randomised and cluster-randomised studies. For all stages, we resolved any disagreements by consulting a third review author. We presented the results by study design and combined clinically homogeneous studies in meta-analyses using random-effects models. We assessed the certainty of the evidence with GRADE.

Main results: We included 11 studies with a total of 2125 participants. One study was conducted in a laboratory setting and was not considered for drawing conclusions on intervention effects. The included studies investigated different and often multiple changes to shift schedule, and were heterogeneous with respect to outcome measurement. Forward versus backward rotation Three CBA trials (561 participants) investigated the effects of forward rotation versus backward rotation. Only one CBA trial provided sufficient data for the quantitative analysis; it provided very low-certainty evidence that forward rotation compared with backward rotation did not affect sleep quality measured with the Basic Nordic Sleep Questionnaire (BNSQ; mean difference (MD) -0.20 points, 95% confidence interval (CI) -2.28 to 1.89; 62 participants) or sleep duration off-shift (MD -0.21 hours, 95% CI -3.29 to 2.88; 62 participants). However, there was also very low-certainty evidence that forward rotation reduced sleepiness during shifts measured with the BNSQ (MD -1.24 points, 95% CI -2.24 to -0.24; 62 participants). Faster versus slower rotation Two CBA trials and one non-randomised cross-over trial (341 participants) evaluated faster versus slower shift rotation. We were able to meta-analyse data from two studies. There was low-certainty evidence of no difference in sleep quality off-shift (standardised mean difference (SMD) -0.01, 95% CI -0.26 to 0.23) and very low-certainty evidence that faster shift rotation reduced sleep duration off-shift (SMD -0.26, 95% CI -0.51 to -0.01; 2 studies, 282 participants). The SMD for sleep duration translated to an MD of 0.38 hours' less sleep per day (95% CI -0.74 to -0.01). One study provided very low-certainty evidence that faster rotations decreased sleepiness during shifts measured with the BNSQ (MD -1.24 points, 95% CI -2.24 to -0.24; 62 participants). Limited shift duration (16 hours) versus unlimited shift duration Two RCTs (760 participants) evaluated 80-hour workweeks with maximum daily shift duration of 16 hours versus workweeks without any daily shift duration limits. There was low-certainty evidence that the 16-hour limit increased sleep duration off-shift (SMD 0.50, 95% CI 0.21 to 0.78; which translated to an MD of 0.73 hours' more sleep per day, 95% CI 0.30 to 1.13; 2 RCTs, 760 participants) and moderate-certainty evidence that the 16-hour limit reduced sleepiness during shifts, measured with the Karolinska Sleepiness Scale (SMD -0.29, 95% CI -0.44 to -0.14; which translated to an MD of 0.37 fewer points, 95% CI -0.55 to -0.17; 2 RCTs, 716 participants). Shorter versus longer shifts One RCT, one CBA trial, and one non-randomised cross-over trial (692 participants) evaluated shorter shift duration (eight to 10 hours) versus longer shift duration (two to three hours longer). There was very low-certainty evidence of no difference in sleep quality (SMD -0.23, 95% CI -0.61 to 0.15; which translated to an MD of 0.13 points lower on a scale of 1 to 5; 2 studies, 111 participants) or sleep duration off-shift (SMD 0.18, 95% CI -0.17 to 0.54; which translated to an MD of 0.26 hours' less sleep per day; 2 studies, 121 participants). The RCT and the non-randomised cross-over study found that shorter shifts reduced sleepiness during shifts, while the CBA study found no effect on sleepiness. More compressed versus more spread out shift schedules One RCT and one CBA trial (346 participants) evaluated more compressed versus more spread out shift schedules. The CBA trial provided very low-certainty evidence of no difference between the groups in sleep quality off-shift (MD 0.31 points, 95% CI -0.53 to 1.15) and sleep duration off-shift (MD 0.52 hours, 95% CI -0.52 to 1.56).

Authors' conclusions: Forward and faster rotation may reduce sleepiness during shifts, and may make no difference to sleep quality, but the evidence is very uncertain. Very low-certainty evidence indicated that sleep duration off-shift decreases with faster rotation. Low-certainty evidence indicated that on-duty workweeks with shift duration limited to 16 hours increases sleep duration, with moderate-certainty evidence for minimal reductions in sleepiness. Changes in shift duration and compression of workweeks had no effect on sleep or sleepiness, but the evidence was of very low-certainty. No evidence is available for other shift schedule changes. There is a need for more high-quality studies (preferably RCTs) for all shift schedule interventions to draw conclusions on the effects of shift schedule adaptations on sleep and sleepiness in shift workers.

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Conflict of interest statement

GH: none known PC: none known GG: none known MP: none known BG: none known CB: is an occupational health physician at Medmark; otherwise no known conflicts of interest IW: none known JL: none known RR: none known DP: none known

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies. Empty spaces represent domains not applicable for at least one study. We did not assess laboratory studies; risk of bias is considered high in such studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study. Empty boxes represent domains not relevant to the study design or outcomes not assessed or reported. We did not assess laboratory studies; risk of bias of laboratory studies is considered high by design.
1.1
1.1. Analysis
Comparison 1: Direction of rotation of shifts: forward versus backward rotation (non‐randomised studies), Outcome 1: Sleep quality off‐shift
1.2
1.2. Analysis
Comparison 1: Direction of rotation of shifts: forward versus backward rotation (non‐randomised studies), Outcome 2: Sleep length off‐shift
1.3
1.3. Analysis
Comparison 1: Direction of rotation of shifts: forward versus backward rotation (non‐randomised studies), Outcome 3: Sleepiness during shift
2.1
2.1. Analysis
Comparison 2: Speed of rotation: faster shift rotation (1 to 2 shifts in a row) versus slower shift rotation (3 to 7 shifts in a row) (non‐randomised studies), Outcome 1: Sleep quality off‐shift
2.2
2.2. Analysis
Comparison 2: Speed of rotation: faster shift rotation (1 to 2 shifts in a row) versus slower shift rotation (3 to 7 shifts in a row) (non‐randomised studies), Outcome 2: Sleep length off‐shift
2.3
2.3. Analysis
Comparison 2: Speed of rotation: faster shift rotation (1 to 2 shifts in a row) versus slower shift rotation (3 to 7 shifts in a row) (non‐randomised studies), Outcome 3: Sleepiness during shift
3.1
3.1. Analysis
Comparison 3: Shift duration: no more than 16 hours versus 24‐ to 28‐hours (randomised studies), Outcome 1: Sleep duration off‐shift
3.2
3.2. Analysis
Comparison 3: Shift duration: no more than 16 hours versus 24‐ to 28‐hours (randomised studies), Outcome 2: Sleepiness during shift
3.3
3.3. Analysis
Comparison 3: Shift duration: no more than 16 hours versus 24‐ to 28‐hours (randomised studies), Outcome 3: Work hours
4.1
4.1. Analysis
Comparison 4: Shorter shifts (8 or 10 hours) versus shifts lasting 2 to 3 hours longer, Outcome 1: Sleep quality off‐shift
4.2
4.2. Analysis
Comparison 4: Shorter shifts (8 or 10 hours) versus shifts lasting 2 to 3 hours longer, Outcome 2: Sleep length off‐shift
4.3
4.3. Analysis
Comparison 4: Shorter shifts (8 or 10 hours) versus shifts lasting 2 to 3 hours longer, Outcome 3: Sleepiness during shift
4.4
4.4. Analysis
Comparison 4: Shorter shifts (8 or 10 hours) versus shifts lasting 2 to 3 hours longer, Outcome 4: Overtime
5.1
5.1. Analysis
Comparison 5: Distribution of shift schedule: more compressed versus more spread out (non‐randomised studies), Outcome 1: Sleep quality off‐shift
5.2
5.2. Analysis
Comparison 5: Distribution of shift schedule: more compressed versus more spread out (non‐randomised studies), Outcome 2: Sleep length off‐shift
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Update of

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References to studies awaiting assessment

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