An –Najah National University Faculty of Graduate Studies Effect of Shift Work Paradigms on Job Performance of Nurses in the Palestinian Health Sector By Majd Adel Abu Amshah Supervisor Dr. Yahya Saleh This thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of Master in Engineering Management, Faculty of Graduate Studies, An-Najah National University, Nablus –Palestine. 2014 iii Acknowledgement Special and sincere respect, gratitude and appreciation are expressed to my supervisor Dr. Yahya Saleh for his valuable supervision, great efforts in guidance, and encouragement throughout the research work. Appreciation and thanks are also extended to committee members, Dr. Mohammad Othman and Dr. Raja’ Jarrar for their time and effort in reviewing this work. My completion of this project could not have been accomplished without the support of my parents my sister and my family, the countless times you supported me will not be forgotten. To my caring, loving, and supportive husband, Mohammad: my deepest gratitude, your encouragement when the times got rough are much appreciated and duly noted. Finally, I would like to dedicate this work to my lovely son "Ghaith". Thank you all, iv اإلقرار Effects of Shift work Paradigms on Job Performance of Nurses in the Palestinian Health Sector Declaration The work provided in this thesis, unless otherwise referenced, is the researcher’s own work, and has not been submitted elsewhere for any other degree or qualification. Student Name: اسم الطالب: Signature: التوقيع: Date: التاريخ: v List of Contents No. Subject Page Acknowledgment iii Declaration Iv List of Tables Vi List of Figures X 1 Chapter One Introduction 1 1.1 General Background 1 1.2 Problem Definition 4 1.2.1 Overview 4 1.2.2 Research Questions 6 1.2.3 Research Objectives 7 1.3 Research Importance 7 1.4 Thesis Structure 8 2 Chapter Two Literature Review 10 3 Chapter Three Research Hypotheses and Methodology 18 3.1 Research Hypotheses 18 3.2 Methodology 25 3.2.1 Introduction 25 3.2.2 Research Types 26 3.2.3 Questionnaire Design 28 3.2.4 Validity and Reliability 31 3.2.5 Sample Size Calculation 33 3.2.6 Questionnaire Distribution and Data Collection 34 4 Chapter Four Data analysis 36 4.1 Respondents Characteristics Distribution 36 4.2 Hypothesis Analysis 48 Chapter Five Discussion and Recommendations 135 5.1 Introduction 135 5.2 Results Discussion 136 5.3 Summary and Conclusion 139 5.4 Nurses Suggestions 141 5.5 Recommendations 144 5.5.2 Suggestions for Future Research 147 5.5.3 Implication of the study 148 References 149 Appendix 154 b vi List of Tables No. Title Page 1 Stress sources ranking in five different countries 3 2 Distribution of nurses by shifts 37 3 Distribution of the first group of nurses by gender 38 4 Distribution of the first group of nurses by governorate 38 5 Distribution of the first group of nurses by age 39 6 Distribution of the first group of nurses by education level 39 7 Distribution of the first group of nurses by workplace 40 8 Distribution of the first group of nurses by years of experience 40 9 Distribution of the first group of nurses by marital status 41 10 Distribution of the first group of nurses by smoking 41 11 Distribution of the first group of nurses by break interval 42 12 Distribution of the first group of nurses by monthly salary 42 13 Distribution of the second group of nurses by gender 43 14 Distribution of the second group of nurses by governorate 43 15 Distribution of the second group of nurses by age 44 16 Distribution of the second group of nurses by education level 44 17 Distribution of the second group of nurses by workplace 45 18 Distribution of the second group of nurses by years of experience 45 19 Distribution of the second group of nurses by marital status 46 20 Distribution of the second group of nurses by smoking 46 21 Distribution of the second group of nurses by break interval 47 22 Distribution of the second group of nurses by monthly salary 47 23 The method of calculating the mean of nurses answers 48 24 Respondents average of answers meaning 48 vii 25 Calculating the average of answers for each hypothesis 50 26 Comparing results between the two groups regarding fatigue and sleep disturbances. 53 27 Comparing between the two groups (H1.1) 55 28 H1.1 Statistical analysis by age 56 29 H1.1 Statistical analysis by presence of children 57 30 H1.1 Statistical analysis by smoking 58 31 H1.1 Statistical analysis by break interval 59 32-34 H1.2 Statistical analysis 60 35 Comparing between the two groups (H1.2) 61 36-37 H1.3 Statistical analysis 62 38 H1.3 Statistical analysis by smoking 63 39 H1.3 Statistical analysis by gender 64 40 H1.4 Statistical analysis 65 41 Comparing results between the two groups regarding health problems 66 42-43 H2.1 Statistical analysis 67 44 Comparing between the two groups (H2.1) 68 45 H2.1 Statistical analysis by gender 68 46-47 H2.2 Statistical analysis 69 48 Comparing between the two groups (H2.2) 70 49-51 H2.3 Statistical analysis 71 52 Comparing between the two groups (H2.3) 74 53 H2.3 Statistical analysis by age 75 54 Comparing results between the two groups regarding social and psychological problems 76 55 Comparing between the two groups (H3.1) 77 56 H3.1 Statistical analysis by salary scale 78 57 H3.1 Statistical analysis by break interval 79 58 H3.1 Statistical analysis by workplace 80 59 Comparing between the two groups (H3.2) 81 60 H3.2 Statistical analysis by gender 82 61 H3.2 Statistical analysis by martial status 83 62 H3.2 Statistical analysis by presence of children 83 63-64 H3.3 Statistical analysis 84 65 H3.4 Statistical analysis 85 66 H3.4 Statistical analysis by gender 86 67 H3.4 Statistical analysis by marital status 184 68 H3.4 Statistical analysis by presence of children 184 69 H3.5 Statistical analysis 87 70 H3.5 Statistical analysis by gender 88 71 H3.5 Statistical analysis by marital status 89 72 H3.5 Statistical analysis by presence of children 90 viii 73 H4.1 Statistical analysis 91 74 H4.2 Statistical analysis 92 75 H4.3 Statistical analysis 92 76 H4.3 Statistical analysis by years of experience 185 77 H4.4 Statistical analysis 93 78 H4.4 Statistical analysis by gender 94 79 H4.4 Statistical analysis by marital status 186 80 H4.4 Statistical analysis by presence of children 186 81 H4.5 Statistical analysis 95 82 H4.5 Statistical analysis by gender 96 83 H4.5 Statistical analysis by marital status 187 84 H4.5 Statistical analysis by presence of children 187 85 Comparing results between the two groups regarding accidents and errors occurring 98 86 H5.1 Statistical analysis 99 87 Comparing between the two groups (H5.1) 99 88 H5.1 Statistical analysis by break intervals 188 89 H5.2 Statistical analysis 100 90 Comparing between the two groups (H5.2) 101 91 H5.2 Statistical analysis by years of experience 102 92 H5.3 Statistical analysis 103 93 Comparing between the two groups (H5.3) 103 94 H5.3 Statistical analysis by years of experience 104 95 H5.3 Statistical analysis by gender 105 96-97 H5.4 Statistical analysis 105 98 Comparing results between the two groups regarding Level of stress they exposed to 107 99 H6.1 Statistical analysis 108 100 Comparing between the two groups (H6.1) 109 101 H6.2 Statistical analysis 110 102 H6.3 Statistical analysis 111 103 Comparing between the two groups (H6.3) 111 104-105 H6.4 Statistical analysis 112 106 H6.5 Statistical analysis by gender 114 107 H6.6 Statistical analysis 115 108-109 H6.7 Statistical analysis 116 110 H6.7 Statistical analysis by gender 116 111 H6.8 Statistical analysis 117 112 H6.9 Statistical analysis 118 113 H6.9 Statistical analysis by gender 118 114 H6.9 Statistical analysis by marital status 119 115 Comparing between the two groups (H6.9) 120 116 H6.10 Statistical analysis 120 117 H6.11 Statistical analysis 121 ix 118 H6.12 Statistical analysis 121 119 Comparing between the two groups (H6.12) 122 120 H7.1 Statistical analysis by workplace 123 121 H7.2 Statistical analysis 123 122 H7.2 Statistical analysis by workplace 124 123 H7.3 Statistical analysis 125 124 H7.4 Statistical analysis 125 125-126 H7.5 Statistical analysis 126 127 Q1 Statistical analysis 128 128 Q2 Statistical analysis 128 129 Q3 Statistical analysis 129 130 Q4 Statistical analysis 129 131 Q5 Statistical analysis 130 132 Q6 Statistical analysis 130 133 Q7 Statistical analysis 131 134 Q8 Statistical analysis 132 135 Q9 Statistical analysis 132 136 Q10 Statistical analysis 133 137 Arrangement of wards by work pressure 134 138 Nurses Suggestions 142 139 Cronbach’s Alpha for questionnaire hypothesis 170 140 Demographic analysis for nurses work more than one shift 171 141 Demographic analysis for nurses work one shift 172 142 Hypothesis 1 results summary 173 143 Hypothesis 2 results summary 174 144 Hypothesis 3 results summary 175 145 Hypothesis 4 results summary 177 146 Hypothesis 5 results summary 179 147 Hypothesis 6 results summary 180 148 Hypothesis 7 results summary 182 149 General questions results summary 183 150 List of targeted hospitals 188 x List of Figures No. Figure Page 1 Nurses distribution by shifts 159 B1-1 Nurses distribution by gender 159 B1-2 Nurses distribution by governorate 160 B1-3 Nurses distribution by age 160 B1-4 Nurses distribution by education level 161 B1-5 Nurses distribution by workplace 161 B1-6 Nurses distribution by years of experience 162 B1-7 Nurses distribution by martial status 162 B1-8 Nurses smoking distribution 163 B1-9 Nurses distribution by break intervals 163 B1-10 Nurses distribution by monthly salary 164 B2-1 Nurses distribution by gender 164 B2-2 Nurses distribution by governorate 165 B2-3 Nurses distribution by age 165 B2-4 Nurses distribution by education level 166 B2-5 Nurses distribution by workplace 166 B2-6 Nurses distribution by years of experience 167 B2-7 Nurses distribution by martial status 167 B2-8 Nurses smoking distribution 168 B2-9 Nurses distribution by break intervals 168 B2-10 Nurses distribution by monthly salary 169 xi Effect of Shift Work Paradigms on Job Performance of Nurses in the Palestinian Health Sector By Majd Abu Amsha Supervisor Dr. Yahya Saleh Abstract With the growing number of people in the world in general and in Palestine in particular, the need to provide medical services to them and work on the upgrade and improvement of these services has emerged, among the most important factors that guarantee the provision of these services with a high level is provided around the clock, and so responsible parties adopted the system of shift work. One of the main problems faced by shift work system is suffering of workers in this sector of psychological, social and health problems, in addition to the occurrence of medical errors and their exposure to accidents while doing their job. In this study problems caused by working in shifts for nurses working in Palestinian public and private hospitals were highlighted, in addition to the discussion of the criteria nurses working in shifts system are selected accordingly, the study also addresses sleep problems and insomnia caused by working in shifts, part of the study has been allocated to look at the factors that control the size of work pressure between the different shifts, the final part of the study, discusses employee satisfaction financially and morally. The results show the suffering of nurses working shifts of health problems that may be chronic diseases or exposure to successive healthy setbacks, xii psychological and social problems have emerged so much where they suffer from isolation and weakness in social relations, the results also showed a lack of standards nurses working in shifts are selected on the basis of and when the distribution shifts among them. During the study, the analysis of each of the previous problems conducted through a comparison between nurses working in shifts and nurses who work in one shift. As these problems have been analyzed according to several demographic variables such as age, sex and other. 1 Chapter One Introduction 1.1 General Background Recently, the need of shift work has significantly increased as a result of high cost of machines and production lines equipment, increase of the demand on services and products at all sectors. Furthermore, technology logic advances, changes in economy and emergence of 24 hour societies contributed to increase of the need for shift work. (Kroemer. H, Kroemer.K, et al., 2001) defined shift work as: one speaks of shift work if two or more persons, or teams of persons, work in sequence at the same workplace. Often, each worker’s shift is repeated in the same pattern over a number of days. For the individual, shift work means attending the same workplace either regularly at the same time (continues shift work) or at varying times (discontinuous, including rotating, shift work). There are two common approaches of shift work; 8- hour shift and 12-hour shift, which are considered as the right choice with few restrictions such as moderate stress, simple tasks (free activities) and free time between shifts should not be less than 16 hours to adopt the approach of 12-hour. Shift work has a lot of consequences that affect the performance of workers at both professional life and social life, (Performance defined as: The accomplishment of a given task measured against preset known http://www.businessdictionary.com/definition/task.html 2 standards of accuracy, completeness, cost, and speed. In a contract, performance is deemed to be the fulfillment of an obligation, in a manner that releases the performer from all liabilities under the contract) as Cosmetatos G.P, Eilon S, 1993 mentioned in their paper. Unfortunately, shift work leads the worker to work against his/her body's natural rhythms and this will cause accidents, fatigue and tiredness, and these consequences usually accumulate with age. In most industrialized countries, approximately one-third of the population has some forms of shift work, above 5-10% of population have shift work that includes night work. There is, however, a clear trend towards more widespread shift work because of the strong trend in society toward around–the clock production and service (Glass. L, Aronson K, 2011). On the other hand, (Bambra, Whitehead, et al, (2008)) mentioned that shift work continues to be commonplace among healthcare and emergency-services personnel with up to 50% of hospital staff working on shifts. A study by (Glazer, Gyurak, (2008)) tested the sources of stress among nurses in five countries; Hungary, Israel, Italy, U.K and U.S. The study ranked these stress sources and the results are tabulated in Table 1. This study showed the difference between sources of stress in each country according to country culture and conditions which mainly concentrated in difficult working environment, sleepiness, social, psychological and health problems. http://www.businessdictionary.com/definition/accuracy.html http://www.businessdictionary.com/definition/cost.html http://www.businessdictionary.com/definition/contract.html http://www.businessdictionary.com/definition/deemed.html http://www.businessdictionary.com/definition/fulfillment.html http://www.businessdictionary.com/definition/obligation.html http://www.businessdictionary.com/definition/release.html http://www.businessdictionary.com/definition/liability.html http://www.sciencedirect.com/science/article/pii/0377221783902862 http://www.sciencedirect.com/science/article/pii/0377221783902862 http://www.sciencedirect.com/science/article/pii/0377221783902862 http://www.ncbi.nlm.nih.gov/pubmed?term=Bambra%20CL%5BAuthor%5D&cauthor=true&cauthor_uid=18407011 http://www.sciencedirect.com/science/article/pii/S014717670700079X http://www.sciencedirect.com/science/article/pii/S014717670700079X#fn1 3 Table 1: Stress sources ranking in five different countries Rank U.S. Hungary Israel Italy U.K. 1st Lack of staff Lack of resources Quantitative workload Lack of staff Lack of staff 2nd Quantitative workload Death Lack of staff Quantitative workload Leadership 3rd Leadership Time pressure Type of patients Leadership Co-workers 4th Co-workers Interaction with patients and relatives Psychological Type of patients Quantitative workload 5th Death Staff shortage Health problems Psychological Time pressure 6th Type of patients Quantitative workload Interaction with patients and relatives Co-workers Type of patients 7th Time pressure Type of patients Co-workers Lack of resources Lack of resources 8th Lack of resources Co-workers Leadership Time pressure Psychological 9th Interaction with patients and relatives Psychological Death Interaction with patients and relatives Negative rewards 10th Negative rewards Leadership Time pressure Death Interaction with patients and relatives 4 1.2 Problem Definition 1.2.1 Overview The Ministry of health (MOH) in Palestine provides free health services for all segments of the Palestinian society and is constantly working on improving its services. MOH charges 900 NIS as annual fees from 130,000 government employees that do not cover their expenses as mentioned in an article of Al-Quds newspaper in June, 2011. Besides, WAFA Agency mentioned in a statistical survey conducted in 2011 that the total number of hospitals in West Bank equals to 45 public hospitals with capacity of 3,803 beds, 11 private hospitals, with capacity of 822 beds, 16 birth hospitals with capacity of 316 beds and 706 health centers. Also, the statistical studies compare between resources availability and usage in the Palestinian hospitals and those in neighboring countries. In particular, they mentioned that the number of nurses equals to 50 nurses per 100000 citizens, while number of beds equals 50 beds per 100000 citizens, where as the number of doctors equals 8.9 per 10000 citizens and 15 employee in medical support occupations per 100000 citizens as mentioned in the Independent Commission for human rights mentioned in their annual report in 2009. Al-Quds newspaper article mentioned also the types of training that the employees of Palestinian health care sector have to receive including practical training, self training, and training through workshops and 5 conferences. National strategic plan (2008-2012) also addressed the issue of human recourses working in Palestinian health care sector that equal to 40,000 could be divided as follows: 8048 doctors, 2035 dentists, 3842 pharmacist, 6652 nurses, 10521 medical support occupations and 7520 administrators. Furthermore, human recourses in the Palestinian health sector, as Shalabi Y and Ladadweh H, (2007) mentioned in their study, suffer from lack of job descriptions and organizational structures, The study also mentioned lack of systems and references related to behavior of employees during service delivery, also it was clear that employees do not receive courses in dealing with the public that affect the level of service provided to citizens. Under the above-mentioned nature of the Palestinian health sector, shift work has been a regular and an indispensable norm of work in health care sector in the Palestinian society because of the nature of the services provided by this sector. In the sequel, it is worthy to highlight many aspects related to shift work effects and problems on nursing personnel job performance in the Palestinian health sector and to find solutions for them. More specifically, job-related physical and mental stresses appeared in nurses working in the Palestinian health care sector according to various shift schedules will be investigated in this study. The above-mentioned statistics clearly reflect suffering of nursing staff in Palestine due to a lack of available resources and the difficult work conditions. Work-related stresses are considered as very influential factors 6 because nurses have to provide services throughout the day and without interruption and this force them to adopt shift work system in three consecutive shifts daily. Several studies examined both long term and short term negative effects of shift work on nurses and their job performance in private and public Palestinian hospitals. Specifically, such negative effects include, but not limited to, physical and health problems (cardiovascular, pre-term births, breast cancer…) and social and mental problems (loneliness, isolation, difficulties in family interactions…). These problems will be addressed thoroughly in our research hypotheses in order to come up with some recommendations for reducing/eliminating such problems among nurses in the Palestinian health sector. 1.2.2 Research Questions This research aims to clarify the problems resulted from shift work of nurses personnel in the Palestinian health sector and to suggest solutions for these problems through finding answers for the following questions: 1-What are the main problems of shiftworking nurses in the Palestinian health care sector? 2-What are the solutions to such shift work problems? 3- Do administration in health care organizations notice these problems? What are their actions to solve these problems? 7 1.2.3 Research Objectives The main goal of this research is to discuss the effect of shift work on the performance of shift work employees (nurses) due to fatigue, stress and social problems they encounter as a result of their work in the Palestinian health sector. This research will result in recommendations for improving their working and living. In particular, the research aims at; first, addressing all types of health, social, psychological, and professional problems of shift work that nurses in Palestinian hospitals are exposed to. Secondly, exploring the effect of these problems on the performance of nurses, Thirdly, suggesting feasible and practical solutions to reduce errors, accidents and poor performance of nurses resulted from shift work problems. 1.3 Research Importance Due to its sensitivity and importance, shift work in healthcare sector has attracted many researchers to focus on aspects that deserve attention and need more investigation. Many studies conducted around the world but what makes this study unique is lack of studies on this subject in the Palestinian health care sector which address the problems caused by working in shifts for nurses in the health sector. Majority of studies that relate to the health sector in Palestine focus on the problems encountered by the sector represented by a lack of personnel, shortages in medicines and lack of medical equipment. However, the problems experienced by nurses are not taken into consideration to address whether they are psychological, 8 social and health problems affect their performance and quality of services they submit. In this research, many questions related to nurses problems will be answered for the first time, where many of the problems faced by nurses in all its forms will be identified suggested solutions and recommendations which may reduce these problems will be provided, the research will focus mainly on the problems of shift work and represented by psychological, social and health problems of nurses, errors and accidents, sleep disturbance and fatigue and scheduling of shifts among nurses. 1.4 Thesis Structure This thesis consists of five chapters, Chapter One introduce for the subject with a simple explanation about working in shifts in the world and the increasing adoption because of the increased need for such systems, in addition to simple presentation of shift work problems in general with indication to the suffering of the Palestinian nurses. Chapter Two introduces a literature review and summaries studies that addressed the issue of working in shifts, In this chapter consequent implications as a result of being shift worker have been highlighted in general. Several studies that discussed the work in shifts and the impact on employees in the health sector and nurses in the hospitals have been surveyed, in particular. 9 Chapter Three represents research hypotheses and previous studies which support the hypotheses formulation. It also provides a summary of the methodology that has been followed in this research. In particular, discussion of how to choose the sample, the questionnaire formulation mechanism, and are given in this chapter the process of data collection. Chapter Four presents the analytical results of demographic variables showing frequencies and percents of each variable for nurses. Also it gives the major and sub hypotheses results. Chapter Five gives a brief conclusion about hypotheses results with a summary of recommendations and future research suggestions. 11 Chapter Two Literature Review Many studies around the world have focused on the problems of shift work and the impact of it on the performance of shift workers, where with mounting echo problems caused by this system of work, almost each country in the world of enterprises and institutions adopt this system of work. Therefore, the interest in this topic is no longer the preserve of certain state or sector. Researchers from different countries all over the world have conducted studies to discuss shift work problems and to suggest solutions for such problems. In Feb.2000 a group of researchers (Hsberg . A. S., 2000.) conducted a study to examine the effect of shift work at the different dimensions of fatigue, using Swedish Occupational Fatigue Inventory (SOFI). There are five main dimensions of fatigue as defined by (SOFI) that are lack of energy, physical exertion, physical discomfort, lack of motivation, sleepiness. The study was conducted in a paper mill in the south of Sweden, 48 men and 44 women participated in the study, their mean age was 41.3 years. Results showed that all dimensions of fatigue stated in (SOFI) are increasing during the night shift. After analyzing the gender variable it was clear that women are affected by fatigue more than men relating to SOFI dimensions. On the other hand, no gender differences were observed concerning question of sleepiness, this showed that there were no 11 differences regarding sleepiness between men and women. The results also suggested that taking breaks between shifts may be sufficient for sleep to recover, while it is not sufficient to rest from physical exertion. A study published in 2011 for (Fritschi L, Tresham L, et al.) focused on the relation of being shift worker and susceptibility to cancer, four main mechanisms were deeply researched which are phase shift, sleep disruption, lifestyle factors and lower vitamin D. Phase shift; shift work system is working against natural rhythm of cells and organs and the synchronized process of sleep-wake cycle, phase desynchronized happens when workers adopt this sleep system, “Confusion of the master clock, such as when a person does shift work, may thus contribute to asynchronies in cell proliferation which may result in cancer”. “Sleep disruption; this could be classified into two main issues first, immune suppression which decreases because all studies of poor sleepers resulted that killer cell activity reduces with sleep disruption. Second, melatonin production which increase at night hours when light is absent which night shifts do not allow it to be produced to prevent rat hepatomas and breast cancer.’’ Life style factor; many daily habits affected by being shift worker include poor diet, smoking, alcoholism, physical inactivity and obesity which all may result in cancer. 12 Lower vitamin D; exposure of day light may be less for people who work in shift work than others which result in decrease of vitamin D in their bodies which reduces the chances of developing certain types of cancer. “Tucker P. and Knowles S.R. (2009) mentioned the Standard Shift work Index (SSI) which was developed in order to address the lack of validated research tools available for the exploration of the complex relations between shift-system design, individual differences, and psychological and physiological health. The SSI consists of six sections, each addressing a specific aspect of shift work. More specifically, section one comprises questions regarding biographical information (e.g., age, gender, marital status), type of shift system worked (e.g., shift start and end times) and job satisfaction (Smith et al., 1989). Section two assesses the effect of shift work on perceived sleep quality and quantity, and fatigue. Section three measures the level of psychological distress (Folkard et al., 1979), while section four assesses the social and domestic aspects of the shift worker’s life which may influence their well-being (e.g., time for family, social activities) (Tucker P. and Knowles S.R. (2009)), Finally, section five assesses how shift workers cope with shift work (Tobin et al., 1984).” Work in shifts in the health sector had a large share of studies due to the sensitivity and seriousness of this sector and due to the cries of distress from the workers there. Several studies conducted in this regard where 13 researchers took samples from people working in hospitals and health centers working 24 hours. These studies mentioned the different types of social, psychological and health problems occurred as a result of shift work. To examine organizational factors affecting the impact of shift work on work life conflict and subjective health a study for (Pisarski, Brook C, et al.) in 2008 targeted 530 nurses working in a large Australian hospital organization that controls several public and private hospitals that provide acute, inpatient adult, pediatric, and maternity services. Researchers have identified three forms of work life conflict: time-based, strain-based and behavior-based conflict. 36% of the 1492 nurses responded to surveys that was distributed. 39 nurses (7%) were male and 491 (93%) were female with a mean of 35 years for their age. Fifty-eight percent of respondents worked rotating 8–10 h shifts that included morning, afternoon and night shifts. 5% worked fixed night shifts, 37% percent worked 8–10 h shifts involving either rotating or fixed morning and afternoon shifts. Several variables were analyzed to link between both physical health and psychological well-being and these variables were (supervisor support, college support, team identity, team climate, control over work environment and Work-family conflict). The results revealed a set of direct and mediated relationships between social support from supervisors and colleagues, team identity and 14 climate, control over the work environment, work life conflict, and subjective health. From the results it was clear the positive relationship between these factors and reducing the work life conflict that resulted in a better life for well beings. “This finding indicates that wider aspects of control over work, not just working hours, have strong positive effects on the work life conflict experienced by shift workers.” Two other additional factors that focus on team climate and team identity were discussed and results came as hypothesized that both physical and psychological variables are positively related to colleagues and supervisors support which will affect their performance positively. A study for Anderson V.V, 2010 which covered a sample of five nurses mentioned that high percentage of shift workers complain about shift work difficulties and the effect of that on their stability, nurses preferred taking morning shift more than evening and night shifts, since evening and night shifts keep them away from their families. After interviewing these nurses the study resulted that nurses who work in shift work are highly exposed to fall into errors which affect safety of them as well as of their patients. “There are five categories whereby nurses coded the type of errors that they recorded: (1) medical, including incorrect administration in terms of dosage, timing, delivery or patient; (2) charting, including incorrect entry in terms of information, timing or patient; (3) procedural, including any deviations from approved procedures; (4) slip or 15 fall, including any physical injuries; and (5) others, including errors not falling into any of the other categories.” Nurses are also exposed to personal accidents and injuries resulted from being shift workers so they feel with fatigue, drowsiness while travelling home that increase accidents or near accidents while driving or cycling home. A study for (Tekindal B, Tekindal M.A, et al. 2012) have been made in a Turkish state hospital focused on the problems usually occurred between nurses and patients, 225 nurses and 222 patients formulated the sample group of this study which addressed examples for nurses problems with their patients they face during their daily dealing with them, such as blaming nurses for poor condition of hospitals, breaking the therapeutic rules that may affect their health, non compliance with doses, patients repeatedly requests without need, lack of patients understanding of specialized details. Other kind of problems that face nurses is dealing with patients relatives as (Kuhlmann B. G, 2004) mentioned in his study, the study conducted interviews with the relatives and other interviews with the nursing staff, study resulted in many problems include inappropriate time for visits, bringing forbidden food, talking with patient, annoying other patients, large number of useless questions that consume nurses time. Also patients and their relatives complained from nurses non responding, medical mistakes, and from being tough with them. 16 Death is the hardest situation that nurses compelled to act when it occurs, the first thing they have to do is to act wisely in the presence of family members, many nurses build a relationship with them such as attending funerals or posting obituaries. After patients death, some nurses use exercise and relaxation therapies, such as a hot bath, to help getting rid of stress caused by patient death after building strong relations with them especially patients that lying in hospitals for a long period so nurses are dealing with them daily and get used to see them as (Domrose C.) mentioned in her study in 2011. Beside to work pressure nurses exposed for, they are also required to be responsible for manual or electronic documentation about their patients condition and their medical records, this help them in information delivery between shifts to follow-up their work. This additional task increases the volume of their hard work since they have to be accurate in keeping these sensitive information such as color of the skin, blood pressure, blood glucose readings, respiration rate, temperature, pulse, level of consciousness, dosing schedules, doctors notes and recommendations, a study for (Driscolla T. R. , Grunsteinb R. R. ) in 2007 took a sample size of 933 nurses 59% are working in different hospitals in Maryland state to fill the questionnaire 41% of the sample working in clinics and the rest are working in hospitals, study resulted that 25%-50% of nurses spend their working time to document patients status and records, hospital nurses 17 reported that hospitals have to pay additional salary for them instead of working beyond normal hours for documentation. (Fields R.) April, 2012 mentioned that shift work is considered as the most prominent issue that damage employee satisfaction in hospitals. She sorted these issues in a descending order starting with “shift work, then expecting staff to work with minimal breaks from management, bureaucratic hold-ups, invisible leadership, limited opportunities for involvement, hiring staff members who don't fit their positions”. Sleepiness has a large effect on the performance of nurses, and to avoid this problem and to stay awake especially at night shifts, Functional Energy Drinks (FED) and stimulated drugs are used, but several investigations mentioned for side effects for this using at the long run. (Jay, Petrilli, et al., 2006). This chapter summarized some previous studies that discussed shift work problems for shift workers and for nurses in particular, these studies constitutes a small part of studies covered this vital topic. 18 Chapter Three Research Hypotheses and Methodology Chapter three stated two main parts of the research, first part summarized hypothesis of the research with the previous studies that have been relied upon in formulating the hypothesis, second part presented in detail the methodology followed in the search. 3.1 Research Hypotheses To formulate the hypothesis of our study several previous studies were also reviewed and summarized, Assumptions were reviewed successively and separately, so that each hypothesis addressed a particular issue related to the work of nurses in shifts, based on the findings and outcomes of previous studies. The following discussion presents the formulation of the hypotheses. 1- Shift workers sleep poorly than others, they have difficulties in getting enough sleep hours because of their duties, and the quality of sleep is also poor because of a lot of awakenings and unusual sleep times. Nurses productivity which could be defined as: (Registered or incorporated entity that provides professional services (which generally require a license from a professional body) such as accounting, legal advice, medical care, to the public. Also called professional corporation, as as Cosmetatos G.P, Eilon S, 1993 mentioned in their paper), may decrease and they may exposed to accidents because of sleep disturbances which may have the symptoms of http://www.businessdictionary.com/definition/incorporation.html http://www.businessdictionary.com/definition/entity.html http://www.businessdictionary.com/definition/provide.html http://www.businessdictionary.com/definition/professional-services.html http://www.businessdictionary.com/definition/license.html http://www.businessdictionary.com/definition/professional-body.html http://www.businessdictionary.com/definition/accounting.html http://www.businessdictionary.com/definition/legal.html http://www.businessdictionary.com/definition/advice.html http://www.businessdictionary.com/definition/care.html http://www.businessdictionary.com/definition/call.html http://www.businessdictionary.com/definition/professional.html http://www.businessdictionary.com/definition/corporation.html http://www.sciencedirect.com/science/article/pii/0377221783902862 http://www.sciencedirect.com/science/article/pii/0377221783902862 19 clinical insomnia. Their circadian system is affected because of the nature of their work and Irregular sleep and being forced to stay awake for long hours and continuously, especially in the night hours.(Akerstedt T, 2009). Shift work, particularly night work, disrupts the natural circadian rhythm, requiring people to be active at times when they would normally be sleeping, and vice versa. This leads to problems with sleep, their bodies Influenced by many things such as the vital sugar and body temperature and the rate of secretion of melatonin (Bambra, Whitehead, et al, (2008)). Based on thesis discussion, the first hypothesis could be formulated as: H1-Shift work nurses suffer from sleep disturbances which may lead to be chronic insomnia. Next it is clearly that shift work has many negative consequences that would increase if the shift worker has inappropriate qualifications to be a shift worker. More specifically, individual differences may not yet be used to select shift workers but individuals above the age of 45 should have a right to transfer to day work to consider their health conditions. Hypnotics may improve daytime sleep to compensate being awake at night hours but should be avoided in the long run because of it’s side effects, and to reduce the effect of being sleep at day hours especially when aging, nurses have to take melatonin by bright light exposure or intake of the pineal hormone melatonin instead of taking it naturally (Akerstedt T, 2009). According to the discussion mentioned above, the second hypothesis could be formulated as: http://www.ncbi.nlm.nih.gov/pubmed?term=Bambra%20CL%5BAuthor%5D&cauthor=true&cauthor_uid=18407011 21 H2-There are certain criteria that should be taken into account upon choosing shift work nurses. Health problems that result from shift work because of stress, poor diet during shift work, stand for long time, caffeine consumption, and disorder in circadian rhythm. Shift workers are exposed more than other workers to health setbacks such as colds and flu, also exposed for chronic diseases like gastro-intestinal problems such as indigestion or ulcers and more cardiovascular disease such as heart attacks and high fat and diabetes as (Boggild. H, 2000) mentioned in his Phd thesis. Disruption of the circadian rhythm can also lead to disharmony within the body, as some functions (e.g., heart rate) adapt more quickly than others, also other vital functions affected such as body temperature and melatonin production. Previous studies have explored relation between being female shift worker and some physiological aspects such as pre-term births, or breast cancer ( Barnes J. L.,Davies K. S., et al., 2010). According to this discussion, the third hypothesis could be formulated as: H3-Diverse health problems may appear as a result of shift work. Due to the nature of working in shifts, many of difficulties face shift workers which prevent them from exercising their normal lives, so they can not find adequate and suitable time to spend with their families, and to practice their hobbies that result in absence of their social life and social relations. In addition, quality child care is almost nonexistent (Goswami R, 2012). Compared with people who do not work in shifts, shift workers do 21 not have time to spend with their relatives and families or even their friends. Shift worker also can not join any personal activities such as participation in clubs and practicing sports since they are usually geared to the normal day schedule. The lack of regular social contact can lead to feelings of loneliness and isolation. (Canadian Centre for Occupational Health & Safety, 2012). Consequently, our next hypothesis could be formulated as: H4-Shift work nurses suffer from diverse social and psychological problems due to the nature of their working times. Being tired and feeling sleepy cause errors and accidents, shift workers are considered as hazard to both themselves and others in these hours. Research from the center for sleep research in Adelaide discussed the effects of sleep deprivation and showed a result related between sleep deprivation and being drunk, results showed that after 17 hours without sleep and being awake person drive as poorly as if he had a blood alcohol level of 0.05 in his blood and after 25 hours of being awake it is the same as a level of 0.10. Shift workers are at a high risk for a sleep-related accident because at the end of their shift they may have been awake for 16 or more hours especially when they have double shift. Studies showed that around of 30% of shift workers in general have had a fatigue- related driving accidents in the previous years because of being fatigued and sleepy after being awake for long hours or for consecutive shifts (Rogers, Hwang A.E. , et al., 2010). http://www.ccohs.ca/ http://www.ccohs.ca/ 22 Exposure for accidents is not only the related problem of shift work, shift workers also are exposed to personal injuries and medical errors as performance fluctuates. For example, a review of injuries and errors related to shift work concluded that workers on rotating shift work had a higher risk of injury and having errors than workers on fixed shifts, also the study resulted that longer workdays such as 12-hour are more hazardous than usual 8-hour workday (Bambra, Whitehead, et al, (2008)). Night shifts account for the highest percentage in the opportunity for accidents, personal injuries and having medical errors as (Flo. E, 2013) mentioned in his thesis. Recently, the latter investigations was extended to search for the immediate causes of fatigue-induced in particular, cars accidents. It was found that the most impact factor was the amount of sleep obtained during the 24 hour before the accident, whereas the length of time driven seemed to play a minor role in causing accidents, driving for long hours does not cause accidents as long as there is sufficient hours for sleeping. Also it was found that most of accidents in 2009 was due to fatigue, caused by reduced sleep and extended work hours resulted from long shifts or double shifts (Akerstedt T, 2009). In this regard our next hypothesis could be formulated as: H5-Errors and accidents may occur as a result of shift work fatigue and stress. http://www.ncbi.nlm.nih.gov/pubmed?term=Bambra%20CL%5BAuthor%5D&cauthor=true&cauthor_uid=18407011 23 The level of stress nurses are exposed to varies according to many factors that contribute to increase this stress and fatigue. Studies showed that nurses affected by the ward they work in, nurses work in emergency rooms and Intensive Care Units (ICUs) and other hospitals wards with high working pressure are more likely to face health and psychological problems of shift work than other nurses. Other factors considered to be a pivotal role in working pressure are kind of shift, patients visitors, cooperation between staff in the shift, limited staff resources, and shifts distribution (Scott W.T., Aiken L.D., 2007). Compared to police officers, nurses have a greater risk of being physically or verbally abused at work (Holt, 1999) and as identified by several authors this causes a major impact on psychological trauma, physical injury and possibly death (Arthur L. Frank, 2000). Based on the above discussion, the next hypothesis could be formulated as: H6-Level of stress shift work nurses are exposed to differs among hospital departments and time of shifts and other factors. Many studies mentioned volume of side effects resulted from shift work; several efforts appeared to solve these problems and to reduce the noticed impact of shift work. Taking naps consider as the most effective countermeasure against sleepiness at work, several studies have shown that 0.5-2-h naps taken 24 during the first part of night will help nurses not to fall in sleeping during the shift (J. Pincombec, A. E. Rogersd, et al., 2011). Many other interventions were tested to determine the relationship between these interventions and reduce the side effects of shift work. Speed of rotation was tested by examining whether the effect of changing from fast to slow rotation will be positive or not. In each study, the switch from fast rotation consisted of a change from six or seven consecutive shifts of the same type to a minimum of three or four consecutive shifts of the same type then adoption of another type of shift, and not to change it daily, and all reported positive health effects. Other positive intervention was found, and good indicators appeared clearly after testing it, which was removal of shift work rotation and many health indicators improved significantly after the intervention: “(1) sleep quality and duration improved (e.g., sleep required decreased slightly, from 8.11 hours to 7.77 hours, and sleep adequacy and quality of sleep improved); (2) psychological symptoms decreased, and the mean severity of symptoms reduced slightly; and (3) the amount of sickness absence decreased (from a total of 1400 hours in the 6 months before the intervention to 883 hours in the 6 months after the intervention)” (Bambra, Whitehead, et al, (2008)). As for decreasing the shift length resulted in significantly improvement in fatigue levels, emotional exhaustion, social and family life. Self scheduling for shifts enables individual shift workers to have some control over which shifts they work, when they start work, or when http://www.ncbi.nlm.nih.gov/pubmed?term=Bambra%20CL%5BAuthor%5D&cauthor=true&cauthor_uid=18407011 25 their rest days occur. “Health and work–life balance outcomes were almost universally improved in all three: there were decreases in absence, fatigue, and complaints about family life recorded in the study, accidents decreased by 20%, opportunities to plan leisure time and social contacts improved and the ability to maintain a work–life balance was improved in the hospital-based study” (Bambra, Whitehead, et al, (2008)). In the previous study and other studies, another intervention was tested and it was clear that changing direction of rotation from backward (night, afternoon, morning) to forward (morning, afternoon, night) has no effect on shift workers performance, health and social life. After previous discussion the last hypothesis could be formulated as: H7- A) Taking naps, B) Changing from slow to fast rotation, C) Removal of shift work rotation and D) self scheduling for shifts may be considered as feasible solutions to reduce the impact of shift work. 3.2 Methodology 3.2.1 Introduction In this part of thesis the methodology that was adopted in conducting this research will be explained via clarifying all sequential steps in where a simple explanation will be provided for each step. All methods and techniques used in their research starting from the process of reviewing literature, questionnaire design, sample size calculation, data collection and http://www.ncbi.nlm.nih.gov/pubmed?term=Bambra%20CL%5BAuthor%5D&cauthor=true&cauthor_uid=18407011 26 analysis and finally recommendations and conclusion will be highlighted here. The first step, was the review of several studies on the shift work, the methodologies and the most important issues and problems that have been addressed in shift work-related previous studies. Various studies have been surveyed included several countries and environments, in some of which surveys have been conducted and others have conducted interviews and visits to the nurses and staff working shifts system. 3.2.2 Research Types Both qualitative and quantitative methods were used in the research methodology, nature of hypotheses and questions to this research has led for that and two categories were emerged where it was not easy to adopt one method, and dispense other, A clear need for integration between the two methods together appeared, uses of qualitative research appear in many different cases and when there is a need for many reasons as mentioned in family health international guide such as: “seeks answers to a question, systematically uses a predefined set of procedures to answer the question, collects evidence, produces findings that were not determined in advance, produces findings that are applicable beyond the immediate boundaries of the study”,(Sofaer S, 2002). “Qualitative methods provide a depth of understanding of issues that is not possible through the use of quantitative, statistically-based http://intqhc.oxfordjournals.org/search?author1=SHOSHANNA+SOFAER&sortspec=date&submit=Submit 27 investigations.” The data that is used in qualitative research come from a range of collection methods. These include: 1. Interviews with individuals, 2. observations of people, places and actions/interactions, 3. the analysis of media (written, spoken, drawn, etc.), 4.content and guided conversations with groups of individuals (focus groups). Each of these approaches to data collection differs in the source(s) of information and what actual tasks the researcher does to collect information, yet all also include the idea of pulling together examples of the content of regularly encountered situations and things”. (Tewksbury R, 2009) Turning to the quantitative method it must be referred to the benefits and uses of this method, first, it used to test hypothesis, second, obtaining accurate data, third, this method is suitable more than other methods when we deal with huge data ,fourth, it does not depend on the researcher preferences and mood. (Bryman, 2006). It was necessary to resort to quantitative method, which has enabled the researcher to obtain results and analysis contributed to the study and support role was as effective as the qualitative method. Quantitative method was very helpful since the research targeted large number of people and obtained huge quantity of data. Clarification of what has been the use of the qualitative method has been conducted through interviews with employees and managers from Ministry of Health, hospital management general directorate in particular and from nursing unit there. During the interviews, some data and statistics 28 related to research were obtained. This has been briefed on the questionnaire prepared initially, their comments were taken into consideration and questionnaire was modified accordingly. Other discussion was conducted with nurses association to identify the main problems faced by nurses through their work and the impact of working in shifts on their performance and what are the consequences of shift work. For a larger amount of information it had to be dealt with a large sample to cover all aspects of research and to answer the questions and hypotheses accurately, large number of the sample led to adopt questionnaire distribution method that will be easier and less expensive than other methods such as interviews. 3.2.3 Questionnaire Design For a great deal of information and to be able to cover a large sample of nurses, the design of a comprehensive questionnaire to all hypotheses put forward in the search. In order to achieve all objectives of the search that focus on addressing shift work problems and to get nurses suggestions and recommendations to solve these issues. A small introduction was presented at the beginning of the questionnaire to explain the main objective of the questionnaire for the participants and to insure that the information will be only used for academic research purposes and will be dealt confidentially. 29 To prepare the questionnaire many methods were followed, it has been relying on the previous studies that focused on the topic of shift work, in addition to defining the problems and the suffering of the nurses working in shifts through interviews with the people of public administration for the management of hospitals and nursing unit, interviews have also been conducted with the heads of nursing in many hospitals to benefit from their experience and to take their comments into consideration. Also, the Palestinian Nurses' Union was contacted for information. The questionnaire was divided into five main parts; participant demographic information, main part of the questionnaire that focuses on the shift work issue, nurses satisfaction, general questions and open questions such that participants can write their comments, suggestions and observations. Part one, demographic informations about participants were collected in the first part to help in grouping nurses by gender, age, educational level, workplace, job title, type of shift, years of experience, marital status, monthly salary, no of children, average sleeping hours, break intervals allowed during every shift and smoker or non-smoker. Part two, included six main sections each section included a number of questions to address a particular issue with 67 as total number of questions, fatigue and sleep disorders, health issues, social and psychological issues, standards that should be followed upon scheduling 31 nurses to shifts, medical errors and accidents, factors that govern size of workload respectively. Questions about job satisfaction and working environment were highlighted in the third part focusing on light, ventilation, privacy and furniture at the work place; also some questions were about their moral and financial satisfaction. General questions were asked in separately in part four addressing several issues as training courses, Palestinian reality and its impact on their work and many other issues. Fifth part which was the Last part was open-ended question about their suggestions and comments regarding improvement of work situation inside hospitals. Part two, three and four asked questions and gave the chance for participants to choose answer out of five, for statically purpose each answer had its own score (Strongly Agree=5, Agree=4, Neutral=3, Disagree=2, Strongly Disagree=1). During preparation of the questionnaire it have been taken into account the simplicity and ease in formulating questions so participants will be able to understand easily. It was moving away from the use of any tough terms or incomprehensible, and also it was taken into account not to have more than one meaning for each question or the possible existence of two answers to the question that leads participants to unambiguous 31 understanding during their answer, questions was divided into parts, each part interested in a particular issue so as not to distract the participant. 3.2.4 Validity and Reliability Validity refers to how well a test measures what it is supposed to measure and truthful of research results, (Phelan. C, Wren.J, 2006). Two main types of validity will be highlighted here due to relevancy purposes; Content validity and external validity. Content validity is the extent to which the elements within a measurement procedure are relevant and representative of the construct that they will be used to measure (Phelan. C, Wren.J, 2006). In this study, the measuring instrument was the questionnaire distributed on nurses, so some procedures have been taken to insure the questionnaire content validity as follows: Formulations of questions based on the hypotheses contained in the research and were the core which has been in work in order to support. These hypotheses were made based on a literature review of relevant studies and by reference to interviews conducted with the people working in the field of nursing and in several positions. Some questionnaires have been excluded from the analysis due to incompleteness pattern answers, some questions developed in a way reveals that the nurse filled out the questionnaire without taking into account the accuracy and without understanding content that it is clear 32 during data entry to Statistical Package for the Social Sciences )SPSS) , what appears conflict of some answers that he had to fill logically and in reasonable manner showing his/ her interest. Reviewers from different backgrounds have reviewed the questionnaire in terms of clarity and ease of answering questions, in addition to comprehensiveness of questions for all aspects of the subject. Reviewers varied between nurses and teachers in the nursing and engineering faculties. In addition to a statistical expert, also the questionnaire was presented to Ministry of Health; general directorate of hospitals in particular for review. External validity could be defined as the ability of generalizing the results (Anthony J, James E, et al., 2003). To ensure maintaining external validity in the research, questionnaires were distributed to shift supervisors personally after the interview with the head of nursing at each hospital and explain the importance of the subject for them to ensure the mobilization of the questionnaire accurately. It also was necessary to meet with nurses and explain the nature of the questionnaire and to emphasize the importance of its findings and recommendations that are in their best interest. Reliability is defined as the extent to which a questionnaire, test, observation or any measurement procedure produces the same results on repeated trials (Miller. J. M, 2008). 33 Cronbach’s alpha was an appropriate method to test questionnaire reliability. SPSS was used to calculate the value of this coefficient, this value was used to check the internal consistency with correlation coefficient at 95% confidence level and with a value did not fall below 0.7. This research passed the test with a value of Cronbach’s alpha of 0.856 for the whole 86 items. 3.2.5 Sample Size Calculation To calculate the accurate number of nurses that must be randomly chosen to fill the questionnaire, several statistical methods were reviewed to find the suitable one to find the accurate sample. This depending on the research conditions and limitations the most appropriate one was Steven K. Thompson method that dealing with the research case that meets all Thompson equation conditions, (Thompson S.K, 2012). This method were used to calculate the sample size (n) (1) Where: Total number of sample (N) = 2800 nurses (Was obtained through a meeting with the Ministry of Health Director) Percentage error (d) = 0.05 34 Proportion of the property offers and neutral (p) = 0.50 The upper α/2 point of the normal distribution (z) = 1.96 After solving the equation with these values, n value was obtained that equal to 338 nurses. 3.2.6 Questionnaire Distribution and Data Collection Seven directorates were selected for questionnaire distribution (Nablus, Ramallah, Tulkarem, Jenin, Qalqilya, Hebron and Bethlehem), where both private and governmental hospitals were targeted in each directorate as stated in table 150. Since governmental hospitals are subject supervisory and administrative to the Ministry of Health, the approval to distribute the questionnaires in these hospitals has been taken from the director of hospitals management unit in the ministry, instruction was distributed by Ministry of health to the concerned people in these hospitals to respond and assist in this task, where private hospitals have been preparing their respective private letter to facilitate the distribution of questionnaires. Coordination with the supervisor of nursing in every hospital where the questionnaires were distributed and collected through him/ her or his/ her help at all sections of the hospital. Most head nurses showed great cooperation, while part of them showed great interest regarding the research especially in private hospitals. 35 Questionnaires were filled and returned to the researcher to review the completeness and readability. A total of 650 questionnaires were distributed, 580 were filled and returned back that equal 89% as response, 19 questionnaires were excluded due to incompleteness. 36 Chapter Four Data Analysis After distributing the questionnaires and collecting them back all data collected became ready for analysis. In this chapter the process of analyzing the data and displaying the results will be stated. The responses of all questionnaires were coded and entered to SPSS software to be analyzed. This program has been used in the analysis as being the most appropriate software to address data in a way show the desired results, using the most appropriate tests to analyze such data. 4.1 Respondents Characteristics Distribution Demographic and descriptive analysis will be showed to demonstrate distribution of nurses in terms of many variables such as gender, age, educational level, workplace, years of experience, marital status, number of children, monthly salary, sleeping hours, break intervals and being smoker. Then each hypothesis and it’s related analysis covered in the questionnaire was stated, in addition to a group of general questions at the end of the chapter. The whole sample was 561 valid questionnaires that have been analyzed and divided into two groups resulted in 410 nurses who work more than one shift (rotating shifts) and called the first group in the analysis, while 151 out of 561 work one shift without any rotation but their shifts may be 37 evening or night shift and not necessarily morning shift and called second group in the analysis. These demographic results were summarized in two tables contain all statistics in appendix C (Table 140: Demographic analysis for nurses work more than one shift, Table 141: Demographic analysis for nurses work one shift). Table 2 shows the distribution of nurses by shifts. Table 2: Distribution of nurses by shifts Whole Sample More than Shift One Shift 561 410 151 When the following tables were stated, missing answers and values were excluded from each table. 4.1.1 Below demographic analysis for 410 nurses who work more than one shift will be shown. Gender Table 3 below shows that 54.6% of the sample is females while 45.4% Males. 38 Table 3: Distribution of the first group of nurses by Gender Gender Frequency Percent Valid Percent% Female 221 53.9 54.6 Male 184 44.9 45.4 Governorate Table 4 below shows the distribution of nurses over governorates, the highest percent in Hebron while the lowest in Qalqilya. Table 4: Distribution of the first group of nurses by Governorate Governorate Frequency Valid Percent% Qalqilya 36 9.3 Tulkarem 41 9.5 Jenin 55 13.5 Ramallah 60 14.8 Nablus 70 16.3 Bethlahem 48 12.8 Hebron 97 23.8 39 Age As shown below 54.5% of the sample their age between 25-35, while only 2.4% their age is more than 47 years old. Table 5: Distribution of the first group of nurses by Age Age Frequency Valid Percent% Less than 25 105 25.7 25-35 years 223 54.5 36-46 years 71 17.4 More than 47 10 2.4 Education Level Education status is shown in Table 6, almost 95.4% of the sample has either diploma or B.A degree. Table 6: Distribution of the first group of nurses by Education Level Educational level Frequency Valid Percent% Below high school 1 .2 Diploma 217 53.1 B.A 173 42.3 Master or More 18 4.4 41 Workplace 53.2% are working in Governmental hospital, 43.9% in Private hospital while only 2.9% are working in both. Table 7: Distribution of the first group of nurses by Workplace Workplace Frequency Valid Percent% Governmental hospital 218 53.2 Private hospital 180 43.9 Both Gov. and Prv. 12 2.9 Years of Experience Years of experiences is shown in Table 8, almost 45% of the sample got less than 5 years of experience. Table 8: Distribution of the first group of nurses by Years of Experience Years of Experience Frequency Valid Percent% Less than 5 years 184 44.9 5-10 years 124 30.3 11-15 years 53 12.9 16-20 years 35 8.5 More than 20 years 14 3.4 41 Marital Status 67.5% of the Nurses are married; table 9 shows the marital status. Table 9: Distribution of the first group of nurses by Marital Status Martial Status Frequency Valid Percent% Single 129 31.5 Married 276 67.5 Divorced 2 .5 Widow/er 2 .5 Smoking 26.4% of the nurses are smokers while the rest are not. Table 10: Distribution of the first group of nurses by Smoking Smoking Frequency Valid Percent% Yes 105 26.4 No 293 73.6 Average sleeping hours The average sleeping hours is 6.1 hours (383 nurses answer this question out of 410). 42 Break Interval Table 11 shows the break interval allowed during every shift, 60.2% got less than 15 minutes break, while 5.3% got more than 30 minutes. Table 11: Distribution of the first group of nurses by Break Interval Break intervals allowed during every shift Frequency Valid Percent% Less than 15 minutes 237 60.2 16-30 minutes 136 34.5 More than 30 minutes 21 5.3 Monthly Salary 60.7% of the nurses their monthly salaries between 2500- 3500 NIS Table 12: Distribution of the first group of nurses by Monthly Salary Monthly Salary Frequency Valid Percent% Less than 2500 NIS 123 30.2 2500-3500 NIS 247 60.7 More than 3500 NIS 37 9.1 43 4.1.2 Below demographic analysis for 151 nurses who work one shift will be shown. Gender Table 13 below shows that 53% of the sample is females while 47% Males. Table 13: Distribution of the second group of nurses by Gender Gender Frequency Valid Percent% Female 79 53.0 Male 70 47.0 Governorate Table 14 below shows the distribution of nurses over governorates, the highest percent in Hebron while the lowest in Bethlehem. Table 14: Distribution of the second group of nurses by Governorate Governorate Frequency Valid Percent% Qalqilya 15 10.2 Tulkarem 21 14.3 Jenin 21 14.3 Ramallah 18 12.3 Nablus 20 13.6 Bethlehem 14 9.6 Hebron 38 25.9 44 Age As shown below 44.3% of the sample their age between 25-35, while only 7.4% their age is more than 47 years old. Table 15: Distribution of the second group of nurses by Age Age Frequency Valid Percent% Less than 25 24 16.1 25-35 years 66 44.3 36-46 years 48 32.2 More than 47 11 7.4 Education Level Education level is shown in table 16, almost 90.6% of the sample has either diploma or B.A degree. Table 16: Distribution of the second group of nurses by Education Level Educational level Frequency Valid Percent% High school 2 1.3 Diploma 71 47.3 B.A 65 43.3 Master or More 12 8.0 45 Workplace 51.3% are working in Governmental hospital, 48.0% in Private hospital while only 0.7% are working in both. Table 17: Distribution of the second group of nurses by Workplace Workplace Frequency Valid Percent% Governmental hospital 77 51.3 Private hospital 72 48.0 Both Gov. and Priv. 1 .7 Years of experience The years of experience is shown in table 18, almost 51.3% of the sample got less than 10 years of experience. Table 18: Distribution of the second group of nurses by Years of Experience Years of experience Frequency Valid Percent% Less than 5 years 39 26.0 5-10 years 38 25.3 11-15 years 35 23.3 16-20 years 24 16.0 More than 20 years 14 9.3 46 Marital Status 73.3% of the Nurses are married; table 19 below shows the marital status. Table 19: Distribution of the second group of nurses by Marital Status Marital status Frequency Valid Percent% Single 33 22.0 Married 110 73.3 Divorced 3 2.0 Widow/er 4 2.7 Smoking 26.4% of the nurses are smokers while the rest are not. Table 20: Distribution of the second group of nurses by Smoking Smoking Frequency Valid Percent% Yes 39 26.4 No 109 73.6 Average sleeping hours The average sleeping hours is 6.9 hours (145 nurses answer this question out of 151). 47 Break Interval Table 21 below shows the break interval allowed during every shift, 55.5% got less than 15 minutes break, while 6.2% got more than 30 minutes. Table 21: Distribution of the second group of nurses by Break Intervals Break Interval Frequency Valid Percent% Less than 15 minutes 81 55.5 16-30 minutes 56 38.4 More than 30 minutes 9 6.2 Monthly Salary 55.7% of the nurses their monthly salaries between 2500- 3500 NIS, while 16.8% are more than 3000 NIS Table 22: Distribution of the second group of nurses by Monthly Salary Monthly Salary Frequency Valid Percent% Less than 2500 NIS 41 27.5 2500-3500 NIS 83 55.7 More than 3500 NIS 25 16.8 48 4.2 Hypothesis Analysis Before starting presenting the results of the hypotheses analysis, the method of calculating these results will be referred to be inferred through the presentation of results as showed below. Table 23: The method of calculating the mean of nurses answers Question S. Disagree Disagree Neutral Agree S. Agree Total Question #1 20 15 30 55 40 160 Question #2 15 20 10 45 70 160 Question #3 10 20 20 65 45 160 Question #4 15 18 12 70 45 160 Question #5 5 10 8 85 52 160 As table showed the assumed sample size= 160 Numbers in the table are the total Answers individuals on each question, the following table clarify the meaning of shaded numbers. Table 24: Respondents average of answers meaning Total What does total mean? 70 Means that there are 70 people of respondents answered the second question with Strongly Agree 12 Means that there are 12 people of respondents answered the fourth question with a neutral 20 Means that there are 20 people of respondents answered the first question to Strongly Disagree 49 Sample of calculation: The following table came as a result of analyzing questions relating to H1. Following will explain the method of calculation to get the values of mean in the table: H1.Total Mean Std. Deviation Std. Error 95% Confidence Interval of the Difference When (б1) 2 =(б2) 2 95% Confidence Interval of the Difference When (б1) 2 ≠(б2) 2 Lower Upper Lower Upper More than one shift 38.1883 5.33314 -5.17886 -10.31077 -7.42575 -10.04681 -7.68972 One Shift 29.3200 8.35562 -4.92624 Example (2): Assuming we have 10 questions for first hypothesis: Total represents the sum of each individual answers to all questions. For example, 33 is the sum of the answers to the first individual in the sample on all the questions in this area. 51 Assuming that there are 500 people in the sample, answers to every person on the previous domain were collected and put the result in the column named Total, which became for each student a certain score does not exceed 50 (the highest coding answer is 5, and the number of questions 10 so, 5 * 10 = 50). Table 25: Calculating the average of answers for each hypothesis Sample Answer of Q 1 Answer of Q2 …. .… .… Answer of Q9 Answer of Q10 Total 1 33 . . . 500 When you use the method in the previous table, taking the total of 410 nurses answers on questions about the first hypothesis, total was divided by 410 to get the mean. If the question requires advanced analysis, for example analyzing one of the demographic variables such as ages, to calculate the mean of each age category, (for example, if individuals who are under the age of 25 is 30, taking the total of 30 nurses answers on questions about the first hypothesis, total was divided by 30 to get the mean of this category. 51 Research hypothesis were analyzed using SPSS software, after this step, the result of each hypothesis was compared with the result of studies mentioned in the second chapter to clarify the difference and the symmetry between these results and research results. This part will state the results and the comparison with mentioned studies respectively. The result of the major hypothesis will be discussed and compared with previous studies. Then a comparison between the two main groups will be clarified first group refer to nurses work in more than one shift and the second group refer to nurses conducting one shift without any rotation. Finally sub hypothesis will be discussed in general and based on a comparison between the demographic variables also. Hypotheses presented in the thesis are those that resulted in a significant difference, hypotheses did not show significant differences were ignored when presenting the hypotheses and demographic variables analysis. Hypothesis 1 H1-Shift work nurses suffering from fatigue and sleep disturbances which may rise to be chronic insomnia. Respondents accepted by 75.8% that Shift work nurses suffering from fatigue and sleep disturbances which may rise to be chronic insomnia, this is consistent with results of previous studies has been mentioned previously 52 in chapter three (Akerstedt T, 2009) and (Bambra, Whitehead, et al, (2008)). After comparing results between the groups it was clear that problem of fatigue and sleep disturbances had the greatest impact on the first group due to the nature of their shifts, their response has a mean of 38.1883 with 95% confidence that is greater than the mean of second group having a mean of 29.3200. http://www.ncbi.nlm.nih.gov/pubmed?term=Bambra%20CL%5BAuthor%5D&cauthor=true&cauthor_uid=18407011 53 Table 26: Comparing results between the two groups regarding fatigue and sleep disturbances. H1.Total Mean Std. Deviation Std. Error 95% Confidence Interval of the Difference When (б1) 2 =(б2) 2 95% Confidence Interval of the Difference When (б1) 2 ≠(б2) 2 Lower Upper Lower Upper More than one shift 38.1883 5.33314 -5.17886 -10.31077 -7.42575 -10.04681 -7.68972 One Shift 29.3200 8.35562 -4.92624 54 Sub Hypothesis H1.1 Nurses who work in shifts do not take enough hours for sleeping and rest, and this problem may increase to suffering from insomnia, so they feel tired and sleepy all the time. Respondents accepted by 82.2% of that nurse who work in shifts do not take enough hours for sleeping and rest so they feel tired and sleepy all the time, this result agreed with the study of (J. Pincombec, A. E. Rogersd, et al., 2011) that emphasized on necessity of taking naps to reduce the effect of being awake for long time. This result agreed with another study for (Akerstedt T, 2009) that resulted in nurses suffering from insomnia as a result of sleep disturbance. Comparing between the groups showed that the first group is suffuring more than the second one relating to sleeping hours and and rest so they feel sleepy all the time their response has a mean of 22.0976 with 95% confidence that is greater than the mean of second group with a mean of 17.8874. 55 Table 27: Comparing between the two groups (H1.1) H1.1Total Mean Std. Deviation Std. Error 95% Confidence Interval of the Difference When (б1) 2 =(б2) 2 95% Confidence Interval of the Difference When (б1) 2 ≠(б2) 2 Lower Upper Lower Upper More than one shift 22.0976 2.78403 0.13749 -5.17886 -3.24143 -4.92624 -3.49405 One Shift 17.8874 5.79027 0.47121 To study hypothesis and linked to the demographic variables those variables were analyzed and the results were as follows: Age: It was clear from the results that the highest age group are suffering the most from the problem of lack of sleeping hours and rest so they feel sleepy all the time, this is the result of the accumulation of stress and suffering through their work during the long years of work, with aging these accumulations begin to appear and show signs of fatigue and insomnia. 56 Table 28: H1.1 Statistical analysis by age. Age Mean Std. Deviation Std. Error 95% Confidence Interval for Mean Lower Bound Upper Bound Less than 25 18.4300 2.97211 0.29721 17.8403 18.6197 25-35 years 19.9170 3.41400 0.22560 19.4725 21.3616 36-46 years 20.7273 4.71362 1.42121 19.8906 21.6927 More than 47 20.7917 3.83438 0.45189 20.2976 20.9791 The presence of children The results showed that suffering of the problem of lack of sleeping hours and rest increases as the number of children so they feel sleepy all the time, with the presence of children and take care of their own burdens, take a break while at home it becomes difficult. This is reflected on the nurses during their work as always feel they do not take enough sleep and rest. 57 Table 29: H1.1 Statistical analysis by presence of children. The presence of children Mean Std. Deviation Std. Error 95% Confidence Interval for Mean Lower Bound Upper Bound None 20.1226 3.30939 0.25532 19.9185 20.9267 Less than 3 21.2444 3.24949 0.27967 20.6913 21.7976 3-6 21.3652 3.98846 0.41583 19.2392 21.8912 More than 7 22.1667 4.83986 1.39715 17.0916 23.2418 Total 21.6069 3.52301 0.17463 20.2636 21.9502 Smoking: Smokers suffer more than Non-Smokers regarding sleeping hours, this result may be referred to caffeine consumption accompanying with smoking. 58 Table 30: H1.1 Statistical analysis by Smoking. Are you a smoker Mean Std. Deviation Std. Error 95% Confidence Interval of the Difference When (б1) 2 =(б2) 2 95% Confidence Interval of the Difference When (б1) 2 ≠(б2) 2 Lower Upper Lower Upper Yes 20.8994 3.29290 0.19043 -1.59483 -0.02908 -1.67568 -0.05178 No 20.0873 3.99114 0.39304 Break Interval: Whenever the break interval decrease the problem of sleeping hours and taking rest increased, this happen because nurses can not take rest or a short nap during their work due to work pressure so they feel sleepy. 59 Table 31: H1.1 Statistical analysis by Break Interval. H1.2 Nurse who work in shifts do not have special place in the hospital for to take a break and do not have entertainment (TV, PC, Internet, beverages,…) Results below showed inability of nurses to take a break and the lack of places dedicated to the comfort and the failure of the hospital to provide the means for their entertainment, this will increase work pressure so they performance will affected negatively. Break Interval Mean Std. Deviation Std. Error 95% Confidence Interval for Mean Lower Bound Upper Bound Less than 15 minutes 21.1149 3.23304 .21090 20.6994 21.5304 16-30 minutes 20.1189 3.57710 0.29913 19.5276 20.7102 More than 30 minutes 18.9048 5.04881 1.10174 16.6066 21.2030 Total 20.6416 3.51870 0.17616 20.2953 20.9879 61 Table 32: H1.2 Statistical analysis Nurses can take break or short nap Frequency Valid Percent Disagree 265 64.6 Neutral 61 14.9 Agree 84 20.5 Total 410 100.0 Table 33: H1.2 Statistical analysis Hospital provides entertainment (TV, PC, Internet, beverages,…) Frequency Valid Percent Disagree 349 85.1 Neutral 16 3.9 Agree 45 11.0 Total 410 100.0 Table 34: H1.2 Statistical analysis There is a special place in the hospital for the nurses to take a break Frequency Valid Percent Disagree 305 74.4 Neutral 29 7.1 Agree 76 18.5 Total 410 100.0 61 After comparing results between the groups it was clear that problem of taking rest and provision of entertainment means had the greatest impact on the first group due to the nature of their shifts, their response has a mean of 7.7512with 95% confidence that is greater than the mean of second group with a mean of 5.8477. Table 35: Comparing between the two groups (H1.2) H 1.2 Total Mean Std. Deviation Std. Error 95% Confidence Interval of the Difference When (б1) 2 =(б2) 2 95% Confidence Interval of the Difference When (б1) 2 ≠(б2) 2 Lower Upper Lower Upper More than one shift 7.7512 4.57179 0.22578 -2.56500 -2.76500 -2.69271 -2.89271 One Shift 5.8477 3.06539 0.24946 62 H1.3 Nurse who work in shifts take stimulant beverages and drugs to stay awake Nurses agreed that they have to take stimulant drinks and sometimes they may have to take stimulant medications, but lower rates of stimulant drinks to stay awake, this result came up with same results of a study for (Jay, Petrilli, et al., 2006) that warned of the impact of long-term use of theses drinks and drugs what may cause addiction and other negative health effects. Tables 36: H1.3 Statistical analysis I have to take drink stimulant beverages to stay awake on the job (coffee, energy drinks, …) Frequency Valid Percent Disagree 98 17.5 Neutral 54 9.6 Agree 409 72.9 Total 561 100.0 Tables 37: H1.3 Statistical analysis I have to take stimulant drugs to stay awake on the job Frequency Valid Percent Disagree 391 69.7 Neutral 71 12.7 Agree 99 17.6 Total 561 100.0 More analysis was conducting to link hypothesis to demographic variables as follows: 63 Smoking: Non-smokers take stimulant beverages and drugs to stay awake more than smokers, this may have a close explanation to a previous hypothesis that linked this phenomenon to caffeine consumption which increase with smoking, so non-smokers can stay awake more than smokers with loss consumption of stimulant beverages and drugs. Table 38: H1.3 Statistical analysis by Smoking Are you a smoker Mean Std. Deviation Std. Error 95% Confidence Interval of the Difference When (б1) 2 =(б2) 2 95% Confidence Interval of the Difference When (б1) 2 ≠(б2) 2 Lower Upper Lower Upper Yes 4.0068 1.09167 0.06378 +0.17408 +0.31281 +0.17374 +0.31246 No 5.0762 1.08038 0.10543 64 Gender: Results showed that female nurses take stimulant beverages and drugs to stay awake more than male nurses, this hypothesis could be explained after linking smoking and caffeine consumption rate to it, because male smokers formed the highest percent of smokers. Table 39: H1.3 Statistical analysis by Gender Gender Mean Std. Deviation Std. Error 95% Confidence Interval of the Difference When (б1) 2 =(б2) 2 95% Confidence Interval of the Difference When (б1) 2 ≠(б2) 2 Lower Upper Lower Upper Male 3.9638 1.10723 0.07448 -0.35463 -0.07571 -0.35423 -0.07531 Female 4.1033 1.08401 0.07991 65 H1.4 Fatigue and drowsiness are only associated with night shifts Results below showed that fatigue and drowsiness are not associated with night shifts and accompanying them in all shifts. Table 40: H1.4 Statistical analysis Fatigue and drowsiness are only associated with night shifts Frequency Valid Percent Disagree 265 64.6 Neutral 62 15.1 Agree 83 20.2 Total 410 100.0 Hypothesis 2 H2- Diverse health problems may appear as a result of shift work. Around 79.4% from nurses filled the questionnaire accepted that diverse health problems may appear as a result of shift work and this result agreed with previous studies in this domain such as ( Barnes J. L.,Davies K. S., et al., 2010). Results showed that the first group was affected more than the second group regard up having health problems due to their work system, their response has a mean of 20.5073 with 95% confidence that is greater than the mean of second group with a mean of 18.6556. 66 Table 41: Comparing results between the two groups regarding health problems H2.Total Mean Std. Deviation Std. Error 95% Confidence Interval of the Difference When (б1) 2 =(б2) 2 95% Confidence Interval of the Difference When (б1) 2 ≠(б2) 2 Lower Upper Lower Upper More than one shift 20.5073 4.41449 0.21802 -2.58222 -1.12116 -2.64318 -1.06020 One Shift 18.6556 3.69332 0.30056 Sub Hypothesis H2.1 Nurses working in shifts system suffering from decrease or increase in weight as a result of the different system of their lives and their diet, nurses can not adopt healthy diet because they take their males at hospital without any choices, also they do not have regular free time to playing sports and exercising. Results showed that respondents accepted this hypothesis but not in a high percentage of acceptance, specially the weight loss one. 67 Table 42: H2.1 Statistical analysis I gained weight due to shift work system Frequency Valid Percent Disagree 160 39.0 Neutral 66 16.1 Agree 184 44.9 Total 410 100.0 Table 43: H2.1 Statistical analysis I lost weight due to shift work system Frequency Valid Percent Disagree 161 39.3 Neutral 86 21.0 Agree 163 39.8 Total 410 100.0 Weights of the first group is affected more than second group whom working in one shift, this may resulted from work stress, so they relieve this stress by consumption of a larger amount of food. 68 Table 44: Comparing between the two groups (H2.1) H2.1Total Mean Std. Deviation Std. Error 95% Confidence Interval of the Difference When (б1) 2 =(б2) 2 95% Confidence Interval of the Difference When (б1) 2 ≠(б2) 2 Lower Upper Lower Upper More than one shift 4.2829 1.11796 0.05521 -0.35412 -0.05317 -0.35739 -0.05643 One Shift 4.0132 1.07502 0.08748 Only one demographic variable showed significant difference when analyzed which was gender, it was clear that females affected more than males. Table 45: H2.1 Statistical analysis by Gender Gender Mean Std. Deviation Std. Error 95% Confidence Interval of the Difference When (б1) 2 =(б2) 2 95% Confidence Interval of the Difference When (б1) 2 ≠(б2) 2 Lower Upper Lower Upper Female 4.0588 0.95878 0.06449 -0.65988 -0.23334 -0.66472 -0.22850 Male 3.5054 1.22362 0.09021 69 H2.2 Smoking levels between nurses may increase as a result of shift work. Result showed that smoking rate of smokers increased due to their work system, this may be a result of work stress so nurses find smoking as way to get rid of this stress, but results showed that non-smokers did not become smokers. Table 46: H2.2 Statistical analysis Cigarettes I smoke increased due to shift work system Frequency Valid Percent Disagree 112 27.3 Neutral 58 14.1 Agree 240 58.5 Total 410 100.0 Table 47: H2.2 Statistical analysis I became a smoker as a result of my work Frequency Valid Percent Disagree 254 62.0 Neutral 63 15.4 Agree 93 22.7 Total 410 100.0 71 The proportion of smokers from the first group is greater than the percentage of the second group; their response has a mean of 3.7951with 95% confidence that is greater than the mean of second group with a mean of 3.1636. Table 48: Comparing between the two groups (H2.2) H2.2Total Mean Std. Deviation Std. Error 95% Confidence Interval of the Difference When (б1) 2 =(б2) 2 95% Confidence Interval of the Difference When (б1) 2 ≠(б2) 2 Lower Upper Lower Upper More than one shift 3.7951 1.62445 0.08023 +0.13308 +0.46999 +0.13422 +0.47113 One Shift 3.1636 1.60323 0.13047 With the aging some smokers lift off from this habit because of illnesses and health problems led to quit smoking, It is noted that the problem of smoking increased among younger age groups as follows: 71 Table 49: H2.2 Statistical analysis by Smoking Age Mean Std. Deviation Std. Error 95% Confidence Interval for Mean Lower Bound Upper Bound Less than 25 3.2000 1.57138 0.15335 2.8959 3.5041 25-35 years 3.4350 1.67494 0.11216 3.2139 3.6560 36-46 years 2.9282 1.48297 0.17600 2.6772 3.3792 More than 47 2.8000 1.93218 0.61101 1.8178 4.5822 Total 3.2983 1.62518 0.08036 3.1403 3.4563 H2.3 Nurses became Susceptible to chronic diseases, frequent health setbacks and intestinal disorders due to shift work. The results showed that nurses are more likely than others to health problems and increase their exposure to health setbacks and intestinal disorders as a result of the nature of their work, this result agreed with the study result of (Boggild. H, 2000) 72 that emphasized on this issue, the study mentioned for the increase of heart attacks, diabetes, beside the increase of cancers, also nurses immunology decrease, so they be exposed more than others for health setbacks as esoteric diseases, cold and flu. Tables 49: H2.3 Statistical analysis I suffer chronic diseases because of my work (pressure, diabetes, …) Frequency Valid Percent Disagree 333 59.4 Neutral 101 18.0 Agree 127 22.6 Total 561 100.0 Tables 50: H2.3 Statistical analysis I have frequent health setbacks due to my work Frequency Valid Percent Disagree 192 34.2 Neutral 102 18.2 Agree 267 47.6 Total 561 100.0 73 Tables 51: H2.3 Statistical analysis I suffer intestinal disorders as a result of shift work system (colic, loss of apppetite, …) Frequency Valid Percent Disagree 119 21.2 Neutral 86 15.3 Agree 356 63.5 Total 561 100.0 After comparing results between the groups it was clear that problem of smoking had the greatest impact on the first group due to the nature of their shifts, their response has a mean of 7.7512 with 95% confidence that is greater than the mean of second group with a mean of 5.8477. 74 Table 52: Comparing between the two groups (H2.3) H2.3Total Mean Std. Deviation Std. Error 95% Confidence Interval of the Difference When (б1) 2 =(б2) 2 95% Confidence Interval of the Difference When (б1) 2 ≠(б2) 2 Lower Upper Lower Upper More than one shift 6.7537 1.85628 0.09168 +0.22460 +0.48682 +0.21883 +0.48105 One Shift 6.0848 1.91269 0.15565 Below it was clear that the older age group are more likely to suffer from this problem. 75 Table 53: H2.3 Statistical analysis by Age Age Mean Std. Deviation Std. Error 95% Confidence Interval for Mean Lower Bound Upper Bound Less than 25 5.9810 1.85525 0.18105 5.6219 6.3400 25-35 years 6.2063 1.76619 0.11827 5.9732 6.4394 36-46 years 6.5958 2.10709 0.25007 5.7970 6.7945 More than 47 6.7000 2.11082 0.66750 4.1900 7.2100 Total 6.1516 1.85808 0.09188 5.9710 6.3322 Hypothesis 3 H3- Shift work nurses suffering from diverse social and psychological problems due to the nature of their working times. Respondents accepted by 77.3% that Shift work nurses suffering from diverse social and psychological problems due to the nature of their working times, this is consistent with results of previous studies has been mentioned previously in chapter three (Goswami R, 2012). A comparison between the two groups was conducted and the results showed that the first group suffer more than the second group, their response has a mean of 66.6659 with 95% confidence that is greater than the mean of second group with a mean of 42.7682. 76 Table 54: Comparing results between the two groups regarding social and psychological problems H.3 Total Mean Std. Deviation Std. Error 95% Confidence Interval of the Difference When (б1) 2 =(б2) 2 95% Confidence Interval of the Difference When (б1) 2 ≠(б2) 2 Lower Upper Lower Upper More than one shift 66.6659 11.82484 0.58399 -26.88709 -20.90819 -26.41761 -21.37768 One Shift 42.7682 17.19436 1.39926 Sub Hypothesis H3.1 Nurses work in shifts suffering from psychological problems due to work pressure Nurses agreed by 70.6% that nurses work in shifts suffering from psychological problems due to work pressure, these problems resulted from situations of death of their patients, their sense of isolation, instability of their shifts and daily problems in dealing with patients needs and their relatives, This result agreed with the study of (Domrose, 2011). 77 Comparing between the groups showed that the first group is suffuring more than the second one relating to psychological problems their response has a mean of 28.2732with 95% confidence that is greater than the mean of second group with a mean of 24.6490. Table 55: Comparing between the two groups (H3.1) H3.1 Total Mean Std. Deviation Std. Error 95% Confidence Interval of the Difference When (б1) 2 =(б2) 2 95% Confidence Interval of the Difference When (б1) 2 ≠(б2) 2 Lower Upper Lower Upper More than one shift 28.2732 5.30521 0.26201 -4.64988 -2.59845 -4.62767 -2.62065 One Shift 24.6490 5.53197 0.45019 To study hypothesis and linked to the demographic variables those variables were analyzed and the results were as follows: 78 Salary Scale: It was clear from the results that the highest group accepted that they are suffering the most from psychological problems is the group of the lowest salaries, this result may be explained that lower standard of living because of the low-income will result in suffering from psychological problems. Table 56: H3.1 Statistical analysis by Salary Scale Salary Scale Mean Std. Deviation Std. Error 95% Confidence Interval for Mean Lower Bound Upper Bound Less than 2500 NIS 28.6423 5.31643 0.47937 27.6933 29.5912 2500-3500 NIS 28.1579 5.32781 0.33900 27.4902 28.8256 More than 3500 NIS 27.7568 5.14461 0.84577 26.0415 29.4721 Total 28.2678 5.30215 0.26282 27.7512 28.7845 Break Interval: It was clear from the results that the highest group accepted that they are suffering the most from psychological problems is the group of the lowest break interval, because they do not have any time to get rid of work pressure or to entertaining themselves. 79 Table 57: H3.1 Statistical analysis by Break Interval Break Interval Mean Std. Deviation Std. Error 95% Confidence Interval for Mean Lower Bound Upper Bound Less than 15 minutes 28.5738 5.21079 0.33848 27.9070 29.2407 16-30 minutes 27.8456 5.30112 0.45457 26.9466 28.7446 More than 30 minutes 27.5238 5.67996 1.23947 25.9383 31.1093 Total 27.8198 5.26492 0.26524 27.7983 28.8413 Workplace: Nurses work in governmental hospitals suffer from psychological problems more than those working in private hospitals, this may be a result of work pressure and difficult working conditions in these hospitals in addition to salaries cutout and strikes are made for this purpose, as following results state: 81 Table 58: H3.1 Statistical analysis by Workplace Workplace Mean Std. Deviation Std. Error 95% Confidence Interval of the Difference When (б1) 2 =(б2) 2 95% Confidence Interval of the Difference When (б1) 2 ≠(б2) 2 Lower Upper Lower Upper Governmental hospital 28.6606 5.31881 0.36024 0.25832 1.84609 0.25825 1.84601 Private hospital 27.8667 5.30879 0.39569 H3.2 Nurses work in shifts suffering from social problems due to work pressure Nurses agreed by 68.4% that nurses work in shifts suffering from social problems due to work pressure, this result agreed with results of a study for (Goswami R, 2012) that emphasized on the difficulty of spending time with family, practicing any hobbies and activities and maintaining social relations. Comparing bet