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International Journal of Nursing Studies Advances logoLink to International Journal of Nursing Studies Advances
. 2021 Apr 24;3:100028. doi: 10.1016/j.ijnsa.2021.100028

A comparison of occupational physical activity and sedentary behavior patterns of nurses working 12-h day and night shifts

RM Benzo a,⁎, A Farag b, KM Whitaker a,c, Q Xiao d, LJ Carr a
PMCID: PMC11080359  PMID: 38746725

Abstract

Background

Past studies have reported nurses working day shifts engage in high amounts of light and moderate-intensity occupational physical activity. However, little is known regarding how occupational physical activity and sedentary behavior is accumulated within shifts and/or over consecutive shifts.

Objective

This study compared occupational physical activity and sedentary behavior patterns of nurses working 12-h. day vs. 12 -h. night shifts. We hypothesized nurses working day shifts would be more active and less sedentary while at work compared to nurses working night shifts and that within shift and between shift differences would emerge.

Design

Prospective-cohort study design

Setting(s)

Midwestern trauma one academic medical center medical units (medical surgical, critical care, pediatrics, mother and baby, and other)

Participants

A total of 56 registered nurses working 12-h. day and night shifts participated in this study.

Methods

Occupational physical activity and sedentary behaviors (e.g., step count, time spent sitting, standing, and walking) were measured for 14 continuous days using the ActivPAL 3 micro activity monitor. Repeated measures mixed-effects regression models were used to examine the effects of shift type, consecutive shifts, and time within a shift on occupational physical activity and sedentary behaviors.

Results

Nurses spent more time standing and walking, and less time sitting overall during day shifts compared to night shifts. Nurses walked less during the third consecutive night shift and stood less and sat more during the second and third consecutive night shifts, compared to day shifts. Nurses tended to walk less and sit more during the middle portion of each night shift compared to day shifts.

Conclusions

Our findings suggest nurses spend more than half of each shift either standing or walking and that differential patterns of occupational physical activity and sedentary behavior exist between day and night shifts. These findings should be used to inform future interventions designed to advance the health and work performance of nurses.

Keywords: Accelerometry, Nursing, Occupational health nursing, Physical exertion, Sedentary behavior, Shift work schedule

What is already known about the topic?

• Previous studies have reported nurses are highly active at work spending most of the shift engaged in light-intensity activity (e.g., standing, walking, patient care) interspersed with bouts of moderate-intensity activity.

• Little is known regarding patterns of occupational physical activity and/or sedentary behaviors between and/or within shifts.

What this paper adds

• Nurses spend more than half of their shift either standing (50%) or walking (15%) which suggests nursing work is physically demanding.

• Nurses working day shifts sit less (35% vs 44% of shift), stand more (49% vs 42% of shift) and walk more (15% vs 13% of shift) at work compared to nurses working night shifts.

• Nurses working night shifts demonstrated a significant rise in sitting time, and a significant decrease in standing and walking time, over the course of three consecutive shifts.

• Nurses tended to sit more and move less during the middle portion of night shifts compared to day shifts.

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1. Background

Healthcare workers are the largest global workforce and approximately half of all healthcare workers are nurses (Organization, 2016). It is well established that nurses are subject to challenging occupational demands including working long hours, shift work, consecutive shifts, and rotating shifts (Chappel et al., 2017). Such challenging work demands have been associated with negative occupational and health outcomes among nurses. For example, the odds of burnout and job dissatisfaction have been reported to be two and a half times higher among nurses who report working 12+ hours/shift compared to nurses working standard 8–9-h shifts (Stimpfel et al., 2012). The risk of occupational injuries has been shown to be higher during consecutive shifts (Folkard and Lombardi, 2006). Both all cause and cardiovascular disease related mortality have been shown to be higher among nurses who report working rotating night shifts for more than five years (Gu et al., 2015). Frequent rotating shifts has also been associated with anxiety and impaired attention among nurses (Chang et al., 2014). Nurses working night shifts have been found to report poorer physical and mental health and less satisfaction with social roles compared to nurses working day shifts (Imes and Chasens, 2019). Finally, shift work and long work hours increase the risk for impaired job performance, injuries, and several chronic diseases including obesity (Caruso, 2014).

Physical activity and sedentary behavior are modifiable health behaviors that have potential for ameliorating many of the negative occupational and health consequences associated with the challenging demands of nursing work. However, these relationships are not fully understood. Current physical activity guidelines for Americans recommend healthy adults “do at least 150 min (2 h and 30 min) to 300 min (5 h) a week of moderate-intensity, or 75 min (1 hour and 15 min) to 150 min (2 h and 30 min) a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity” (U.S. Department of Health and HumanServices 2018). Sedentary behavior is defined as any wakeful behavior expending less than 1.5 metabolic equivalents while in a sitting, reclining, or lying position (Tremblay et al., 2017). While specific guidelines for sedentary behavior have not been recommended in the U.S., the guidelines recommend healthy adults sit less and avoid long periods of inactivity. We currently do not fully understand occupational patterns of physical activity and sedentary behavior among U.S. hospital nurses, or if they meet the Physical Activity Guidelines for Americans (U.S. Department of Health and HumanServices 2018).

Previous studies have examined the occupational physical activity behaviors of nurses. A systematic review conducted by Chappel et al. (2017), which included an international sample of nurses (from Canada, China, Japan, Poland, Saudi Arabia, Switzerland, Taiwan, United States), found that nursing work consists mostly of light-intensity physical activity (non-sedentary waking behavior that requires less than 3.0 metabolic equivalents), interspersed with bouts of moderate-intensity (non-sedentary waking behavior that requires between 3 and 6 metabolic equivalents) (Chappel et al., 2017). The authors concluded nurses spend most of their shift either walking or standing (Chappel et al., 2017). The review also concluded day shifts tend to be more physically active and demanding than night shifts (18% vs. 9% of time spend in moderate-intensity physical activity, respectively) (Nicoletti et al., 2014). A study by Makowiec-Dabrowska et al. (2000) found occupational physical activity may differ by setting as authors reported from a sample of Polish nurses working in administrative roles spend more time in light-intensity (52%) than moderate-intensity physical activity (34%) during nursing shifts (Makowiec-Dąbrowska et al., 2000). Little is known regarding how physical activity levels fluctuate within a given shift. It is also unknown whether physical activity levels change over the course of several consecutive shifts (Chappel et al., 2017).

Sedentary behavior is another modifiable health behavior, that has been associated with several negative health outcomes independent of physical activity. For example, prolonged sedentary time has been associated with an increased risk of several chronic diseases, including cardiovascular disease, type II diabetes, and various cancers (Biswas et al., 2015, de Rezende et al., 2014). Few studies have explored the occupational sedentary behaviors of nurses in general. Prince et al. measured the occupational sedentary behavior of 313 Canadian nurses using two subjective measures of sedentary behavior and an accelerometer (Prince et al., 2018). Their findings suggest nurses spent an average of 7.2 h per workday sedentary. Schall et al. objectively measured occupational sedentary behavior of 36 American registered nurses over a single shift. They found shift working nurses (including night and day shifts) spent 58.2% of the shift in light-intensity physical activity, 7% in moderate-intensity physical activity, and 34.9% of the shift sedentary. Kolbe et al. compared occupational sedentary behaviors of South African nurses working day shifts (n = 80) versus night shifts (n = 81) over seven consecutive days (Kolbe et al., 2015). They found nurses spent 96% of their time either sedentary or engaged in light intensity physical activity. The authors also reported nurses working night shifts spent less time sedentary (56%) than those working day shifts (60%, p = 0.02). In conclusion, results from these studies suggests nurses spend a significant amount of occupational time sedentary. However, little is known regarding how occupational sedentary behaviors fluctuate within and between shifts among nurses.

Previous studies in this area have predominantly relied on subjective measures of physical activity and sedentary behavior which are less accurate than objective measures (Almajwal, 2015, Lee et al., 2005, Wilbur et al., 1999). For example, two separate studies (Almajwal et al., Lee et al.) reported that nurses’ occupational physical activity was of light-intensity (Almajwal, 2015, Lee et al., 2005), in contrast a study conducted by Lee et al. reported that the average energy expenditure across a shift equated to moderate-intensity physical activity (Wilbur et al., 1999). Previous studies have also been limited by short observation periods which limits our ability to understand the effect of consecutives shifts on occupational physical activity and sedentary behavior. Finally, few studies have examined within-shift patterns of physical activity and sedentary behavior among nurses working 12-h. day and 12-h. night shifts. Understanding between and within shift patterns of occupational physical activity and sedentary behavior and the factors that influence changes in occupational physical activity and sedentary behavior could help inform optimal scheduling procedures and interventions focused on improving the health and work performance of nurses.

Therefore, the purpose of this study was to investigate the effects of shift type (day: 7 AM – 7 PM, and night: 7 PM – 7 AM), consecutiveness of work shifts (aim one), and hour of each work shift (aim two), on nurses’ occupational patterns of physical activity and sedentary behavior. We hypothesized nurses would be more physically active (step count, standing time, walking time) and less sedentary (sitting time) during day shifts compared to night shifts. We also hypothesized nurses would become increasingly less active and more sedentary over the course of consecutive shifts.

2. Methods

2.1. Design

This project was part of a larger parent study (n = 1137) focused on understanding patterns and predictors of nurse fatigue and its impact on medication errors and near misses (Groves et al., 2020). The parent study was a three-phase mixed-methods study that collected qualitative and quantitative self-report data and real time measurement (ecological momentary assessments and accelerometry). In the first phase participants completed a battery of questionnaires, the second phase participants were asked to wear accelerometers and report momentary measures of fatigue, medication errors, and near misses, and the third phase nurses were invited to participate in personal interviews about their inter-shift recovery measures.

Although the data for the parent study were collected from 8 sites, for the feasibility of distributing and retrieving the wearables, data for this study were collected from a single site (trauma one academic medical center). A total of seven units were randomly selected to be included in this study.

A prospective cohort design that included repeated measures was used for the current study. The inclusion criteria for this study were (1) registered nurse, (2) working 12-h. shifts, (3) owned a smartphone capable of receiving and sending text messages, and (4) currently working in critical care or in-patient units at the study site. Nurse managers, agency nurses, and travel nurses were excluded from the study.

2.2. Sample

A total of 116 participants were approached to participate in the study. Of those 116 participants, 58 participants agreed to participate and were included in the final analyses. Participants were recruited from seven medical units: medical surgical, critical care, pediatrics, mother and baby, emergency department, float (no department), and other. Only nurses from five of these departments participated in this study (see Table 1).

Table 1.

Study Participant Demographics.

Survey Variables Study Population
Observations 58
Individual Level Factors
Average Age (years) 30.8 (9.1)
Percent Female (n) 83% (52)
Regular Exercisers (n) 57% (33)
Average Days of Weekly Exercise Engagement (SD) 3.3 (1.11)
Minutes a day of Exercise Engagement (SD) 48.5 (18.56)
Self-Reported Average Sleep Hours per NightDuring the Last 30 Days (PSQI) 6.5 (1.13)
Occupational Level Factors
Years of Nursing Experience (SD) 5.7 (7.7)
Typical Hours Worked per Week (SD) 36.2 (5.9)
Work Status (n)
PRN 0% (0)
Part-Time 19% (11)
Full-Time 81% (46)
Medical Unit (n)
Medical Surgical 54% (31)
Critical Care 26% (15)
Pediatrics 2%% (1)
Mother and Baby 13% (8)
Other (n) 4% (6)
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Abbreviations: SD, standard deviation; PRN, “pro re nata” (Latin term; i.e., as needed); n, count.

Differences in variables between subgroups were analyzed using unpaired t-tests when only two subgroups were involved or one-way ANOVA if multiple subgroups were involved.

*** p < 0.001, ** p < 0.01, * p < 0.05

2.3. Measures

Participants’ demographic information was collected with a paper survey administered to nurses via their work mailbox . sedentary behavior and physical activity outcomes were measured objectively using an ActivPAL activity monitor (ActivPAL3™ and ActivPAL3™ micro; PAL Technologies Ltd., Glasgow, UK). The ActivPAL™ 3 and ActivPAL™ 3 micro monitors are small (7 mm and 5 mm thick, respectively) and light (20 g and 9 g, respectively) monitors worn on the midline of the anterior portion of the right thigh (Calabro et al., 2014, Powell et al., 2016). The ActivPAL is both an accelerometer and an inclinometer that uses proprietary algorithms (Intelligent Activity Classification™) to estimate steps, time spent sitting, time spent standing, and time spent walking (Edwardson et al., 2017). Participants were asked to wear the ActivPAL™ monitor 24-h a day, for 14 consecutive days. Participants were advised to remove the monitor during bathing and swimming activities.

Invalid days and periods of non-wear/sleep were identified using a validated algorithm developed by Winkler et al. (Winkler et al., 2016). Waking wear time was defined as any period not labeled as non-wear/sleep by the algorithm (Winkler et al., 2016). The algorithm has been evaluated in previous studies which found an ‘almost perfect’ (kappa > 0.8) agreement compared to the diary method in a great majority of participants (88%) and ‘substantial or better’ agreement (kappa > 0.6) for approximately the entire sample (97%) (Winkler et al., 2016). All periods identified as sleep/non-wear were excluded from the analyses of this project.

Work shifts that included at least 10 h of valid data were included in the final analysis. Individual hours with at least 50 min of valid data were included in the final analysis. Previous studies have used similar thresholds of waking wear time to determine the validity of observation periods (Edwardson et al., 2017).

2.4. Analyses

Stata software version 14.2 software (StataCorp LP; College Station, Texas) was used for all analyses. Two datasets were used in the analyses to take advantage of the statistical approach implemented which allows for missing values. The dataset for aim one includes all shifts that were categorized as valid (80% of shift recorded as waking wear time), and the dataset for aim two includes all hours categorized as valid (80% of the hour recorded as waking wear time).

Repeated measures mixed-effects (syntax ‘xtmixed’) regression models (Fitzmaurice et al., 2011), were used to examine the effects of shift type (12-h day vs. 12-h. night), consecutiveness of work shift (aim one), and hours of a work shift (aim two) on physical activity (steps per hour, minutes spent standing per hour, and minutes spent walking per hour) and sedentary behavior (minutes spent sitting per hour) outcomes. Thus, for aim one, the unit of time-variable was defined as consecutiveness of work shift (1st, 2nd, or 3rd shift). And, for aim two, the unit of analysis was each hour of the 12-h nursing shift (hour 1 to hour 12).

For all outcome measures (physical activity and sedentary behavior), between-subjects’ effects were estimated by the two main factors: shift-type and time (consecutive shift – aim one; and hour of a work shift – aim two). Within-group differences (differences across hours of work), or the effect of time for each shift, was examined using tests of simple effects and pairwise comparisons. Between-group comparisons include differences of the main effect and simple effects. Interactions between shift-type and hour of work shifts were examined for statistically significant differences for all outcome measures. The trend over time was fitted over coefficients of orthogonal polynomials (e.g., linear, quadratic, cubic) in order to test for difference in slopes. Post-hoc analyses of interactions (overall slope) and partial interactions (slope between timepoints) were performed to identify where significant interactions were detected. Linear growth models were used to estimate the slope of outcome over time for both day and night 12-h nursing shifts. We used linear growth models to test for statistically significant differences between slopes between participants working day vs. night 12-h nursing shifts. We considered a P value of < 0.05 as statistically significant.

A waiver of the signed consent was requested and granted by the academic institution Human Subjects Office. Completing and mailing the survey back indicated nurses approval/consent to participate in the study (IRB# 201703758).

3. Results

Demographic characteristics of participants of the study are presented in Table 1. Participants were young to middle aged, mostly female, on average met the physical activity guidelines (160 min of exercise per week) and slept an average of 6.5 h per night. Participants reported working on average 36 h per week, had an average of six years of nursing experience, and most worked either in the medical surgical unit, the critical care unit, or the mother baby unit.

3.1. Aim one – non-adjusted averages of physical activity and sedentary behavior outcomes by shift type

A total of 195 12-h work shifts were observed including 127 day shifts and 68 night shifts. When combining both day and night shifts, nurses sat for an average of 272 min (38%), stood for an average of 339 min (47%), and walked an average of 101 min (14%) for a mean total of 8172 steps per 12-h shift.

When comparing day vs. night shifts, nurses working day shifts walked more steps per shift (p = 0.003; 95%CI = 301.39, 1472.67), spent more time standing (p > 0.001; 95%CI = 25.46, 75.67)and walking per shift (p = 0.001; 95%CI = 4.95, 19.17), and spent less time sitting per shift (p < 0.001; 95%CI = −92.06, −35.40), compared to nurses working night shifts (Table 2).

Table 2.

Non-adjusted physical activity and sedentary behavior outcomes per hour.

Total Day Shift Night Shift p-value
Shifts Observed 195 127 68 -
Avg. Step Count per shift (SD) 8172 (2,276) 8429 (2,300) 7542 (2,020) 0.003⁎⁎
Avg. Min Sitting per shift (SD) 272.4 (112.2) 252.8 (110.2) 316.5 (98.5) 0.000⁎⁎⁎
Avg. Min Standing per shift (SD) 339.3 (99.5) 355.3 (98.5) 304.7 (86.8) 0.000⁎⁎⁎
Avg. Min Walking per shift (SD) 101.4 (29.1) 104.8 (28.30) 92.8 (24.3) 0.001⁎⁎
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This dataset includes means and standard deviations of variables presented; the values in this table do not include predicted marginal differences (i.e., not adjusted for the effect of consecutive work shifts and shift-type). Differences in variables between subgroups were analyzed using unpaired t-tests when only two subgroups were involved.

⁎⁎⁎

p < 0.001,

⁎⁎

p < 0.01, * p < 0.05

3.2. Aim one – the effect of shift type on average physical activity and sedentary behavior outcomes per shift

When exploring between group differences during specific consecutive shifts, nurses working night shifts walked fewer steps (p < 0.001; 95%CI = −5284.41, −1818.34) and spent less time walking (p < 0.001; 95%CI = −66.14, −26.05) compared to those working day shifts on the third consecutive shift (see Fig. 1A and C). Conversely, nurses sat more during the second (p = 0.039; 95%CI = 2.99, 117.58) and third consecutive night shifts (p = 0.01; 95%CI = 56.05, 218.72) compared to day shifts (see Fig. 1D). Nurses also stood less during the second (p = 0.020; 95%CI = −112.19, −9.60) and third consecutive night shifts (p = 0.014; 95%CI = −164.76, −18.51; see Fig. 1B) compared to day shifts.

Fig. 1.

Fig. 1

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Patterns of occupational physical activity and sedentary behavior over consecutive shifts for day and night shift workers.

3.3. Aim one – interactions between shift type and consecutiveness of shift

Significant interactions were observed between the effects of shift type and consecutiveness of shift for step counts per shift (χ2(2, N = 195) = 16.74, p < 0.001), minutes spent walking per shift (χ2 (2, N = 195) = 19.58, p < 0.001), and minutes spent sitting per shift (χ2 (2, N = 195) = 196.70, p = 0.035). No interaction was observed between the effects of shift type and consecutiveness of work shift on minutes spent standing (χ2 (2, N = 195) = 3.98, p = 0.137).

3.4. Aim one – trends of physical activity and sedentary behavior outcomes over consecutive shifts

When examining trends in occupational physical activity and sedentary behavior variables over the course of three consecutive shifts, between group differences emerged. Specifically, a significant increasing trend in step counts/shift was observed over consecutive day shifts (m = 227.8 mean steps per shift, p = 0.003; 95%CI = 48.57, 941.34) while a significant decreasing trend in step count was observed over consecutive night shifts (m = −792.8 mean steps per shift, p = 0.011; 95%CI = −1406.76, −178.92). Time spent walking per shift declined over consecutive night shifts (m = −9.92; p = 0.006; 95%CI = −17.00, −2.84) but did not change over consecutive day shifts. Time spent standing per shift declined over consecutive night shifts (m = −39.35 mean min standing per shift; p = 0.002; 95%CI = −64.42, −14.28) while no trend (change over time) was observed over consecutive day shifts. Finally, minutes spent sitting per shift declined over consecutive night shifts (p = 0.001; 95%CI = 18.96, 74.77) while no changes were observed over consecutive day shifts.

3.5. Aim two – non-adjusted averages of physical activity and sedentary behavior outcomes per hour

A total of 2186 working hours were observed including 1461 day shift hours and 721 night shift hours. During day shifts, nurses accumulated more steps (p < 0.001; 95%CI = 28.54, 94.04), spent more time standing per hour (p < 0.001; 95%CI = 2.09, 4.29), more time walking per hour (p < 0.001; 95%CI = 0.44, 1.20), and less time sitting per hour (p < 0.001; 95%CI = −5.22, -2.59) compared to night shifts (see Table 3).

Table 3.

Non-adjusted physical activity and sedentary behavior outcomes per shift

Participants whose schedule included: Day Shift Night Shift p-value
Shifts Recorded 128 98 –
Steps per hour 737 (373) 675 (364) 0.000⁎⁎⁎
Min Sitting per Hour 20.7 (14.0) 24.6 (15.0) 0.000⁎⁎⁎
Min Standing per Hour 30.2 (11.8) 27.0 (12.5) 0.000⁎⁎⁎
Min Walking per Hour 9.1 (4.3) 8.3 (4.2) 0.000⁎⁎⁎
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Standard errors in parentheses and p values are testing for differences between day and night shifts using unpaired t tests.

⁎⁎⁎

p < 0.001, ** p < 0.01, * p < 0.05

3.5. Aim two – the effect of shift type on hourly averages of physical activity and sedentary behavior outcomes

When exploring differences by shift type at the hourly level, nurses walked significantly more steps during the middle hours of each day shift (hours 7-10) compared to night shifts but walked significantly fewer steps at the beginning and end of each shift (hours 1, 2 and 12; see Fig. 2A). Nurses spent more time walking more during middle hours of each day shift (4-10) (p < 0.05) compared to night shifts (see Fig. 2C) while nurses spent more time walking during hour one of each night shift. Nurses stood significantly more during day shift hours of 2, 4-9, and 11 (see Fig. 2B) compared to night shifts. Finally, nurses sat significantly less during middle shift hours (4-9), compared to night shifts (p < 0.05; see Fig. 2D).

Fig. 2.

Fig. 2

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Within shift patterns of occupational physical activity and sedentary behavior for day and night shift workers.

3.6. Aim two – tnteractions by shift Type and hour of shift for physical activity and sedentary behavior outcomes

Significant interactions between shift type and hour of shift were observed for step count (χ2 (11, N = 2,182) = 54.97, p < 0.001), hours spent walking (χ2 (11, N = 2,182) = 61.69, p < 0.001), hours spent standing (χ2 (11, N = 2,182) = 40.00, p < 0.001), and hours spent sitting (χ2 (11, N = 2,182) = 45.97, p < 0.001).

3.7 Aim. two – trends physical activity and sedentary behavior outcomes over hours of a shift

A significant linear decrease in hourly steps was observed during night shifts (night shift: m = −15.40 average step count per hour; p < 0.001; 95%CI = −22.83,-7.97) which was significantly than the trend observed during day shifts (day shift: m = −3.69 steps/min; χ2 (1, N = 2,182) = 6.36, p = 0.012). Similarly, a significant decreasing trend in minutes spent walking over the course of each night shift hour was observed (night shift m = −0.19 mean min walking per hour; p < 0.001; 95%CI = −0.28, -0.11) which was greater than the trend observed over the course of day shift hours (day shift:m = −0.04 mean min walking per hour; χ2 (1, N = 2,182) = 7.96, p = 0.005). Significant decreasing trends in minutes spent standing per hour were observed during both day (day shift: m = −4.99 mean min standing per hour, p < 0.001; 95%CI = −0.59, -0.26) and night shifts (night shift: m = −15.40 mean min standing per hour, p < 0.001; 95%CI = −0.83, -0.36) but between group differences for trends were not significant (p = 0.250). Finally, significant increases in minutes spent sitting over the course of a given shift was observed during both day shifts (m = 0.51 mean min sitting per hour, p < 0.001; 95%CI = 0.31, 0.71) and night shifts (m = 0.84 mean min sitting per hour, p < 0.001; 95%CI = 0.55, 1.12) but the between group trend difference was not significant (p = 0.069).

4. Discussion

This study examined the effect of work schedule characteristics (shift-type and consecutiveness of shift) on nurses’ patterns of occupational levels of physical activity and sedentary behavior. The findings from this study suggest nurses spend more than half of their time in each shift (7.4 out of 12 h) either standing (47%, 339 min) or walking (14%, 101 min) which suggests nursing work is physically demanding. This finding is consistent with those of Schall et al. who observed a sample of nurses working at the same institution as those included in the present study spent 7.9 h of a single 12-h shift physically active (total time spent in light-, moderate-, and vigorous-intensity activity, or otherwise not classified as sedentary) (Schall et al., 2016). To put this activity level into context, nurses included in this study walked more steps during a single 12-h shift (8172 ± 2276 steps) than the average American adult walks over a full waking day (Althoff et al., 2017). For example, in an observational study of 388,124 U.S. adults, Althoff et al. (2017) reported U.S. adults walk an average of 4,774 steps per day when measured using an iPhone (Althoff et al., 2017). Basset et al. used pedometers to assess daily steps of 1136 participants and found adults, on average, accumulate a total of 5117 steps per day (Bassett et al., 2010).

Nurses in this study walked an average of 101 min per 12-h shift. With this volume of walking and an estimated metabolic equivalent range for walking between 2.0 and 3.0 metabolic equivalents, our findings suggest these working nurses (average of 36 h/week) were achieving 600–900 metabolic equivalent minutes/week while at work alone. This volume of activity is similar to the Physical Activity Guidelines for Americans which recommend achieving 500–100 metabolic equivalent-minutes per week. (Piercy et al., 2018) While this could be viewed as an indicator of positive health behavior, it is important to consider this in relation to the health paradox that may exist between occupational and leisure physical activity.

Henwood et al. (2012) found nurses included in the Australian and New Zealand e-Cohort Study who reported high levels of occupational activity but low levels of leisure activity had a higher body mass index and reported more sick days compared to nurses reporting high levels of leisure activity and low levels of occupational activity (Henwood et al., 2012). Data from Hallman et al. (2017) suggest that this health paradox may be partially explained by the differential impacts occupational and leisure physical activity have on the autonomic nervous system (Hallman et al., 2017). In a cohort study of 514 blue-collar Danish workers, Hallman and colleagues (year) reported a beneficial relationship between leisure activity and nocturnal heart rate and heart rate variability but the relationship diminished with higher levels of occupational activity (accelerometer-measured) (Hallman et al., 2017). Ultimately, it is critical that the relation between occupational physical activity and health among nurses be further explored before interventions are proposed. For instance, if higher levels of occupational physical activity are associated with poorer health outcomes, interventions designed to further increase occupational physical activity among nurses would not be advised.

The present study is one of the few to objectively measure light intensity occupational physical activity and/or occupational sedentary behavior of nurses in the U.S. We found nurses spent 38% (4.56 h) of each 12-h shift sitting and 47% (5.64 h) of each 12-h shift standing. Our findings are similar with those of Schall and colleagues who found a sample of 36 U.S. nurses spent 35% of a single shift sedentary and 58% of each shift engaged in light intensity activity when measured with a waist worn Actigraph GT3X+ accelerometer (Schall et al., 2016). However, it is worth noting the waist worn Actigraph monitor estimates sedentary behavior and light intensity activity based on counts/minute while the ActivPAL used in the present study uses an inclinometer to measure time spent sitting and standing.

There is limited data on the health consequences and/or benefits of standing at work. However, a controlled laboratory study by Baker and colleagues found two hours of uninterrupted standing resulted in increased levels of physical discomfort and impaired levels of attention reaction time and mental state (Baker et al., 2018). Given the large amount of time nurses spend standing at work, future studies should explore the effect of prolonged bouts of occupational standing on health and work performance outcomes among nurses.

While previous studies in this area have controlled for shift type (Nicoletti et al., 2014, Almajwal, 2015, Schall et al., 2016(Almajwal, 2015), Welton et al., 2006, Irimagawa and Imamiya, 1993, Takahashi et al., 1999, Wakui, 2000), little is known regarding how nurses’ occupational physical activity and sedentary behavior levels fluctuate within a shift or over the course of several consecutive shifts. In general, our findings suggest nurses are more active and less sedentary during day shifts compared to night shifts. This finding is consistent with Welton et al., who also found nurses working 12-h day shifts had higher step counts (8529 steps) compared to nurses working 12-h night shifts (8021 steps; Chi-squared = 4.60, p = 0.032) (Welton et al., 2006).

The 14-day objective observation of our study allowed us to dive deeper into patterns of occupational physical activity and sedentary behavior over consecutive shifts and within shifts. We also found nurses tended to stand less and sit more over consecutive night shifts compared today shifts and nurses tended to sit more over the course of each given shift. There may be multiple explanations for these changes in occupational physical activity and sedentary behavior over consecutive shifts and within shifts. First, it is possible that nurses working night shifts become increasingly fatigued over the course of consecutive shifts and physically need to sit more to rest and recover. If true, these findings would support scheduling changes that minimize the occurrence of three consecutive night shifts.

However, our findings also show that nurses working day and night shifts exhibit differential patterns of physical activity and sedentary behavior over the course of each shift. For example, no between group differences were observed in time spent sitting or standing during the first and last hours of each shift. These similarities suggest there may be common nursing-related tasks (e.g., inter-shift handoff responsibilities) that dictate nurses occupational physical activity and sedentary behavior during these times (Birmingham et al., 2015). Conversely, we found nurses working day shifts were more active and less sedentary during middle portions of each shift. We hypothesize that a primary reason for the observed difference between shift types is due to between group differences in occupational responsibilities during these times. For example, during the day shift, a large portion of time is spent communicating with patients in their rooms and completing hands-on tasks (Yen et al., 2018). In contrast, the primary goals during night shifts include: (1) providing patients with sufficient rest to restore their strength for healing and treatment, (2) provide qualified care via independent assessments, and (3) to prepare the medical unit for day time activities so as to hand over the unit in the best possible state (Nilsson et al., 2008). Also, duties at night have to be performed quietly with the lights dimmed.

Interestingly, nurses working night shifts exhibited a significant increase in time spent sitting over the course of each shift. In contrast, our findings show that nurses working day shifts had a relatively stable pattern of sedentary behavior throughout their shift. It is possible that fatigue may be contributing to the increase in sedentary behavior over each shift during night shifts. If true, this would support interventions designed to interrupt prolonged bouts of sedentary behavior during night shifts to maintain the health and work performance of night shift nurses. For instance, our previous work has found interrupting long bouts of sitting with 10 min of standing each hour was associated with improved levels of physical discomfort and mental alertness (Benzo et al., 2018). Further research is needed to determine predictors of increasing sedentary behavior during night shifts as well as the effects of prolonged sedentary behavior on health and work performance variables of nurses.

This study had many strengths including, the use of an accelerometer with a built-in inclinometer function which allowed us to differentiate between time spent sitting, standing and walking at work. The 14-day observation period allowed us to examine patterns of physical activity and sedentary behavior both over the course of consecutive shifts and within shifts. This study had several limitations. First, the sample was composed of a primarily female sample and thus we cannot generalize to the male population (10.7%) of U.S. registered nurses (2016 ACS PUMS 1–Year Estimate, U.S. Census Bureau). This is also important given the known sex differences for physical activity and sedentary behavior levels. Second, nurse's break (e.g., bathroom) and meal times were included in the analyses, as we did not require nurses to report the timing or duration of these periods. Third, given the relatively small sample size we were unable to examine differences in physical activity by nursing characteristics (i.e., nursing grade, medical unit, etc.). And fourth, fatigue could have contributed to the differences in physical activity and sedentary behavior but was not accounted for in this study.

5. Conclusions

In conclusion, we found that nurses working night shifts are, on average, significantly less active and more sedentary compared to nurses’ working day shifts. Specifically, the notable differences in sitting, standing, and walking time between shift types were most evident during the middle portions of the shift. More research is needed to understand the contributing factors of these differential patterns of occupational physical activity and sedentary behavior between day and night shifts and how occupational physical activity and sedentary behavior patterns impact nurses’ health and work performance. Given the current shortage of nurses across the nation, and considering that approximately one million nurses will retire by 2030 (Buerhaus et al., 2017), there is a need to develop and test interventions aimed at advancing the health and performance of U.S. hospital shift working nurses.

Declaration of Competing Interest

None.

Acknowledgments

Acknowledgements

We would like to thank all participants of this study.

Funding sources

Funding was obtained from the National Council State Board of Nursing.

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