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On-call work and health: a review Nicol, Anne-Marie; Botterill, Jackie S Dec 8, 2004

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ralEnvironmental Health: A Global ssBioMed CentAccess Science SourceOpen AcceReviewOn-call work and health: a reviewAnne-Marie Nicol*1 and Jackie S Botterill2Address: 1Centre for Health and Environment Research, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada and 2School of Cultural and Innovation Studies, University of East London, 4–6 University Way, London, E16 2RD, UKEmail: Anne-Marie Nicol* - anicol@interchange.ubc.ca; Jackie S Botterill - J.S.Botterill@uel.ac.uk* Corresponding author    AbstractMany professions in the fields of engineering, aviation and medicine employ this form of scheduling.However, on-call work has received significantly less research attention than other work patternssuch as shift work and overtime hours. This paper reviews the current body of peer-reviewed,published research conducted on the health effects of on-call work The health effects studies donein the area of on-call work are limited to mental health, job stress, sleep disturbances and personalsafety. The reviewed research suggests that on-call work scheduling can pose a risk to health,although there are critical gaps in the literature.BackgroundThe question of whether work hours and schedules affectpeople's health has been reviewed for a range of work pat-terns including shift work and overtime. Research in theseareas indicates that shift work, and in particular nightwork can interrupt sleep patterns [1], aggravate existingmedical conditions and increase the risk of cardiovascu-lar, gastrointestinal, and reproductive dysfunctions [2-4].However, the health effects of on-call work, where work-ers are called to work either between regular hours or dur-ing set on-call periods, has not merited as much attention.This form of work scheduling occurs in a variety of diverseoccupations, for example medical technologists, doctors,ship engineers, utility workers, electrical technicians, tugboat pilots, midwives, information technologists, mediapersonnel and junior airline pilots. For many of these pro-fessions being on-call is not an option, but rather a com-ponent of the job. This form of scheduling is often used toprovide 24 hour coverage, 7 days a week, for facilities suchwhere the volume of evening and weekend work does notnecessitate full shift coverage. Having employees on-call,even if they are being paid a stipend for their call time, isoften seen as less expensive for employers than providingfull shift coverage during off-peak hours [5].While on-call work scheduling may be less expensive, it isnot without human costs. On-call employees must plantheir lives and the lives of their families around a callschedule. This often means limiting behaviours andobliges employees to restrict their on-call time to activitiesthat would not interfere with their ability to work. Theunpredictability of the call scheduling can also generate agreat deal of stress, as home life is interrupted and workersare required to "change hats" to shift to their professionalroles at any time during call. These limitations and inter-ferences present unique challenges for on-call workersthat are not encountered by those working set schedulesor even people with rotating shifts. It is thus not surprisingthat researchers have found that on-call work patterns canPublished: 08 December 2004Environmental Health: A Global Access Science Source 2004, 3:15 doi:10.1186/1476-069X-3-15Received: 08 July 2004Accepted: 08 December 2004This article is available from: http://www.ehjournal.net/content/3/1/15© 2004 Nicol and Botterill; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 7(page number not for citation purposes)as hospitals and laboratories, where emergencies requirepersonnel to immediately deal with critical situations andhave a major influence on employees' lifestyles and theirinteractions with family members and friends [6]. How-Environmental Health: A Global Access Science Source 2004, 3:15 http://www.ehjournal.net/content/3/1/15ever, in addition to the impact on lifestyle and relation-ships, on-call work patterns may impact the health ofemployees.Within the limited literature that has explored on-callwork, there exists some pertinent findings concerning theimpact of on-call for an employee's physical and psycho-logical health, and social relationships, which this reviewseeks to bring together. Specific attention has beendevoted to the areas of stress, sleep, mental health andpersonal safety.Types of on-call workThe implementation of on-call schedules varies. For manyoccupations, workers leave their place of employment andare placed "on-call" on evenings and weekends, whichmeans they can be called back to work during these peri-ods. For many professions this form of scheduling is anormal component of the occupation, for example,marine pilots can spend up to 60% of their working timeon-call. However, for a limited number of occupationssuch as airline pilots, on-call hours are reduced with sen-iority. Generally, but not always, employees are compen-sated monetarily for the period of call, usually with astipend which is less than their hourly rate. When on-callemployees are usually expected to restrict their use of alco-hol and limit distance or travel time from the work-site.The on-call experience of these workers includes aspects ofinterruption, either of sleep or family or social life, andoften includes an element of uncertainty as to the time ofcall or the occurrence of the call.Other forms of on-call include work done by junior doc-tors during their medical training. Medical residentsspend periods of time "on-call" at a hospital, where spacemay be provided for them to sleep. This form of on-callwork is distinct because workers remain at work to under-take their call duty. During these periods, residents oftenput in 30–36 hour shifts with little to no sleep [7], result-ing in a combination that is both a night shift and an over-time shift. Because of the intensive demands placed onmedical residents during their apprenticeship, this grouphas received a fair amount of research attention. This hasbeen particularly so in the 1990s as the rigors of thisperiod in junior doctors' training has come under muchscrutiny both in the UK and in the US. New working reg-ulations have been introduced in an attempt to deal withwhat is considered, by many, to be harsh and unaccepta-ble working conditions. The debate over and outcome ofthese interventions continues [8-10].This review focuses on the health effects of on-call work inwhich an employee spends a period of time on-call out-excluded because the medical resident experience is dis-tinctly different from that of other professions where on-call is utilized. However, research on medical residents isused to illustrate findings from other work-related areaswhen appropriate.MethodsThis review explores the published literature referring toon-call work patterns and health. For the purpose of thisreview, the on-call period may be formal (e.g. a person isdesignated as being on-call for the weekend or overnight)or informal (emergency call back during a crisis). Searchterms for this review included "on-call" and "work sched-ule tolerance". The terms "stand-by" and "night call" areused by some professions to describe on-call type work,and were also used as search parameters. This literaturereview was undertaken on journal articles included indatabases up to December 2000. Database searches wereperformed on the following electronic sources:1) OVID Databases: including Medline (1966–2000) andCurrent Contents (1996–2000).2) Canadian Centre for Occupational Health and SafetyDatabase3) Cambridge Abstracts (Environmental Science and Pol-lution Management) 1981–2000.4) PsycInfo (1989–2000).5) Web of Science: including Science Citation Index andSocial Science Citation Index (1989–2000).A manual review of the references generated from thecomputer-search was also done. Articles were excludedfrom the review if they were not original research, werenot written in English or focused on medical residentsexperiences with on-call work.Two reviewers read through each of the eligible researchpapers independently.ResultsIn total, 24 papers met the search criteria. Eight (8) wereexcluded as they focused on the impact of on-call workpatterns on patient's health and not on the health ofworkers. The remaining sixteen studies were used for thisreview. The results are divided into four health-related sec-tions; 1) Stress, 2) Sleep, 3) Mental Health and 4) Per-sonal Safety.On-Call Work and StressPage 2 of 7(page number not for citation purposes)side of their workplace and/or their regular workinghours. The research on medical residents has beenOf the five studies pertaining to on-call and stress uncov-ered in this review, all focus on the General PractitionersEnvironmental Health: A Global Access Science Source 2004, 3:15 http://www.ehjournal.net/content/3/1/15(GPs) as their subject. In these studies, the relationshipbetween on-call work and stress was measured throughself-report and perceived stress.Three of the studies were part of a major UK study carriedout from 1989 to 1998 [11-13]. In the early 1990s theBritish health care system experienced considerable finan-cial and administrative restructuring. This large study wasconducted at different points in time to determine GP'ssatisfaction with the changes in their workplace. GPs wererandomly selected throughout Britain in 1987, 1990 and1998 to fill out postal questionnaires. The studies yieldedsample sizes of 1817, 917, and 999 respectively, repre-senting rather low response rates of 48%, 67% and 47%.However, the authors' assessment of all three samplesfound that they tended to be fairly representative of thelarger population of GPs in the country [13].In the first two studies, GPs ranked working on-call atnight as one of the top two most stressful aspects of theirwork situation [11,12]. However results from the thirdstudy in 1998 revealed that night call was no longer amajor source of stress, dropping to 12th in a ranking of 14major stressors. The authors believe this reduction in thelevel of stress from on-call work could be explained by theintroduction of GP co-operatives in the mid 1990s for themanagement of out-of-hours calls. This cooperative sys-tem allowed GPs to either do their own calls or share themwith a cooperative formed by 10 or more doctors. Thecooperatives gave GPs greater flexibility for how andwhere they saw their patients and how they implemented24-hour care and appear to have successfully reduced thestress of night visits for GPs. Indeed, night visit stress wentfrom being one of two top stressors for GPs in 1987 and1990 to being one of the least stressful issues by 1998. Theauthors also posit that this "success may also explain thereported reduction by 1998 in stress attributable to distur-bance of home/family life" [[13] pg. 370].The fourth study also dealt with the changes in the Britishhealth care system, in particular the introduction of par-tial shifts to decrease long on-call periods [14]. A smallsample of GPs'(n = 14 and 12) were surveyed about theirstress levels before and after the new system was in place.Doctors' stress levels were significantly reduced, particu-larly in relation to their mental well-being and their jobsatisfaction.The fifth study on GPs and stress was a qualitative analysisof 25 GPs and their spouses in Manchester [15]. Thisresearch found that for male GPs, the uncertainty of beingon-call caused them to be unhappy. Some doctors spokequite frankly about how night calls could "perturb familyuted to the male GPs' unhappiness. Female GPs werestressed by factors other than on-call, including time pres-sure, role conflict and work overload. They were also con-cerned about how their work schedule decreased theamount of time they spent with their children. Thesemarked differences between how male and female doctorsexperience the stress of on-call work signals the impor-tance of examining gender as a variable in this research.Other studies have revealed that the amount of time spenton-call varies between male and female doctors, but noclear pattern has emerged [16,17]. It has been hypothe-sized that female doctors who work reduced on-call hoursdo so because of the dual role they must play as bothworker and care-giver [17,18].Research conducted in other professions support the ideathat work patterns, particularly night shifts, can increasestress in workers and have a negative impact on familylife. Working late afternoon and evening shifts has beenrelated to increased stress for both workers and their fam-ilies [2]. Variable shifts have been shown to cause morestress than regular shifts [19] and working more than 50hours per week is associated with increased job stress [20].Many on-call workers regularly experience variation intheir work patterns, as well as being expected to work atnight, and undertake greater than normal hours whencalled in.On-Call Work and SleepBesides stress, the interruption of sleep is another majorcomponent of on-call work, particularly for those whowork nights on-call and in professions that deal withemergencies that occur at all hours. Three studies havedealt specifically with the sleeping patterns and problemsexperienced by train and ship engineers and transplantcoordinators, all of whom regularly work on-call.The first study researched the on-call sleep patterns of 198train engineers using prospective activity logs over a 14-day period in the United States [21]. It was determinedthat those working on-call had greater difficulty fallingasleep and staying asleep while on-call versus when theywere not on-call. Train engineers working on-call also hada greater number of days where there was less than 24hours between the on-set of their work shifts. These engi-neers reported more sleep-related problems that thosewith at least 24 hours between the on-set of their shifts.The researchers also explored how sleeping was impactedwhen it was undertaken in different locations. They foundthat train engineers sleep varied when at home versus"away". (Engineers can finish a shift away from home,and have "away" terminals where they can sleep.) ThePage 3 of 7(page number not for citation purposes)life and wreck personal intimacy" [[15] p. 158). Theuncertainty of their on-call commitments also contrib-researchers compared the amount and quality of sleepengineers had while both "at home" and "away" andEnvironmental Health: A Global Access Science Source 2004, 3:15 http://www.ehjournal.net/content/3/1/15found that engineers on-call slept less at home than theydid "away". The authors attribute the difference to thepresence of family and social obligations in the home thatconflicted with the workers' ability to sleep while workingon-call. However, the authors note that the response rateof this study was low, only 25% of the sampled popula-tion of approximately 800. The authors caution readers toremain critical of their findings, because their sample maybe biased towards those who generally have difficultysleeping. An analysis of the final study group did find thatthe responding sample reflected the age and gender distri-butions of the larger population, factors that the authorssuggest indicate robustness even with the low responserate.The second study of on-call and sleep explored the sleep-ing patterns of 53 predominantly female organ transplantcoordinators in the UK, using a postal questionnaire [22].This research determined that not only was sleep affectedwhen people worked on-call (51% occasionally had diffi-culty and 6% frequently had difficulty falling asleep) butthat the effects carried over to time off call as well. Sixty-eight percent of the sample reported that the time theyspent on-call negatively influenced their off-call lives.Workers pointed out that after being on-call they oftenhad to spend additional time catching up on sleep. Theyalso complained that on-call work left them too tired toundertake social and home activities. But although theworkers complained about being fatigued at home, thiswas not correlated with days absent from work. Theauthors suggest that this finding may be the result of trans-plant coordinators "guilt" around placing an extra burdenon a co-worker if they were absent. Another possibleexplanation was the overall satisfaction of the type ofwork being done by the coordinators, a factor which maydecrease their willingness to take time off.The third study, conducted on a small sample (n = 5) ofship engineers in Sweden, measured sleep during on-callperiods using electroencephalogram (EEG) and electro-cardiogram (ECG) recordings and subjective ratings. [23].This research found, like the others, that the sleep qualityand quantity of the ship engineers was affected by theinterruptions of being on-call. In their subjective assess-ments, the engineers reported being more drowsy duringthe day after being on-call, a finding similar to that of thetransplant coordinators. But, the authors also found thatthe apprehension associated with the possibility of beingawakened for call duty also negatively impacted sleep.On-call sleep registered less slow wave sleep (SWS) andrapid eye movement (REM) and a higher heart rate thanwhen workers were testing during their normal sleep.Many of these conditions occurred prior to being awak-at sea. This population also found it difficult to fall asleepon nights when they were on watch. The anticipation ofalarms that would wake them up was seen as an obstaclethat prevented workers from relaxing enough to allow fornormal sleep patterns to develop [24].The impacts of sleep loss on job performance remainunclear and controversial. For example, research on thecognitive performance in sleep deprived medical residentshas produced mixed results [25-27]. However, research onanaesthetists found that 86% reported fatigue relatederrors [28]. Job performance and fatigue have also beenstudied in relation to age, a factor not explored in the on-call studies. Significant changes were found betweenyounger and older shift workers, with younger workersbetter able to maintain performance across day and nightshifts and older shift workers prone to more sleep disrup-tion [29].Work-related fatigue has been related to an increase in caraccidents. A review of traffic accidents determined thatfalling asleep while driving accounted for a major propor-tion of accidents while driving under monotonous condi-tions [30]. This finding has been corroborated withresearch done on medical residents working long nightshifts. Seventy-five percent of accidents incurred by a pop-ulation of emergency medicine residents happened afterworking a night shift [31]. In this study, the number ofmotor vehicle accidents and near misses was positivelycorrelated to the number of nights worked per month. Asimilar study done on paediatric residents indicated thatresidents fell asleep at the wheel significantly more thanother professionals, with 90% of these events occurringafter a night on-call [32].On Call Work and Mental HealthSix studies were found that examined the impact of on-call work schedules on mental health. All of these studiesused self-reported questionnaires and/or mood diaries.Five studies were conducted on GPs in the UK and oneexamined gas and electrical employees in France.Two surveys were conducted by Chambers et al. [33,34]on GPs in Staffordshire, UK. The first survey, conducted in1994 (n = 704), was designed to research the factors pre-dictive of anxiety and depression in GPs [33]. The studydetermined that working one or more nights on-call perweek was significantly predictive of anxiety. Other factorspredictive of anxiety were depression and three or moreweekdays feeling exhausted or stressed. Males and femalesshowed no significant differences in anxiety or depressiondeterminants.Page 4 of 7(page number not for citation purposes)ened for call duty. Earlier research by the same authorsexamined the sleep patterns of Swedish merchant marinesThe second survey conducted by Chambers et al in 1996(n = 620) employed the Hospital Anxiety and DepressionEnvironmental Health: A Global Access Science Source 2004, 3:15 http://www.ehjournal.net/content/3/1/15scale to assess the mental health of GPs [34]. It was deter-mined that both anxiety and depression were associatedwith the amount of on-call duties undertaken. Findingsrevealed that both anxiety and depression increased withthe frequency of time spent on-call per month. Again, theresults were the same for both male and female GPs, andthe authors conclude that GPs' mental ill health is associ-ated with workload, of which on-call is a major factor.A third survey done on GPs in Leeds in 1993 was designedto determine the psychological symptoms and sources ofstress among 268 GPs [35]. This survey used the UK Gen-eral Health Questionnaire as well as qualitative questionsregarding mental health and workload. Problems withphysical and mental health were significantly associatedwith several aspects of workload, including the amount oftime spent on-call per month. The study also found thatthose GPs who spent more time on-call each month weremore likely to feel their work affected their physicalhealth. Males and females reported differences in thesources of their stress, with females showing greater jobsatisfaction than males. The authors suggest that this find-ing may be due to the fact that, for this study population,female doctors worked fewer hours and spent significantlyfewer nights on-call [34].The fourth study in this area surveyed mental health andjob stress on 414 GPs in England in 1992 [36]. Thisresearch determined that interruptions, a category whichincluded taking night calls, remaining alert on-call, 24hour patient responsibility and telephone interruption offamily life, was a predictive factor for decreased mentalhealth, depression and somatic anxiety. These factors weresimilar for men and women, although their contributionto each condition varied by gender.A pilot study of 44 male and female volunteer GPs usingcognitive behavioural diaries assessed self-reported emo-tional states recorded in conjunction with hourly activitiesover 2 days [37]. Doctors' moods were significantly low-ered when on-call as compared to off-call. Doctors on-callalso had significantly increased tension and frustration.The main reported cause of dissatisfaction was the uncer-tain nature of the doctors working hours [37].The sixth study examined male gas and electrical employ-ees working in France [38]. Employees who worked on-call (n = 145) were assessed for health status and psycho-logical problems and were compared to those not work-ing on-call (n = 195). Workers were also questioned aboutthe impact of their job on their family life. Although noparticular mental or health disorder was found to be morefrequent in the on-call group, the psychological equilib-nificantly worse global-well being and indicated signifi-cantly higher levels of social disturbance. On-call workersreported that their family and social life were acutely dis-turbed and they were significantly less likely to beinvolved in clubs or take on outside responsibilities.The research conducted on GPs in the UK supports a neg-ative role of on-call work related to mental health. How-ever, the results from the gas and electrical workers do notreflect the same findings from the research on GPs. Thismay be the result of either a difference in study methodol-ogy or a difference that is profession-specific. On-call gasand electrical workers did experience psychological dis-ruption and the lack of significant diagnostic findingsmay be a function of other factors, such as self-selection,in this profession, where those most affected opt out earlyon. The on-call gas and electrical workers experience offamily and social life disruption does mirror the experi-ences of doctors and transplant coordinators as discussedpreviously [13,15,22].On-call Work and Personal SecurityWorking on-call often necessitates leaving home alone, atnight, to attend work, conditions that can jeopardize per-sonal safety. Unfortunately, there is only sparse dataregarding this issue. A study done in the north west ofEngland, in a hospital where the on-call sleeping quarterswere separate from the hospital found that 40% of anaes-thetists feared for their safety while walking through hos-pital grounds at night [39].In medical professions, patients can also present a dangerto those working on-call. Doctors have cited fear of vio-lence from night call visits as a significant stressor [11]. Astudy of 327 nurses in remote areas who worked on-callfound increased incidences of violent acts perpetrated bypatients, particularly in smaller communities [40]. Thisstudy found that working on-call increased the number ofincidents ranging from verbal abuse to property crime andphysical assault compared to working regular shifts.This issue has only been peripherally studied and furtherattention needs to be given to personal safety, particularlywhen being called in at night.DiscussionWhat emerges from this review is the limited research thathas been done in the area of on-call work. Preliminarywork done in the areas of stress and mental health sug-gests that on-call work may play a role in increasing stressand decreasing mental well-being. The three studies thatexamined sleep indicate that on-call work does decreasethe quality and quantity of sleep for workers and can leavePage 5 of 7(page number not for citation purposes)rium of the on-call workers was significantly worse thanthe comparison group. On-call workers also reported sig-people feeling fatigued for periods after their on-call work.Environmental Health: A Global Access Science Source 2004, 3:15 http://www.ehjournal.net/content/3/1/15The current body of literature on the health effects of on-call work is limited in part due to the narrow range of pro-fessions studied. The majority of research done to date hasbeen on general practitioners. It is reasonable to assumethat the effects of on-call will vary across occupations,given the host of other factors that can influence occupa-tional health. However, the degree to which this variationexists might only be determined by examining a wideroccupational base. The need to undertake more on-callresearch across a greater variety of occupational groups issuggested given that this form of work scheduling touchesmany occupations, and given that on-call work is esti-mated to continue to increase in many sectors in thefuture [6].There is also an obvious lack of research focusing on theimpact of on-call shifts on psychosocial factors. Given thevery disruptive and limiting nature of on-call schedules, itwould not be surprising that workers' family and sociallife suffer due to this type of scheduling. The results of theresearch addressing gender (discussed above) do suggest,albeit indirectly, that such social and familial impacts maybe significant. However, without more research, it is notpossible to determine the magnitude of these effects, northe relative importance compared to other factors such asphysiological responses.More rigorous methodological designs are needed forfuture research in the area of on-call work and health. Thecurrent research is predominantly cross-sectional innature, a factor that makes it difficult to determine causal-ity. Only two studies employed external comparisongroups [21,38] and only a limited number have measuredeffects in workers on-call versus off-call (own-controls)[22,23]. Additionally, most of the measurement has beensubjective in nature and often the operationalization ofon-call work is not clear. In the GP studies, on-call is gen-erally measured as the "number of nights spent on-call"either per week or per month. Some attempt is made tomeasure the amount of sleep during these periods, butthere is little refinement of factors such as whether thesubject were actually called in to work and for how long.Additionally, little attention has been paid to the amountof time worked or sleep obtained prior to the on-call shiftsor factors such as second jobs or outside work, variablesthat may confound the outcomes. Other factors, such asage and personality type, that have been shown to be sig-nificant variables in other areas of work scheduling[41,42] also need to be explored. Attention also needs tobe paid to the possible self-selection of workers out of on-call professions or adaptive strategies that workers mayemploy to cope with on-call (such as the sharing of on-call shifts). More controlled research that includes bothFuture research on the health effects of on-call work alsoneeds to examine the role of gender, not only from a phys-iological standpoint, (e.g. reproductive issues), but alsofrom a psychosocial perspective. Many of the articlesreviewed above indicate differences in how males andfemales experience the stress of on-call work[11,15,17,36]. Research in other work-related areas sug-gests that males and females cope differently with theimpact of job schedules [43-45]. While gender may be afactor that directly mediates health effects, it may also bean indirect measure of other phenomena such as the divi-sion of labour outside of the workplace. More carefulresearch is needed to illuminate the role gender may playin the effects of on-call work.The range of health effects studied in relation to on-callwork has to date been inadequate. Health conditions suchas cardiovascular disease, reproductive problems, gas-trointestinal issues and overall mortality need to beexplored as has been done in conjunction with work pat-terns such as overtime and shift work [41,45]. Factorssuch as personal safety and car accidents have only brieflybeen touched upon, and merit more attention.ConclusionsWhile the results of this review are limited, initial researchin this area suggest that being on-call can have negativeimpacts on workers' sleep patterns, mental health andpersonal life. Further research in this area is required toprovide a clear picture of the risks of this form of workscheduling.List of abbreviationsUK, United KingdomUS, United States of AmericaCompeting interestsThe authors declare that they have no competing interests.Authors' contributionsAMN designed the research project, carried out the litera-ture search, reviewed articles and drafted the manuscript.JSB reviewed articles and edited the manuscript. Bothauthors approved the final manuscript.AcknowledgementsThis research was supported in part by the Occupational Health and Safety Association for Healthcare in BC (OHSAH), a non-profit agency. The authors wish to thank Dr. Kay Teschke (UBC), Rachel Notley and Carol Riviere (Health Sciences Association of BC) and David Murphy (SFU) for their assistance with this review.ReferencesPage 6 of 7(page number not for citation purposes)subjective and objective measures would provide betterevidence regarding the effects of on-call work.1. 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