.7..-.-._.._‘ .... ,7. _ ‘ Illlllfllllllllllllllllllllll 3_ 1293 10722 2097 I. [Ii 5%: :‘1 A; f 1 * Mn“? U15 “"5 WU’T 3" 'v w . _ v i I, ‘ 3.3.7 1-— This is to certify that the thesis entitled A MULTIDISCIPLINARY ANALYSIS OF DISRUPTIVE FACTORS IN SHIFTWORK presented by Jack Noel Rose has been accepted towards fulfillment of the requirements for Ph.D. Jggreein Social Science gallium Major professor Date 71L518L 0-7 639 MSU RETURNING MATERIALS: Flace in 500E drop to remove this checkout from w your record: FINES_w'lll be charged if book is returned after the date stamped below. M W“ Sues-63'3— fllh 31934 313819902 A 0138?. MATION Submitted to A ' can men when“, “I! Mflllmt of m Imam ~ ‘ to: the 609m of A MULTIDISCIPLINARY ANALYSIS OF DISRUPTIVE FACTORS IN SHIFTWORK BY Jack Noel Rose A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY College of Social Science 1981 Copyright by Jack NOel Rose 1981 “the tr: . I ' A”? ”fact:- 93' ,"‘ Caitlirn Wmtn'e ‘ nu .., w.” ' L“ The 'lzl‘... ‘ 5:”. 061: ’ .1: . .‘U Q' ‘* funk“ to; , . ‘ ,._ 31' 4 I, z" “er. tC .‘iw" é v-- ‘ N ‘ i a; 11:0 I L: ‘ ' v a .- ~‘ *0 SHE} ‘v‘;-'l.’.~i ”4 “ ’r' >,L ‘ " \n "WI!“ '- ‘3‘ r '. ° ' ' ' . * . ‘ “u ”Qt'y‘i'lu' . ‘ ‘ N , (M4 4. '0 " f Iii-"'9 i ‘ 77'3” -" "-'- * ° 3* H- ... - "a. ‘ Wtru&o‘uflrt' 3. {Jr-y ‘ i“ 1‘ ‘ l , . .. - . Y . . I l " t V . ° - ' 'i in the "nL‘tLV'? i b ~ - ' l - :4", mfilkh c- . ‘ ‘ ttutmns t": r '1! _-- -_- r w » :~ «pg-,3, 138591101693”. 21., :xrn' : , M a. ~~ fiibY Chiftflol". ,\Z!)L"’.f'.';., ‘.--!‘- ‘.--. ‘3_ 1‘ _“g‘roup consist-ad of $3: r.» i am: .-. 34". ‘ $1“ .. ~ included all mix-sun «3" ;~ new <- fi‘Kt the ggfl'uGipntion. You the cue um mt ABSTRACT A MULTIDISCIPLINARY ANALYSIS OF DISRUPTIVE FACTORS IN SHIFTWORK BY Jack Noel Rose The theoretical aim of this research was to study the effects of shiftwork from the perspective that the socio- cultural impetus toward time optimization has been a dis— ruptive factor in various work situations. The basis for this investigation initially involved the construction of a multidisciplinary theoretical frame- work for exploration of the social and behavioral signifi- cance of time in an actual setting. A desire for time optimization and the widespread use of shiftwork scheduling was seen to have emerged from new cultural values relating to work. Such values have become increasingly more impor- tant as societies have undergone a transition from primitive to industrial-technological. Within the setting of five rural New York State health care institutions, the effects upon nurses of disrupted biological, psychological, and sociological life factors, stimulated by shiftwork scheduling, were analyzed. The ini- tial study group consisted of 162 nurses at the five insti— tutions, and included all nurses who were willing to volun- teer their participation. For the purposes of hypothesis testing, the responses of 12 supervisory nurses and 7 male nurses, were eliminated from the data to enhance homogeneity Jack Noel Rose of the sample. Thus, a total of 144 responses were used in the final data analysis. Data obtained by structured interviews based upon a questionnaire, included informa- tion about each subject's demographic characteristics, as well as two measures of holistic well-being. The measures of well-being were specifically of psychological strain (Gillis, 1977), and of social isolation (Dean, 1961). It was hypothesized that both measures would show greater amounts of disruption as one analytically proceeded from day shift scores, to afternoon shift, night shift, and rotating shift measures. From analysis of data obtained, it was found that: (l) Psychological strain was significantly related to persons on different shifts. (2) Social isolation was not significantly related to persons on different shifts. The evidence indicates that the multidisciplinary approach to studying the disruptive factors in shiftwork has potential merit, yet further research using improved models is needed. ACKNOWLEDGEMENTS I would like to acknowledge the members of my graduate committee, Drs. Chris K. Vanderpool, John T. Gullahorn, William A. Goldberg, and Raymond W. Frankmann, for their assistance with the completion of this dissertation. In addition, I thank Dr. Sigmund Nosow for his helpful comments. Finally, I wish to state my sincere appreciation to my wife, Barbara, for her inspiration and understanding. ii Chapter I. II. TABLE OF CONTENTS THE PROBLEM......... ........ ................ Statement of the problem..... ............... Importance of the study....... ........ . ..... Theoretical framework........ ....... . ....... Time as an interdisciplinary issue.......... Philosophy of time................... ....... Anthropological perspectives on time........ Sociological perspectives on time..... ..... . Psychological perspectives on time ........ .. Perspectives on time in Biology and Chemistry............ ....... ................ Perspectives on time in Physics............. Interdisciplinary considerations of past, present, and future. .................. Theoretical rationale guiding the research.................................... Summary..................................... REVIEW OF RELATED LITERATURE...... .......... Introduction................................ Framework for stress research...... ......... Response-based definitions of stress........ Situation-based definitions of stress....... Stress as an organism-environment transaction.ODIOI.IOOIOIQIOOIOIICOOOOOCIOIOD The engineering analogy: a transac- tional definition........................... A frame of reference for stress research.... Page 11 17 19 19 21 22 24 25 25 27 28 30 30 31 32 Chapter Page Time factors and stress.................... 33 The physical and sociocultural aspects of the environment .......... .... ........ ... 34 Stress and the coping process.... ..... ..... 34 Summary of stress research framework....... 35 Contribution of conceptual framework for stress research to the present study... 36 Work and values.......... ......... ... ...... 37 Leisure time: a contradiction............. 40 Motivation to work......................... 41 Theories of motivation in general.......... 45 Expectancy theory.......................... 46 Exchange theory............................ 47 Aspiration level theory.................... 48 Other theories of motivation............... 48 Measurement of satisfaction with work...... 49 Time-and—motion and shiftwork compared..... 50 Stress as psychological strain............. 52 Alienation and low job satisfaction........ 55 Women and work............................. 58 Nursing and the health care system......... 58 Early Development of Nursing............... 59 Florence Nightingale....................... 60 Male nurses................................ 60 Nursing education.......................... 61 Nursing students........................... 62 Structural features of nursing............. 64 iv Chapter Page Nursing: occupation or profession?........ 64 Status of the role of nurse................ 67 Other aspects of the nurse role............ 68 Sociological perspective on nursing and shiftwork.............................. 69 Shiftwork and leisure...................... 72 Shiftwork studies.......................... 73 Previous shiftwork research (male— Oriented).....UIOOUOUOOOO..IQIIIOOOOOOOOD'. 77 The Mott, et. al., (1965) study............ 78 Previous shiftwork research on nurses...... 82 The Pilon and Zang (unpub1.) study......... 84 The Tasto and Colligan (1978) study of nurses and food processers................. 86 Shiftwork, role conflict, and nursing...... 87 Previous research relevant to the theoretical rationale...................... 88 Summary.................................... 105 III. METHODOLOGY AND PROCEDURES................. 107 Type and design of study................... 107 Site of study.............................. 112 Subjects................................... 114 Procedures for gathering data and instrumentation.DCOI...-IIOOOOOI-IIUIIOIQOI 115 Psychometric characteristics of Gillis (1977) and Dean (1961) scales.............. 118 Strengths and limitations of the methodologYIOOOOOO.......OOIOOOIOCCDCCII... 125 Chapter Page Summary...................................... 129 IV. RESULTS AND DISCUSSION....................... 131 Background variables......................... 131 Analysis of variance......................... 133 Post hoc comparisons......................... 137 T-tests.............................. ...... .. 138 Multiple regression analysis................. 143 Implications for future research............. 147 Summary...................................... 153 V. SUMMARY AND CONCLUSIONS...................... 155 Sources Consulted............................ 158 VI. APPENDIX 1: Questionnaire used in the survey...................................... 186 VII. APPENDIX 2: Definition of terms............ 190 vi Table 10 11 12 13 14 LIST OF TABLES Summary of Sample. ........ ......... ...... .... Intercorrelation Matrix of the Index of Psychological Strain Items................ Intercorrelation Matrix of the Index of Social Isolation Items............... ..... Preliminary Analysis of the Data: Mean Sources from AOV of Psychological Strain and Social Isolation......................... Intercorrelation Matrix of Shift Schedule, Demographic Variables, and Psychological Strain....................................... Analysis of Variance of Psychological Strain by Shift Schedule..................... Analysis of Variance of Social Isolation by Shift Schedule............................ Analysis of Variance of Desire to Change Shift by Shift Schedule............... Scheffe Procedure to see Differences Across Shift Groups in Psychological Strain.........-..-o.........o...........o... Differences Among Shifts in Psycholo— gical Strain (t-teStS)...-.......o....o.oc... Differences Among Shifts in Desire to Change Shifts (t-tests)nouoootcooooonoo-OI Marital Status Differences in Psycholo- gical Strain and Social Isolation............ Stepwise Multiple Regression Analysis of Amounts of Variance (R Square) Predicted by FactorSIOOIOIOI......IOIOOOUOI...0.000.... Selected Frequencies Related to the Cultural Context of the Research............. Page 117 120 121 124 132 134 135 136 138 140 140 141 145 146 CHAPTER I. THE PROBLEM Statement of the problem In this study, the investigator explored the usefulness of a holistic analysis model for explaining the disruptive effects of shiftwork scheduling, viewed as a major event operating within human society. Holistic analysis is used herein as the equivalent of a systems analysis frame of reference which considers the interaction of each person's biological, psychological, and social selves as a total system. Shiftwork scheduling has become increasingly perva- sive in a multitude of work situations within our current culture, as an impetus toward time optimization has per- meated the social organization of work. Time saving has become a cultural value which has been held in high regard by many in the industrial-technological world, and in parti- cular, by administrators of complex organizations. The specific purpose of this study was to explore the usefulness of the holistic model for explaining the disrup- tive effects of shiftwork upon nurses at five health care facilities in rural New York State. Certain assumptions are necessary in any scientific endeavor. The present study is based upon the following set of assumptions, evidence for which is later presented in the theoretical framework and literature reviews. The socio- cultural phenomenon of time optimization has brought about the major activity of shiftwork in a variety of work situations. Although a minority of workers may actually prefer shiftwork, it has certain intrinsic drawbacks for which a better theoretical understanding is desirable. A holistic or systems model is useful for explaining the interrelated disruptive effects of shiftwork along bio- logical, psychological, and social dimensions. The relation— ships among these three areas of effects are complex and subtle (King, 1972:129). Various indicators of holistic disruptions have appeared in the literature in recent years. No single indicator has combined all dimensions satisfac- torily, therefore two indices were selected for use in the present study. Indices of psychological strain (Gillis, 1977) and of social isolation (Dean, 1961) fulfill criteria of selection which demand coverage of biological, psycho- logical, and sociological effects. The psychological strain index deals with the individual level of analysis, while the social isolation index applies to a societal, or "meta- individual" determinant (White, 1967:136). The Gillis (1977) scale is represented by questionnaire items 23 through 37 as appear in Appendix 1. The Dean (1961) scale is represented by questionnaire items 38 through 46 in the same Appendix. Importance of the study There are at least five ways in which this study is expected to contribute to social science research: 1 (1) This study is expected to provide a multidisciplinary (2) (3) (4) (5) perspective on the use of time, and to discuss the sociocultural process of the structuring of time. The process of shiftwork is on the rise, sociocul- turally and will continue to have a direct sociocul- tural impact upon the world. Further theoretical understanding of the use of this "new frontier" of time as described by Melbin (1979), is needed. There is a particular need for examination of the evidence relating to work and values, to determine why this particular pattern of structuring time has become so popular. After a preliminary analysis of nursing as an occupa- tion and profession, this study will examine how the process of shiftwork affects women in general, and nurses in particular, as such information is currently limited. The present study will provide an improved theoretical analysis (compared with previous studies described in the literature) of the implications of the current development of the major social phenomenon of shiftwork in the area of stress research within the social sciences. This study will contribute to the development of a model for administrative management of the major social organizational activity of shiftwork, which may become the dominant format for work in the future world cul— ture. Direct implications for the optimal scheduling of shiftwork in complex organizations will be dis- cussed. Theoretical framework In order to appreciate the reasons that shiftwork has become such a popular way to structure working time socio- culturally, an examination of the meaning of time as a multi- disciplinary issue would seem useful. Impressive efforts have been made by some modern socio- logists to establish general conceptions that can help unify all of the social sciences (Gross, l964a:201). The most noteworthy pioneer in this direction has been Talcott Parsons, who, along with collaborators from the disciplines of psychology and anthropology, aimed at establishing a general theory in the social sciences (Gross, 1964a:201). As has been true of attempts to construct a "grand theory", criticisms of Parson's theory have been leveled mainly at confusing terminology and purported loss of contact with the empirical world. Time as an interdisciplinary issue The analytical use of time within various disciplines differs, as does the meaning of time for each of a variety of disciplines. It is felt that the meaning of time can best be approached by a systematic examination of the dif- ferent uses of time in selected disciplines. Since all phases of human culture are related and interdependent, to gain a real understanding of a phenomenon such as time, it is necessary to pursue its meaning from several viewpoints (Hunt, 1972:26). To alleviate the difficulty of making dis- ciplinary distinctions, a multidisciplinary perspective on time is formulated, following the systematic examination of the use and meaning of time in selected disciplines. This discussion will then lead to the statement of a theoretical framework for exploration of the social and behavioral signi— ficance of time, as applied to a research problem in an actual setting. Philosophy of time Philosophers have sought to know whether time is real or illusory, and have devoted much attention to questions about the nature of time. Time can be viewed either as metaphysi- cally ultimate (process philosophy) or as illusory (philosophy of the manifold). For centuries it has been viewed as a significant dimension in the philosophy of history and in the theology of redemption (Encyclopedia Britannica, Micropedia, (9), 1974:1013). Yaker (1971) has noted that the Hebrews perceive of time as a linear succession of instants whereas the Greeks view time as a geometric projection of a spatial and cyclic movement. It is from world views such as these that Western culture has inherited a variety of patterns of time use. Time has not only been considered by philosophers, but is the key concept in some philosophical systems (Doob, 1971:92). The meaning of time for philosophy is to debate the nature of time itself, which accomplishes awareness of issues concerning basic premises of human existence and the true meaning of life. Orme (1969) has noted that there appears to be a general tendency for philosophers to limit the variety of time phenomena considered, and also a ten- dency to examine time as conceived by the physical scientist for his convenience (Orme, 1969:147). I could, perhaps not unprofitably, follow the philo- sophical investigations of time in greater detail, outlining the historical evolution of the various debates over the major issues as decisively as I would be able (Heidegger, 1962; Gelvan, 1970; Husserl, 1973; Toben, 1975; Sklar, 1976: 241). Instead, I will show how the meaning of time is such that time has taken on an intrinsic sociocultural "value", and is therefore subject to optimization by shiftwork sche- duling. Anthropological perspectives on time From an anthropological perspective, the cultural use of time has undergone a transitional sequence: Time-keeping passed into time-saving and time—accounting and time rationing. As this took place, Eternity ceased gradually to serve as the measure and focus of human actions (Mumford, 1963:14). Time optimization, meaning effort directed towards obtaining the maximum value from time available in terms of work out- put, has been a major outgrowth of these changes in the cultural use of time. And this has led to the creation of shiftwork as a major cultural phenomenon. There is a good deal of evidence for aspects of time awareness having developed from simple zoological forms (Zeuner, 1949:247; Maxwell, 1971:37). Using conditioning techniques developed by behaviorists, researchers have demonstrated that various species can remember, as indicated by responses to rewards and punishments (Skinner, 1938; Mc- Connell, 1962; Peretti and Zrout, 1975; Logan and Beck, 1977; Schwartz, 1978). Since dogs and chimpanzees appear to anti— cipate future rewards and punishments, an anthropological argument has been made that early ancestral hominids had this anticipatory time awareness ability, as well (Maxwell, 1971:33). It has been stated by those involved in linguistics, that speech is a tool which facilitates human thought pro— cesses (Brown and Lennenberg, 1954; Brown, Black, and Horo- witz, 1955). Whorf's (1956) hypothesis, derived from his hobby of studying North American Indian languages, suggested that different linguistic structures present different ways of viewing the world and of perceiving time, particularly in relation to different modes of grammatical tense construc- tion (Anderson, 1980:384). Whorf also assumed that the gram- matical categories of a language were indicators of cogni- tive categories of thought. Others have argued similarly, that language is an integral part of cognitive functioning (Lenneberg, 1969; Bourne, Dominowski, and Loftus, 1979). Since the Hopi language has two grammatical categories that are strange to English speaking people (e.g., one category for temporary events and another for long-term events), Whorf concluded that the Hopi organize their world along a dimension of time which English speaking people tend to overlook (Krech, Crutchfield, and Ballachey, 1962:296: Bourne, Dominowski, and Loftus, 1979:124). The cross-cultural studies of time perspective found in the work of Kluckhohn (1956) and Kluckhohn and Strodt- beck (1961), are deserving of analysis. The Kluckhohn's assume that there are fundamental questions for which all persons cross-culturally must find answers, in order to give direction to their lives. In the study by Kluckhohn and Strodtbeck (1961), questions which pertain to dominant value orientations were used to construct value profiles of five neighboring Southwest communities inhabited by ex—Texan, Mormon, Spanish-American, Navaho, and Zuni groups. The researchers attempted to ascertain each individual subject's dominant time perspective, either past, present, or future- oriented. A societal time orientation was then made up using the consensus of individual value orientations. Differences among community members in this study, were often greater than the differences between the communi- ties themselves. On the question of consensual time pers- pectives, the Mormons appeared to be past—oriented, the Spanish—Americans present-oriented, and the ex-Texans future-oriented. Geertz examined both variation (1959) and uniformity (1973) with regard to Balinese social structure. In his pursuit of the latter, he examined the cultural apparatus in terms of which Balinese people think about individual persons. Employing a classification scheme derived from Schutz (1962), Geertz distinguished between the following overlapping classes: (1) Consociates are individuals who actually meet somewhere in the course of daily life; (2) Contemporaries are persons who share a community of time but not of space and do not normally meet; (3) Predecessors are not yet born and (4) Successors have died so neither can by definition be interactants. In Bali there are six kinds of labels of individuality in person-definition. An important point derived from Geertz's excursion into this subject is that among the Balinese, time is relegated to a much less significant place than in more complex cultures. In fact, the Balinese may be said to have an achronic approach to life, or an achronic value orientation (Bateson, 1963:35). Thus, the Balinese, culturally downplay the death process, the effects of remembering the dead on one's present life, and the potential effects of today's actions on tomorrow's as yet unborn children. Any cultural development which would alter Balinese experiences of time, person-perceptions, or notions of propriety would transform their lives entirely (Geertz, 1973:409). For example, shiftwork would have such an effect even though the Balinese do not adhere to Western concep- tions of time. If the Balinese were compelled to adopt schedules of shiftwork, it would disrupt their qualitative, 10 static appreciation of time. It will be later argued that shiftwork has an even more pervasive disruptive influence for cultures which are rooted in clock—dominated systems of time structuring. In his study of time and social structure among resi— dents of the Ashanti Confederacy, Fortes (1970) used a Western conceptualization of time. Norms for the times of domestic residential transitions (e.g., change of resi- dences after marriage; how children are viewed socially at different ages of social maturation) were calculated and interpreted as a means of better understanding the Ashanti social structure. Systems of time reckoning and ordering, such as calen- dars, seem to be directly related to societal needs to coor- dinate large groups of people (Sorokin and Merton, 1937; Sorokin, 1964; Maxwell, 1971:51). Smaller, more homogen- eous groups require less precision. Levi-Strauss (1967) has emphasized that whole cultures can be characterized by a preference for change or periodicity (Maxwell, 1971:52). Maxwell (1971:51) states that Malinowski (1927) was among those to point out the relationship between precision of time scales and societal complexity. Although Malinowski advocated measurement in numerous ways in anthropology, he himself was never very systematic about this prescription (Kaberry, 1957:80). E. E. Evans-Pritchard (1939, 1940) made a distinction between ecological time and structural time in his studies 11 of the Nuer, which was basically a statement of the dif- ference between time based upon natural phenomena (e.g., rainy or dry seasons), and time based only upon social re- lationships as an artifact of a given culture (Maxwell, 1971:53). In numerous socially static societies, the seasons and human generations repeat approximately uniformly, and often residents of these societies have very little time sense (as the Balinese), and lack the keen sense of history and of past and future that members of Western culture share (Schlegel, 1961:185). In summary, time is used in at least two ways in anthro- pology. One use that has been discussed is to examine cul- tural differences in time perspectives. Another use has been for analysis of the accomplishments of mankind accor- ding to epochal events. The use of time in anthropology places man's cultural development and achievements in an understandable perspective. In addition, it shows the trend toward optimization of time and speaks to potential effects of this trend. Sociological perspectives on time It has been stated by Davis (l972:vii), that on the whole sociologists have been negligent of the topic of time. When sociologists have considered time, it has often been treated as a simple chronological variable with which to order other social data, or to correlate them (Davis, 1972: viii). How people subjectively experience time, how much 12 experience is patterned with a variety of situational and career influences, how organizations structure and regulate the uses of time, and how cultures interpret its passage, are among those matters which have been given little empha— sis by sociologists (Davis, l972:viii). The question arises, as to how time has been used in sociology (in addition to simple chronological use), and what the significance of such use has been? Every society, it appears has some system of reckoning time (Doob, 1971:49, 75fn.). The calendar, in particular, is a social creation which generates and gives meaning to a myriad of social purposes (Davis, l972:18fn.). One use of time in socio- logy has been to conceive of time as an alternate plane of existence (Melbin, 1978, 1979). This is accompanied by increased specialization within the society along the dimen- sion of time (e.g., shiftworkers are specialized to work on a given shift) (Davis and Moore, 1945:249). One could de- bate the merits and justifications for the use of time as proposed by Melbin (1978, 1979). Man subsumes the continuing quality of experience by saying that he lives in time (the dimension of his becoming) even as he lives in space (the dimension of his move- ments) (Encyclopedia Britannica, (18), 1974: 421). Melbin was thinking along such lines when he developed his perspective of time as an alternate plane of existence to space. His major premise is that time can be a "container for living“ in much the same way as space is typically ‘7. l3 occupied. Melbin thereby divides the concept of space- time into separate components. (Melbin, l978:5). Another use of time in sociology has been to analyze the effects of clock time on human groups. A key variable that has been considered in this regard is that of role relationships. The effects of time on such relationships are considered across several analytical levels: actor, personal relations (including family), organization, com- munity, and society. Jensen and Ellwood (1964) have commented on an attempt by Sorokin to translate certain natural science concepts (e.g., cause, space, time) so they may be meaningfully applied to sociocultural phenomena. Attempts have been made to find a shortcut to methodological maturity in social science by using the methods of natural science to study sociocultural phenomena (Jensen and Ellwood, 1964:v). The rationale for attempting to do so is based upon the erroneous assumption that a fundamental similarity between physical, biological, and sociocultural phenomena exists. By way of definition, an empirical sociocultural system consists of (l) a system of meanings, (2) embodied in material objects or vehicles, and (3) employed by human agents. Physiologi- cally one can study what agents in a sociocultural system do as they interact. But, study of the reasons for their behav- ior, the "why" of their behavior, is not examined through natural science inquiry. Therefore, in order to understand the component of "meaning", an essential aspect of 14 sociocultural reality (and exclusive of physical space, physical time, and causality of natural science), it is necessary to transform natural science concepts and methodology. Sorokin (1964:34-35) gives an overall compari- son of the principles and methods of the natural sciences with those of the sociocultural sciences, which he feels is homologically parallel, though profoundly different. Sorokin's work represents a "total response" to a prob— lem by a sociologist exhibiting a complex unity of thought, feeling, fact, and value (Dawe, 1973:43). His analysis of sociocultural time begins by his specification of a variety of "physicomathematical time systems," each with different structures, aims, and functions (Sorokin, 1964: 159). All of these are cited as examples of what socio- cultural time is not, although sociocultural time is seen as homologous to each of them. His examples include classi- cal mechanics, quantum theory, and relativity theory, each of which represent use of different systems of time. Sorokin's analysis continues by his specification of several "biological times," cited for the same analytical purpose as were the "physicomathematical time systems". Introducing biological times with a review of the time sys- tem of evolution (seen as epochal, not continuous), Soro- kin proceeds to distinguish physiological time from physical time (e.g., persons of equal age may be physiologically quite different) (Sorokin, 1964:113). 15 In his treatment of "psychological time," Sorokin draws connections to biological time. He refers to mental measurement, the subjectivity of individual time perception as "flow of consciousness" that is not related to physical time, and the connection of time with memory. Each of these topics has been the subject of intensive investigation by psychologists. Sorokin then states, "whatever conception of time is offered, it is conditioned by the total character of the culture and society in which its author lives and works ... all elaborate conceptions of time in any field of thought are socioculturally conditioned and are sociocultural time in a broad sense" (Sorokin, 1964:168). By this definition, there is ultimately only one kind of time - sociocultural time. Without belaboring Sorokin's analysis further, it can be summarized as follows. The natural sciences use an objective means of conceiving and measuring time, which, though useful, ignores the social nature of time. The social sciences, or sociocultural sciences as Sorokin pre- fers to call them, necessarily use subjective analytic com- parison as the basis for understanding phenomena. A variety of societies use social events as the points of initial time reference (Sorokin, 1964:174). And among primitives, time reckoning per se is almost absent, yet, despite its discontinuity and brevity, it is characterized by specification of social events (Sorokin, 1964:175). 16 Thus, the idea of time and its divisions is to a great degree a social convention (Sorokin, 1964:184). Purely quantitative time cannot replace sociocultural time and is itself inadequate for a study of sociocultural phenomena, as it breaks a Gestalt, and the meaning of the period is lost (Sorokin, 1964:197-201; Perls, 1972, 1974). For the present study, along with the mathematical calculations of differences across shifts (related to natural science time), an attempt has been made to specify the subjective aspects of sociocultural time for nurses on shiftwork. Shiftwork derived from sociocultural time, as it represents specification of social events pertaining to work, that are to occur at particular times. Sorokin's analysis culminates with reference to the medieval divisions of sociocultural time into the following planes: (1) Aeternitus (ideational time which is truely eternal) (2) Aevum (co—participant in the ideational world of pure meanings and in the changing world of sensory perception) which is semi-eternal, e.g., a scienti- fic law remains until superceeded (3) Tempus (serviceable convention to which most refer when using the word time - clock time) (Sorokin, 1964: 215-217) In a discussion of social time, Gioscia (1971) de- scribes his sociological paradigm which consists of three parameters of time. One dimension is called the meta- chronic-anachronic, which refers to being ahead or behind 17 the times of social process. The second parameter is called the epichronic-catachronic, meaning elation or depres- sion at the times. And the third dimension is the hyper- chronic-hypochronic, or degree of sensitization or rate tolerance to the times, as when one person is patient while another is bored by the same social event. These three dimensions are considered to form a synchrony in which all dimensions are dialectically interrelated. Using this paradigm, Gioscia explores the origins of various social interactions (e.g., social revolution results from a meta- chronic age agroup impeding against an anachronistic society) (Gioscia, 1971:73). In summary, time has been used in several ways in sociology. Aside from the chronological use of time, time has been used to describe sociocultural phenomena (Sorokin, 1964); for restructuring conceptualizations about planes of existence (Melbin, 1978, 1979); and as the basis for a synchronous paradigm for exploring the origins of social interactions (Gioscia, 1971). Psychological perspectives on time In psychology, the effects of clock time on the indi— vidual are of greatest importance. Key considerations include perception of time, feelings about time, motiva— tional properties and uses of time (Knapp and Garbutt, 1958), personality traits that endure over time (Hall and Lindzey, 1957; Jourard, 1974; Monte, 1980), disruptions of time “"41 18 relating to mental illness (El—Meligi, 1971; Salinger, 1971), and the effects of time deprivation. Time perception varies inversely with the amount of interest an event or activity stimulates. Dull activities seem to take forever, whereas, interesting ones seem to be over all too soon. Time can have strong motivational properties. Anxiety generated by the passing of time can lead to constructive activity (Doob, 1971:411). However, when people establish artificial goals for themselves within arbitrary time frames, they risk personal disappointment and,concomitant psycho- logical distress if their goals are not reached by the time they have specified. Some psychotherapies attempt to cur- tail such a practice in order to help people avoid such self—initiated disappointments (Perls, 1974). Personality theory explores enduring traits or behavior patterns that are related to time (Doob, 1971:408). By definition, traits are behavior patterns that persist over time. Mann, Siegler, and Osmond (1971) have suggested that time is derived from one's personality temperament and type, and is therefore a wholly private perception rather than a learned social perception. Using Jungian typology, they constructed a theory of different individual temporal orien- tations. In addition, they provide case studies using charac- ters from novels, films, and history, to illustrate persons of each particular type (Mann, Siegler, and Osmond, 1971:148). 19 Perspectives on time in Biology and Chemistry Time has been used in biology and chemistry to examine regularities of numerous physical processes within organisms. Physical processes are often seen as having timing mecha- nisms — called biochemical or biological clocks - yet, the locations of such clocks remain a mystery. The classical doctrine of "imprinting" has shown that biological oscilla- tion couples itself to external temporality to produce bio- logical clock time (Pittendrigh, 1971). Thus, the produc— tion of these clocks is an identifiable phenomenon, but the function of such clocks is speculative. Use of clock time based on the earth's rotation affords the ability to quantify a host of physical bodily processes in relation to one standard of measurement (Taffel, 1965:25). When a person, for example, begins to work a different shift schedule, the change in time may be correlated with changes in biochemical bodily processes in order to observe possible changes of such processes. A casual relationship is believed to exist in the instance of a strong correlation. Biological clocks are modifiable within limits by changes in the environment: organisms respond to external cues which have temporal sig— nificance although just how the process works may remain a problem for research (Doob, 1971:70). Perspectives on time in Physics Physics uses time in two respects, referred to here as classical time and relativity. Man's first need for high precision time measurement was in sea navigation. Pendulum 20 clocks had been developed at the time this need arose, but they do not work at sea. Harrison was offered 20,000 pounds by the British government to solve the problem of construc- ting an effective clock for sea travel. He constructed the first clock having a balance wheel, based on the use of an escapement that converted pendular swings to even movement. At present, using precision atomic clocks (which use an atom as the pendulum), physicists can measure the speed at which the earth's rotation is slowing down. An inherent danger of this practice of measurement, is that of the ten- dency to sacrifice ideational time which is truely eternal, for the short-sighted but eminently practical techniques of time measurement for coordination of human actions. Fortunately physicists have found aspects of the world which do not share the onward motion of classical time (Schlegel, 1961:193). These aspects are cyclic processes that are out of the stream of non—cyclic changes in the universe (Schlegel, 1961:193). Physics also uses time as a basis for theoretical for- mulations about the nature of the universe, such as relativ- ity theory. Relativity is the theory which shows that time is affected by motion, developed by Albert Einstein. Physi- cists now accept that time arises from events, rather than that time exists before events (Schlegel, 1961:183); Ridley, 1976:54). Assumptions in Einstein's theory necessitate an eventual return to the philosophical debates about the nature of time. For example, relativity theory addresses 21 the question as to whether two thoughts can occur simul- taneously. Some philosophers maintain this can happen, but relativity theory states that this cannot occur. Since the classic interpretation of Einstein's special theory of relativity by Hermann Minkowski, it has been clear that theoretical physics has to do not with the two entities of space and time taken separately, but with a unitary entity called space-time (Encyclopedia Britannica, (128), 1974:421). Interdisciplinary considerations on past, present, and future Time, as measured by physicists' mechanical devices is always past, and time, as the philosophers use the concept is always either past or future (Von Mises, 1966:100). From these viewpoints, the present is nothing but an ideal boun- dary line separating the past from the future. However, as Von Mises (1966:100) notes: But from the praxeological aspect there is between the past and the future a real extended present. Action is as such in the real present because it utilizes the instant and thus embodies its reality. Davies (1977:221), a physicist, suggests that the origin of the division of time into past, present, and future, is in the mind (psychological), rather than in the physical world. When anthropologists establish time orientations of socie- ties or groups, they are assessing the prevalence of an essentially psychologic quality. Ordinarily, we may not be aware of time until some purpose is thereby served (Doob, 1971:48). 22 The impression of a moving, flowing, passing time, a time of uni—directional acti— vity, is so fundamental to all experience (at least in Western civilization) that it pervades our entire society. The reluctance to discard the passage of time as an illu— sion is tremendous (Davies, 1977:220). Cause and effect are essentially human concepts for human situations, and are the cornerstone of social scien- tific research (Davies, 1977:219). In fact, the known universe is the product of human conventions (Douglas, 1975:xiv). For example, in physics, cause and effect describe time-oriented interactions in terms of the decay of organization, itself a purely human notion (Davies, 1977:219). Thus, physics leads us to return to the philo- sophical question posed by time, as to the meaning of life or existence: It is probably better to regard the universe as a total phenomenon - the world is space—time, matter and interactions, exten— ding from past to future, from place to place, from event to event in a vast network of complexity and existence (Davies, 1977:219). As Novel laureate chemist Dr. Ilya Prigogine (1979), has philosophically stated: "We must change from the static view of being to a dynamic concept of becoming" (Prigogine, 1979:23). Theoretical rationale guiding the research An important factor for the present research derives from the foregoing theoretical framework. In order to make the best use of chronological time in an industrial-techno- logical culture, a sociocultural pattern has emerged. That 23 is, administrators of various occupational work groups have instituted shiftwork schedules. This is the source of the first premise of the set of theoretical propositions guiding the present research. The other propositions were logi- cally derived from a review of the literature on the socio- logy of work and health related effects, nursing as an occu- pation and/or profession, and studies of shiftwork, which follows. (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) The sociocultural trend toward time optimization stimulates shiftwork scheduling of workers. Shiftwork stimulates biological disruptions. Shiftwork stimulates psychological disruptions. Shiftwork stimulates sociological disruptions. Biological disruptions stimulate psychological disruptions and vice versa. Psychological disruptions stimulate sociological disruptions and vice versa. Biological disruptions stimulate sociological disruptions and vice versa. Biological disruptions contribute to psycholo- gical strain and social isolation. Psychological disruptions contribute to psycho- logical strain and social isolation. Sociological disruptions contribute to psycho— logical strain and social isolation. Shiftwork induced disruptions contribute to psychological strain and social isolation, in direct relation to the amount of deviation from normal daytime scheduled work demanded by the shiftwork schedule. 24 Summary The problem for research was explained as formulation of a theoretical time framework for explaining the social and behavioral significance of time, in a human behavioral setting. It was proposed that a sociocultural trend toward time optimization in the working world, has stimulated increased use of shiftwork schedules in recent years. This is particularly applicable to the industrial-technological societies in the world today. These shiftwork schedules are believed to be responsible for stimulating a complexity of disruptions in the lifestyle of the worker. They are also believed to aggravate preexisting problems. From this theoretical basis was derived the specific problem for research, of exploring the significance of selected disrup- tive factors of shiftwork among a group of nurse subjects. CHAPTER II REVIEW OF RELATED LITERATURE Introduction In this chapter, a multidisciplinary body of available literature is considered to assist with formulation of the theoretical basis for this study. The specific areas of exploration were largely determined by the preceeding theoretical analysis of the multidisciplinary nature of time. This discussion led to the idea that time optimiza- tion, a socioculturally determined trend, is related to work. First, a conceptual framework for stress research relevant to work, is provided. Next, various aspects of the social organization of work and related cultural values are reviewed in light of their relevance to the specific problem for research - the stressful effects of shiftwork on nurses. The discussion of work is followed by examina- tion of nursing as an occupation and/or profession. Then, a review of studies by other researchers on various factors relating to shiftwork is presented. Each topic is assessed in terms of what is generally known, and for potential contributions to the problem for study. The chapter con— cludes with a restatement of each of the premises of the theoretical rationale guiding the research, strengthened by their connection to relevant points revealed in the litera- ture review. In reviewing the literature described, some specific questions relevant to the problem for study, were addressed: 25 26 (1) How has stress research been treated theoretically? A framework for stress research is discussed in response to this question. (2) How does the social organization of work and the cul— tural values which frame it affect the worker? This includes consideration of the related factors of lei- sure and time; motivation and incentives; and alienation and depersonalization. (3) What is the holistic perspective afforded by social science on health and illness as a major social phenom- enon, and how is it applicable to shiftwork? (4) Has nursing become a profession? Discussion of this question should serve to enhance the sociological con- text of the present study. (5) How are workers affected by the stress of shiftwork in multidisciplinary terms? From this discussion derives the present problem for research. The technique used to search the related literature may be of interest. Initially, a broad computer search of four data bases was made for the period January, 1966 through July, 1976. The data bases searched were as follows: Med— lars, Psychological Abstracts, ERIC, and Biosis (State Uni- versity of New York at Albany, University of Libraries Reference Services Department, 1975). The search was re- peated on the same data bases for the period July, 1976 through September, 1979. The title used for each of the searches was as follows: Biological, Biorhythmic, 27 Psychological, and Sociological effects of Shiftwork. Several thousand abstracts were retrieved by the searches. Subsequently, several hundred articles were retrieved and reviewed. Using the demands of the theoretical framework to establish criteria of acceptability, those contribu- tions considered relevant to the present study were incor- porated herein. In addition, several university libraries were searched for holdings under relevant subject headings. Framework for stress research McGrath (1970) has developed a conceptual framework for the conducting of stress research. Many of the ideas presented in this section are therefore credited to his systematic efforts. There are intimate relationships be- tween physical and social conditions as antecedents of stress, as well as among biological, psychological, and social interactional responses to stress (McGrath, l970:5). Given a certain structural framework, it can then be used to generate a paradigm of the dynamics of operation of shiftwork. The guiding principle is holism - for the framework as well as the paradigm - they should take into account as many related phenomena as possible. The present study will, then, explore selected segments of this multi— disciplinary theory. Stress has been defined in many ways (Selye, 1956; Appley and Trumbull, 1967; McGrath, 1970). For the present study, the concept is used as a general rubric having 28 heuristic value as a basis for connecting seemingly diverse interdisciplinary areas.‘ (McGrath, 1970:11). From this conceptual formulation, the present study further refines the focal concept of stress by specification of behavioral phenomena (e.g., indexes of psychological strain and social isolation) for investigative use in a given stressful situation. Admittedly, such techniques for measuring stress and its effects are as yet less advanced than measurement of other human attributes such as intelligence, attitudes, or perceptual skills (McGrath, l970:3). Response-based definitions of stress Cannon (1932) experimentally studied the relationship between emotions and physiological change. He described the "fight-flight reaction" to stress. In this physiolo- gical state the body was predisposed, due to excitement of the sympathetic nervous system, to either stand and fight danger or to run away from it. The emotions involved, stimulated by adrenalin secretion, were either fear or rage. Selye (1956) elaborated on the research of Cannon (1932), in his formulation of the dominant response—based definition in use today (Mirkin, 1979). His general adapta- tion syndrome to stressors of any sort, consisted of a constant physiological pattern of responses that defined the occurrence of stress. Selye also believes that in addition to stress having the negative effects associated with the general adaptation syndrome, there also exists a positive type of stress. If a person is experiencing negative stress, 29 Selye suggests ways to convert such stress to a positive experience (Cherry, 1978). It would, of course, be naive to view all stress as endowed with such a potential for conversion. Similarly, there are according to Ellerbrock (1978:95), two reactions to stress. If it makes a person miserable, his/her body will have all kinds of deleterious reactions. If the stress is enjoyable, it will result in optimal personal functioning. There are, however, some weaknesses to response-based approaches. First, there are numerous "stress inducing" conditions which subjectively vary from person to person as truly stressful. For example, consider the truism that some persons find regular exercise stressful, yet others do not. Thus, exercise might be excluded as a generally stressful situation, as might practically any other condition one specifies for analysis. Second, the same syndrome may arise from entirely different states of affairs, in a qualitative sense. Compare physical exertion with purely psychological fright. Both stimulate increased blood pressure and heart beat, etc. Third, all symptoms in the general adaptation syndrome do not always appear together; that is, there are exceptions (Lazarus, 1966). Perhaps the most generally acceptable operational defi- nition of psychological stress would be one propounded by Parsons (1966), which describes stress as a very broad term covering a considerable variety of conditions underlying avoidance and escape responding (Haythorn, 1970:160). For 30 Parsons, stress is what we escape or avoid (Weitz, 1970: 125). This definition, though a disturbingly broad one, has much to recommend it to the behavioral scientist (Haythorn, 1970:160). Situation-based definitions of stress Stress may involve the presence of certain classes of situations, or situations involving certain classes of stim— ulus properties. This type of definition has some advan- tages over the response-based definitions, but has some limitations as well. Some questions immediately raised by situation-based definitions are as follows. First, what kinds of situa- tions, and what properties of them make for stress? Second, how shall the researcher handle individual differences in response to the same, presumably stressful situation? Third, how can the situational properties be measured to yield quantitatively, the degree of stress present in different situations? Without such measurement, the tendency will be to develop separate stress theories for each distinct situa- tion. Stress as an organism—environment transaction Stress is not just an intraindividual emotional state, as the preceeding discussion might seem to imply. It is a particular kind of reaction to environmental events. The occurrence of environmental change is a starting place for building a transactional definition of stress, yet some 31 stress reactions arise from continued interaction with an "objectively" unchanging environment. The earlier questions of measurement and specification of boundaries for classes of potentially stressful situations, however, remain. The engineering analogy: a transactional definition It is useful to draw an analogy between the social scientist's use of the term stress with the civil engineer's use of it. In engineering, stress is the application of an external force which produces "strain," to be reckoned in terms of the substance to which it is applied. The stress- strain effect is a relationship between an entity and its environment. Environmental stress can cause structural damage when there is no visible or apparent change in the application of external force because stress can be contin- ual or cumulative over time. The social scientific use of stress differs from the engineering use. First, the social scientist has problems in measuring the stressing forces with which he/she deals, restricting the results of research to the stimulus situation. And second, the social scientist has to reckon with the added complexity that the effect of the force can be altered by the subject's perceptions of it. All four definitions of stress critiqued so far, point up the diversity of meanings of stress, and reinforce the need for an organizing framework for its conceptualization. The definitions also direct attention to necessary considera- tions for any organizing framework attempting to present a 32 comprehensive conceptualization of the stress area. It is not the purpose of the present study to attempt to provide a comprehensive conceptualization of the stress area. This has been done by McGrath (1970). The preceeding discussion is useful in order to explain the conceptual formulation used in the present research. Each of the definitions pre- sented may be related to the present study, as may the limitations of each. A frame of reference for stress research A frame of reference for stress research has been formulated by Kahn (1970), and will be briefly stated here. (1) Focal organism or "actor" for stress research can be at any level - individuals, groups, or organizations. The organism at whatever level is embedded and func- tions within a broader physical-social system. (2) The stress problem involves four stages: The first of these takes place in the environment - the physical-social system in which the focal organism is embedded. This class of events can be called demand (or load, input, "stressor," press, environmental force, etc.) Second, there is the reception (recognition, cognitive appraisal, perception, acceptance) of that "objective" demand by the focal organism. This class of events can be labeled strain (or subjective demand, or personal definition of stress). Third, there is the focal organism's responses to the subjective demand at physiological, psychological, behavioral, and social-interactive levels (including cul- tural). Fourth, there are the consequences of response, 33 both for the focal organism and for the larger system or environment in which it is embedded. It has been noted by McGrath (1970:16), that in principle, stress research efforts should be concerned with these events and linkages, but specific studies may well wish to limit concern to certain portions of this total span. Time factors and stress Discussion and analysis of the concept of time forms the broad range basis for the theoretical framework of this study. It has been seen that time has a multidisciplinary meaning and varied uses in social science inquiry. A socio- cultural trend towards optimization of time has led to shift- work. And, shiftwork brings with it a variety of disrup- tions of a stressful nature which may then be theoretically considered in relation to time sequence. The sequence of events in the stress problem, that is, objective demand - strain (subjective demand) - response - consequences, takes place through time. Furthermore, "feedback loops" are needed to reflect the "flow of events", and these four stages are most appropriately considered as a cyclic pro- cess through time (McGrath, 1970:17). Temporal factors are involved in both methodological and substantive issues with regard to stress research. They relate to stressor condi— tions, the experience of stress, coping behavior and consequences. In addition, there are temporal considera- tions at both macrolevels (for example, questions of 34 longitudinal studies versus studies at a single point in time) and microlevels (questions about the interval between signal and stress, about duration of demands, etc.) (McGrath, 1970:23). The physical and sociocultural aspects of environment Behavioral scientists have often not bothered with physical environment properties in stress research due to their assumptions about the nature of psychological stress. In other contexts, physical environment properties may be important determinants of behavior, as in use of space (Hall, 1963), or in isolation studies (Haythorn, 1970; Altman and Lett, 1970). If, for example, psychological stress inevitably has an intraorganismic and psychological component (e.g., anticipation of inability to cope), then physical conditions of the environment will affect psycho- logical stress only after their translation into socio- psychological terms. If so, it is better to study these more proximal sociopsychological variables as they affect psychological stress, than to work with the more distal physical variables from which they originate. Some argue that the behavioral sciences should concern themselves with sociopsychological variables and not become involved with physical variables (McGrath and Altman, 1966). Stress and the coping process The coping process refers to a variety of behavior patterns by which an organism can actively prevent, alleviate, 35 or respond to stress-inducing circumstances (McGrath, 1970: 33). A thorough treatment of coping processes is provided by Lazarus (1966). It should be noted that choice of coping as a focal concept for stress research is based on the value premise that stress is bad and should be reduced (McGrath, 1970:56). Selye has noted the inherent weakness of such a premise in his exploration of positive as well as negative stress. Summary of stress research framework The occurrence of stress and its effects can be mea- sured at physiological, psychological, behavioral (task and interpersonal performances), and at the organizational level. Within each of these levels, various operational types of measures can be applied: subjective reports, aided or un— aided observation, trace measures, archival records. Alter- measures within level and type do not always agree; nor is there always convergence of measures across types and/or levels. Such lack of convergence of measures can be viewed as methodological weakness (alternate measures of the same property - stress - yield different results), or as substan- tive information (alternate measures represent alternate and more or less substitutable responses to stress). In one sense the utility of stress concepts is promoted by their lack of specificity, since the use of an ambig- uous rubric promotes interdisciplinary links between biology, psychophysiology, psychology, and sociology (Mechanic, 1970: 104). Mechanic (1970) does not believe it is either possible 36 or fruitful to come to agreement on the referents of the rubrics of stress and adaptation. He notes that "these con- cepts take on different meanings depending on the problem being investigated, the methods being used, the theoretical orientations of the investigator, and personal tastes" (Mechanic, 1970:105). Attempting to force stress research problems into a common mold implies the possibility of a viable integrated theory of behavior; a possibility that is fruitless to pursue at present because of lack of know- ledge (Mechanic, 1970:105). Perhaps this is an extreme view to take as there is much to be gained in attempting to contribute to the formulation of such an integrated theory. For example, research, such as that by Dohrenwend (1973) on life events as stressors, has conceptualized stressfulness in quantifiable life change units. Contribution of conceptual framework for stress research to the present study Several stress-inducing conditions are hypothesized to be involved in shiftwork in a real life setting: (1) actual or anticipated physical disruption (2) actual or anticipated psychological disruption (3) actual or anticipated disruption of social relationships (4) a constraining environment which leads to deprivation (McGrath, 1970:63-64) Deprivation is a compound form of stress which includes depri- vation of physical needs (usually sleep), psychological needs (e.g., varied stimulation, time awareness) and/or -‘-—._———_.—‘.—7 37 interpersonal needs. The question of interest for the present study is as follows. Assuming shiftwork is a stressful situation for nurses (evidence will be presented indicating that this is a fair assumption), what are the various disruptive effects in multidisciplinary terms? Mechanic (1970:113) notes that one probably achieves a more useful perspective on stress if considered from both a personal and societal perspective simultaneously. Within the conceptual framework specified, it seems reasonable and convenient to define psychological strain and social isolation as particular reactions to stress. From a theoretical organizational perspective, Gross (1964:853) has suggested that empirical studies should in- clude both situational and psychological data. And Moss (1973) encouraged sociologists to consider biological pro— cesses in their work, yet noted the inherent difficulty of finding researchers capable of conceptualizing and measuring both social and biological properties (Moss, 1973:vii,3). Admittedly such a task is difficult, but not impossible. Psychological stress has been used conceptually, in the pre- sent study, to refer to the conditions that produce psycho- logical strain (Indik, et. al., 1964:27; Gillis, 1977:428 fn.). Work and values Cross-cultural studies of work may contribute to our understanding of work and cultural values in the United 38 States (Osipow, 1973). Writers such as Benedict (1946) and Roe (1956) have been among those to have extensively dis— cussed work in various cultures. The work of Mead (1937, 1939), who studied South Pacific islanders revealed (as might be expected in primitive cultures), that work was begun at a very early age and was assigned according to the individual's abilities. The work of such children was socially considered as important, in contrast to the work of American children which is usually considered as unimpor- tant (Osipow, 1973:253). The artificiality of work for American children may well generate culturally unwholesome attitudes towards work in later life (Osipow, 1973:253). Sociological studies of work and values have shown a changing trend in the value system of Americans. For most of this century, and in particular during the period fol- lowing World War II up to about 1970, the value system of most Americans centered around a number of powerful, cul— turally derived middle-class symbols that relied upon their ability to provide at least some of the essentials of psychological well-being (Yankelovich, 1978:47). These ‘values were typified by Whyte's (1956) discussion of organi- zational control in America, entitled The Organization Man. The "organization man" is a vague term which refers to anyone in the generation of bureaucrats during the 1950's. Organi- zation men talk of the “treadmill," the "rat race," and of the inability to control one's direction. Whyte points out that organization life does not always go along with the 39 precepts of the Protestant Ethic. Advancement by personal connections is a notable exception to this ethic. Whyte proposes the existence of a Social Ethic; a body of thought beyond the Protestant Ethic that has been taking care of the redefinition of the organization man's place on earth. This Social Ethic rationalizes the organization's demands for reality and gives those who subscribe to it a sense of dedication in doing so. It is an ideology that morally legitimizes pressures of society against the individual. Although no organization member would be likely to admit outright that he believes in the Social Ethic, many would subscribe wholeheartedly to the following separate compo— nent ideas that, when synthesized, form it: (1) A belief in the group as the source of creativity; (2) A belief in "belongingness" as the ultimate need of the individual; and (3) A belief in the application of science to achieve the belongingness. Whyte's main thesis is that emphasis of the Social Ethic is wrong. We need to know how to cooperate with the organization while simultaneously knowing how to resist certain of its aspects. In a sense, he was recommending that one overtly value the organization highly, while covertly maintaining a more self-restrained sentiment about the value of the organization and one's work. A change to a new set of values has involved either time away from the organization, or suggested change in the nature of jobs in the organization to accommodate the new 40 values. The following work-related ideas are included among these new values: (1) the increasing importance of leisure (time is seen as a measure of one's values), (2) the symbolic significance of the paid job (as opposed to un- paid housework), and (3) the insistence that jobs become less depersonalized or alienating (Yankelovich, 1978:77). People also want the chance for personal growth through jobs, in recent years (Renwick, Lawler, et. al., 1978). For some people, the acquisition of material symbols is no longer valued as a primary goal in life (Abbott, 1977:29). These people have accepted non-material values because of a general uncertainty about what values should replace those being discarded. Yet for many, there remain a variety of motivational reasons for work (Caplow, 1954). Etzioni (1977) has suggested that millions of Americans may be embracing a new ethos, as they increasingly pursue what used to be called nonproductive activities as legitimate patterns of living (e.g., study, public life). Leisure time: a contradiction Predictions that a future of leisure time would emerge, have not been fulfilled (DeGrazia, 1971:444). One may de- bate whether these predictions will ever be realized. Thus far, peOple seem caught in an endless circle of wanting things that cost money that costs work that costs time (De- Grazia, l97l:447). This is typical of those subscribing to the dominant values of the "rat race" of organizational life 41 (Whyte, l956:2). Presently, after giving the first and best part of one's day to work, one is left with freedom which formerly meant engaging in pastimes but today involves other work, chores, moonlighting, or sometimes play (De- Grazia, l97l:453-454). An underlying value in this situa- tion is that a person who is not working at his/her job should: (1) do something, and, (2) preferably do something productive. No other nation is as precise in its time sense or so time-conscious as the United States (DeGrazia, 1971: 458). Time is, therefore, valued for the fact that work can be accomplished within its structure. Thus, whatever free time we have is really unfree, but is indirectly linked to worktime to which we ultimately re— turn (DeGrazia, 1971:474). The phrase, "leisure time," is contradictory, since leisure has no adjectival relation to time (DeGrazia, 1971:476). Leisure is a state of freedom from everyday necessity, and one would engage in truely leisure activities for their own sake - an ideal that is seldom approached by most. No specific leisure time acti- vity is inherently more satisfying than any other. It is the ability to identify oneself as a participant in any specific activity that makes one's use of time satisfying and valued ("Time: A Measure of Our Values," 1979:201). Motivation to work Levenstein (1973) argues that in an age of affluence in industrial societies, the traditional intrinsic rewards 42 of creative attachment to work are lost, creating the need for new incentives. What motivational incentives exist for work in today's society? In attempting to answer the question of why people work, one might consult the writings of Maslow (1978) who specified a hierarchy of human needs. Maslow classified needs based on the priority with which they tend to be satis- fied. Generally, once the most basic need is fulfilled, a person will be motivated to realize a higher need (although there are exceptions to this pattern). The needs specified are as follows: survival (physiological); security (safety); social (love and belonging); esteem (ego, self-identity); and self-actualization (infinite pursuit of being and becom— ing one). Several assumptions underly Maslow's model. The most significant of these are as follows: the organism is holistic; an act usually has more than one motivation; clas— sification of motivation is based on goals rather than drives; motivation theory is human-centered; motivations are only one class of behavior determinants since behavior is also biologically, culturally, and situationally determined. Since there are exceptions to the sequence or process implied in need fulfillment, the hierarchy is best viewed as an organizing concept rather than as an explanatory model (O'Shaushenessy, 1976:91). There have been numerous offshoots of Maslow's theory, two of which will be described here. Argyris (1960) and Strauss (1963) have written about complex organizations using 43 concepts and ideas derived from Maslow's theory. Argyris wanted to provide knowledge concerning the difficulties the individual faces and the opportunities he has for self- actualization in industrial organizations, for application to any genotypically similar complex organization. He sees most human problems in organizations as arising because relatively healthy people are asked to participate in formal work situations which coerce them to use few of their more than "skin-surface" abilities. Argyris contends that the existence of the organization is symptomatic of sick organi— zations that should be changed to facilitate individual growth. Strauss (1963) states what basically amounts to Mas- low's model as the "personality versus organization" hypo- thesis. Strauss advocates that management should not provide high wages and liberal employee benefits, but rather should promote job enlargement, general supervision, strong cohe- sive work groups, and decentralization - all "power-equali- zation" techniques. He criticizes the personality versus organization hypothesis for overemphasizing the individual's desire for freedom and underemphasizing his/her desire for security. In direct opposition to Argyris (1960), Strauss (1963) sees a need for conforming, unimaginative types of "organization men." Although workers may be apathetic and dependent in Argyris' terminology, Strauss feels that they are not necessarily actively dissatisfied, as they seek meaning in life from home and community activities rather 44 than from their jobs. Thus, Strauss concludes that there is a broad range of people that do not seek self-actualiza- tion on the job, and that this is okay because it would be too difficult to redesign some jobs to permit self-actuali- zation to occur. Others, such as Herzberg (1966), and Vroom (1964), have attempted to assess the determinants and effects of work satisfaction. Herzberg (1966) has compared work satisfiers with dis- satisfiers and developed a two-factor theory of motivation. His theory was developed from a series of interviews with engineers and accountants about their work. Strong deter- miners of job satisfaction that emerged in Herzberg's re- sults were achievement, recognition, work itself, respon- sibility, and advancement (Herzberg, 1966:72). The major dissatisfiers were company policy and administration, super- vision, salary, interpersonal relations and working condi- tions (Herzberg, 1966:74). Satisfiers or "motivators" seem to describe man's relationship to what he does, while the dissatisfiers or "maintenance" factors describe his relation- ship to the context or environment (Herzberg, 1966:74). Thus, good feelings were associated with job content factors, while bad feelings were associated with job context factors. Shiftwork is a job context factor that would therefore be a potential source of negative feelings for the worker. Kornhauser (1978) has noted that jobs in which workers are better satisfied are conducive to better mental health; 45 jobs in which larger numbers are dissatisfied are correspon- dingly conducive to poorer average mental health (Kornhauser, 1978:85). The criteria for participation in organizations have been specified by March and Simon (1958, Ch.4). Their analysis also shows the major dissatisfying factors affect- ing a worker's decision to change jobs. Financial compensation is certainly an important factor in worker motivation (Opsahl and Dunnette, 1966). Money operates as a generalized conditioned reinforcer (Skinner, 1953), a conditioned incentive (Dollard and Miller, 1950), an anxiety reducer (Brown, 1961), and as an instrument for gaining desired outcomes (Vroom, 1964), according to various theoretical viewpoints. Lawler (1969) has argued that when jobs are structured in a way that makes intrinsic rewards appear to result from good performance then the jobs themselves can be very effec- tive motivators. Theories of motivation in general Psychological research into the nature of motivation has largely emphasized animal behavior and sought a physio- logical explanation (Warr and Wall, 1975:168). Focusing on observable behavior in such efforts, motivation has been seen as its hypothesized cause, with little attention paid to such concepts as experience and feelings (Warr and Wall, 1975:168). A more satisfactory view, especially for human applications, would have to consider these aspects. Thus, 46 models of wanting have been constructed to complement the presently limited behavioral motivation theories (Warr and Wall, 1975:168-177). Expectancy theory A group of models, called expectancy or instrumenta- lity theory have attempted to specify a person's feelings about different events or actions in terms of the perceived likelihood that they will have desirable consequences (Warr and Wall, 1975:169). They try to predict the course of action an individual will take when given the chance to choose his behavior. The theory originally derived from the work of psychologists Tolman (1932) and Lewin (1935), and includes the work of Vroom (1964). Vroom (1964) believes that people work for both economic and motivational reasons. He predicts that given the chance a person will choose to work when the valence of outcomes which he expects to attain from working, are more positive than the valence of out- comes he expects to obtain from not working (Vroom, 1964:29). Expectancy theory has been valuable for recognizing that people operate in complex ways in motivational decision- making, yet the theory has some drawbacks, noted by Warr and Wall (1975). First, the measurement of subtly differentiated judgements is difficult, if not impossible as it requires precise measurement of valences. And second, expectancy theory places too strong an emphasis on an assumed future time orientation in people, and ignores the probability that 47 people are at times more present-oriented in their wants as Freud (1949) noted. Exchange theory A set of models that does consider more immediate sources of wanting has been called equity or social compar- ison theory (Warr and Wall, 1975:171; Janis and Wheeler, 1978), as well as exchange theory. These include models by Festinger (1954) and Homans (1961). Festinger argued that people seek to resolve uncertainty about their opinions and abilities by social comparison acti- vities. People want their ratio of inputs to rewards to be similar to that of others. If another person is receiving greater rewards relative to inputs, a person who is com- paring himself with that person will be expected to have increased wants. This coincides with Homans' (1961) concep- tion of the rule of "distributive justice" which states that a man's rewards in exchange with others should be propor- tional to his inputs. One of the major analytic tools of modern sociology is the social role concept (Neff, 1977:40). Gullahorn and Gullahorn (1971) explored the information processing involved in resolution of role conflict, using an application of Homans' (1961) theory of social behavior and Simon's (1957) work on decision-making, to their computer similation of human behavior. 48 Aspiration level theory A third theoretical approach is concerned with wants, generated to the extent a person has come to expect them to be fulfilled. In Lewin's (1935, 1947) laboratory research on so-called aspiration levels, a recurrent theme was that task success tended to raise a person's aspiration levels. Like Vroom, Lewin used the concept of valence to indicate the strength of an individual's preference for some out- come to which he/she aspired. Other theories of motivation McClelland (1961) categorized three human motivational needs: (1) the need for affiliation, (2) the need for power, and (3) the need for achievement. Warr and Wall (1975) have commented on McClelland's work, noting that some people are particularly prone to set themselves tar- gets which necessitate personal effort and skill for their attainment, and to evaluate their own performance against high internal standards of excellence (Warr and Wall, 1975: 160-161). This tendency may be both satisfying and stress- ful to the individual. Likert's (1961) theory of motivation is quite general. He feels that motivational forces come from the workers direct perceptions, from attitudes, and from the values and goals of the individual's work group (Likert, 1961:99). His ideas are cognizant of the social forces affecting the worker's life. As Likert notes, "To minimize these conflicts 49 and tensions, the individual seeks to influence the values and goals of each of the different work groups to which he belongs and which are important to him so as to minimize the inconsistencies and conflicts in values and goals" (Likert, 1961:165). Such conflicts are believed to be aggravated by shiftwork, particularly as the schedules detract from the worker's ability to selectively partici- pate in groups outside of the work organization that are important. Measurement of satisfaction with work Aside from the specification of satisfier and dissatis- fier factors in work situations by Herzberg (1968), there has been little attempt to assess the relationship between personality variables and job satisfaction in theoretical terms. Most of the empirical work represents an effort to establish a relationship between measures of adjustment or neuroticism and job satisfaction (Vroom, 1964:161). Numer- ous methods of measuring adjustment have been used, inclu- ding personality inventories. Research such as that of Mayo (1945) and the group dynamics research of Lewin (1935, 1947) has stimulated organizations to re-evaluate and change their personnel administration policies. Such re-evaluation has focused upon the protection and enhancement of the individual employee's self-esteem. The importance of at least moder- ate self—esteem for adequate individual mental health has 50 been recognized by many authors such as Adler (1939, 1954, 1958), Fromm (1947), Horney (1937), Reik (1964), Rogers (1961), and Watts (1968). In the work situation, the organizations's members are the primary contributors to the enhancement or defeat of a given individual's self-esteem. Reduction of freedom to make time allocation choices of work and leisure activities as when shiftwork is imposed, would also tend to reduce self-esteem. Shiftwork would theoretically place a burden on such choice—making, result— ing in undesirable mental health consequences, with regard but not limited to individual self-esteem. Time-and-motion and shiftwork compared From the classic work of Taylor (1911), and his move- ment towards the rationalization of production by scienti- fic management, the routinization of all types of indus- trial roles was increased (Schneider, 1957:155); March and Simon, 1958:12-13). In light of this we may compare and contrast one of the earliest applications of administrative technological concern with the use of time called time-and— motion study, with the later application of shiftwork. PrOponents of the rationalization of production reasoned that since the efficiency of the machine depends on the economy of its movements, the movements of the worker should be similarly arranged to optimize productivity. This view led to intensive studies of the most efficient methods of employing the worker's time and motions (Schneider, 1957: 155). Implicit in such pursuits was a disregard for worker 51 satisfaction, since the prescription of the most efficient guides for industrial work usually involved psychologically boring patterns of repetitive cyclical movements which re- sembled the operations of a machine. The benefits to the industry at cost to the worker were obvious. Unions attempted to intervene and even to furnish the engineers to conduct the time-and-motion studies, with the expecta- tion that this would guard workers against radical changes in production methods and concomitant distress (Schneider, 1957:311). Ironically, the procedural changes recommended after time-and-motion studies have been completed, are often inefficient. As DeGrazia (1971:464) notes, a person's own style of movements may take longer, but due to personal idiosyncracies will tire the person less in the long run. A comparison may be drawn between the use of time in time-and-motion endeavors, and the use of time in the regula- tion of shift schedules. The most notable feature of both is that they evidence disregard for the mental state of the employee, and can lead to all sorts of negative outcomes for individual workers beginning with general dissatisfaction. Ironically, cost reduction may increase a system's total cost if measures of total system performances are not consi- dered (Churchman, 1968). The time-and-motion recommendations treat the individual as if (s)he were a machine that produces a certain output, rather than as someone who thinks about work outcomes. The shiftwork schedule treats the individual as (s)he were a machine, ever ready to be turned on or off 52 at the whim of management. This is particularly likely in the case of the rotating shiftworker, whose "on-off switch" is ever accessible and manipulated by an overseeing control- ler. If one were to contrast time-and-motion endeavors with shiftwork, it would be necessary to concede that of the two, the former is the least desirable from the standpoint of the worker. Shiftwork has some redeeming aspects to commend it, whereas time-and-motion restrictions do not seem to have any redeeming aspects at all. Among the posi- tive aspects of shiftwork are the various reasons people have given for their preference for certain shift schedules. Nursing seems to have escaped time-and-motion efforts, but has not evaded shiftwork scheduling. Stress as psychological strain There have been many thousands of studies related in some way to stress. Many have shown that work contributes to stress in people's lives. One indicator of stress is psychological strain. The historical development of the psychological strain index used in the present research was traced. Examination of the relative merits of various questionnaire items, for inclusion or exclusion in the present study, was facilitated by the historical search as to the origins of this index. Each study mentioned in this section was selected because it was directly refer- enced by the study that succeeded it chronologically. The 53 sequence was found to originate with the work of Stouffer, et. al., (1950), and terminate with the study of Gillis (1977). Thus, the index used to measure what is referred to herein as "psychological strain" has undergone sequen— tial development and refinement over a thirty year period. The United States Army's Neuropsychiatric Screening Adjunct (Stouffer, et. al., 1950) provided the initial basis for deve10pment of the index of psychological strain used in the present study. It was modified and used in a Health Opinion Survey by MacMillan (1957), of psychoneuro- tic and related types of disorders conducted in a rural Canadian community. A modification of the Health Opinion Survey by Gurin, et. al., (1960) was used for a nation- wide interview survey in the United States, and contained a four factor index of twenty total symptoms "expressing emotional stress and disturbance" (Gurin, et. al., 1960: 177). Another large study took a similar tack. As noted by Langner (1962), the classic study of mental disorder in midtown, Manhattan, New York City, used his screening instrument of twenty-two psychiatric symptoms indicating impairment. A study of 8,234 employees of a single form, carried out by Indik, et. al., (1964), used a single factor self— report check list to assess "psychological strain." This instrument, used by Indik, et. al., (1964), was a shortened form of the Gurin, et. al., (1960) index, and was similar to the Langner (1962) instrument used in the midtown 54 Manhattan study. The Indik, et. al., (1964) instrument of psychological strain showed all interitem correlations to be positive, with 90 percent of them significant at the .10 level, and split-half index reliability was estimated to be +.85 (Indik, et. al., 1964:29). A slightly modified version of the Indik, et. al., (1964) instrument was used in a study of psychological strain in high rise housing conducted by Gillis (1977). The modifications of omitting one item, and unifying the coding scales for the remaining items, were made by Gillis (1977), to expedite field use of the scale. The methodological integrity of the instrument re- mained consistent with the reliability figures reported by Indik, et. al., (1964). That is, all interitem correla- tions were positive with over 95 percent significant beyond the .05 level, and a single factor accounted for 69 per- cent of the variance (Gillis, 1977:429). Consideration was given to various recommendations mentioned by McGrath (1970) concerning stress research in general. It was decided that the index of psychological strain (Gillis, 1977) would be a useful indicator of holis— tic effects, mainly in the areas of physiological and psychological disturbance. In order to enhance the multi— disciplinary view of shiftwork, an index that would pertain to social factors was additionally desired. The following section describes the results of the literature review on this point, which led to adoption of an index of social isolation (Dean, 1961). 55 Alienation and longob satisfaction Alienation is the separation of man from his work, and man from his workmates (Scott, 1970:76). A rift is said to develop between man's productive ability and the power to control his own economic status. In some of his early writings, Marx advanced a theory of the impact of alienation on human relations in industry (Broom and Selznick, 1963: 648). For Weber (1946) and Durkheim (1951), the price that mankind has been forced to pay for technological and social progress has been an increasing alienation of human beings from each other, from established systems of ethical and social values, and from their work (Neff, 1977:45). For example, a morbid exemplar of extreme alienation among nurses who work night shifts, is revealed by a story about such nurses placing bets as to when terminally ill patients would die ("Life and Death Bets," 1980:115). This activity may be seen as an extreme form of alienation from normative ethical and social values. Benoliel (1976:13-14) has noted that nurses who work in Intensive Care Units face stress comparable to the "dehumanizing and meaningless experience" of the Vietnam War. If this observation is correct, it serves to explain, but not justify the betting activity described above. Fromm (1955) has observed that not only does a bureau- cratic situation cause people to become alienated from the apparatus for which they work, but that there is also a serious tendency toward man's alienation from himself 56 (Fromm, 1955:120-143). And Argyris (1957) has noted how easily formal organizations foster frustration, conflict, and psychological failure in initially psychologically healthy individuals. Workers are "alienated" in the sense that they feel that they have no control over the work process, that their work is meaningless, that they are not really part of the work community, and that work is not a significant feature of their personalities or lives (Argyle, 1974:3). Some sociologists have approached job satisfaction in terms of this concept, as has been mentioned. Marx first cited division of labor and exploitation of workers by employers during the Industrial Revolution, as its cause. And some sociologists have expanded the concept of alienation to in- clude four kinds (Argyle, 1974:225-226): (1) Powerlessness - lack of control over management policy, the conditions of employment or the immediate work process (2) Meaninglessness - inability to see the purpose of the work done or how it fits into the whole production pro- cess (3) Self-estrangement - failure to regard the work as a central life interest or means of self-expression, exper- iencing a depersonalized detachment while at work (4) Isolation - not belonging to working groups or guided by their norms of work behavior Since rotating shiftwork in hospitals entails changing from one work group to another, it was expected in the 57 present study, that nurses on rotating shiftwork schedules would evidence the social isolation aspect of alientation to a greater extent than other factors. It was also felt that night and afternoon shiftworkers would feel less guided by behavioral norms than would day shiftworkers. Within the hospital, occupational groups tend to be discrete from one another, not only in terms of function but in their patterns of association, in their values, and in their per- ceptions of the institution and each other (Croog and Ver— Steeg, 1972:295). For this reason, it was felt that nurses might be particularly likely to feel various amounts of social isolation while at work. It was hypothesized that greater amounts would be found among nurses who worked on night shift when overall activities are at a low, and among rotating shift nurses who lack consistency in the ability to relate to their co-workers. Rotating shift workers can- not be certain when their social conversations with friends will continue, as they are often not certain as to their hours of work. For these reasons, an index of social iso- lation (Dean, 1961), encompassing both social and psycho- logical aspects with regard to alienation, was selected for comparative use (Robinson and Shaver, 1973:275-276). This particular index, from among those used by Dean (1961) to study the phenomenon of alienation, had a higher reliability. when tested, than did the other components of powerlessness and normlessness (Robinson and Shaver, 1973:275). 58 Women and work Working females will constitute 58 percent of workers by the turn of the century ("Working in the let Century," 1979:16). A study of psychological factors that inhibit women from engaging in the kinds of work achievement—direc— ted behavior necessary to ensure promotion to managerial ranks, is found in O'Leary (1974). Hall and Gorden (1973) noted that among married women, irrespective of whether or not they were working, home pressures contributed most to role conflict. It does seem clear, throughout the litera- ture, that women face obstacles in the pay they receive, promotions, and the accessibility of certain positions as a function of sex; and, such discriminations would be expec- ted to have an influence on female career development not experienced by males (Gilmer, 1961:274-275; Osipow, 1973: 265; Lopata, 1974; Higginson and Quick, 1975:147-149: White- hurst, 1977). Nursing and the health care system The traditional social interaction in the health care relationship has been between physician and patient (Cocker- ham, 1978:145). The modern health care system has expanded to include many additional occupational roles and inter- actants. Of major interest for the present study, is the role of nurse. Nursing represents the largest single group of health workers in the United States, with about 815,000 R.N.'s and 492,000 L.P.N.'s as of 1974 (Cockerham, 1978:147). 59 There remains a distinct prestige differential, to be discussed later, between the physician and subordinate roles such as that of nurse, which are classified as "paramedical" (Cockerham, 1978:146). Ultimately the physician exerts con— trol over the other health care workers, with the possible exception of administrators (Melick, 1959). The hospital administrator may have certain power over the physician, yet remains as a secondary status level, as does the nurse. During recent years, perhaps no other occupation has been the object of as much study and analysis as nursing (Mauksch, 1972:206). Early Development of Nursing Historically, males have performed nursing tasks, yet the social role of the nurse is today identified with tradi- tional female functions (Cockerham, 1978:148). There are indications that the earliest hOSpital nurses in ancient India around 1600 B.C. were men, because women held an inferior position in the society (Maclean, 1974:48-49). The original concept of nursing was influenced by prac- ticing nuns who felt that such work was a way to attain spiritual salvation. They did not adhere to the authority of doctors and practiced nursing as they deemed appropriate. They would, if they desired, refuse either doctors' orders or treatment of categories of patients they did not like, such as unwed mothers or persons with venereal disease 60 (Cockerham, 1978:148). Secular nurses who, at that time worked in public hospitals were characterized as lower- class. Florence Nightingale Florence Nightingale, during the middle of the nine- teenth century, changed the role of nursing in Western society in the direction of becoming an honored and respec- ted occupation (Cockerham, 1978:149). Having successfully brought a contingent of nurses to aid the British wounded in the Crimean War, the British public endowed Nightingale with fame and popularity (Friedson, 1970:61; Cockerham, 1978:149). She was able to raise enough money to establish a nursing school which used her approach to training that emphasized a code of behavior idealizing nurses as "respon- sible, clean, self-sacrificing, courageous, cool—headed, hard-working, obedient to the physician, and possessing the tender qualities of the mother" (Cockerham, 1978:150). This image detracted, however, from establishing a View of nurses as capable leaders. Nursing was thus defined as a subordinate part of the technical division of labor sur- rounding medicine (Friedson, 1970:61). Male Nurses It may surprise some to learn that male nurses consti- tute about an eighth of all nurses in the National Health Service hospitals in England and Wales (Scott, 1970:138). In fact, as mentioned earlier, the tradition of male 61 nursing predates Florence Nightingale, going back to the Knights Templar and to the monasteries. In the United States, the majority of male nurses are found working in psychiatric hospitals. Male nurses in such hospitals were not used as subjects in the present study, because there are many more stress-producing features present in such environments than are present in the general hospitals and nursing homes. Nursing Education Unlike the generally similar programs of education found in various medical schools, nursing education has been characterized by a curious assortment of different types of educational experiences, any one of which can qua- lify a student as a nurse. It usually takes about one year to become a Licensed Practical Nurse (LPN), and from two to five years to obtain a Registered Nurse (RN) diploma. In programs lasting four or five years, a university bac- calaureate degree is obtained, as well. Most nurses in the United States have been educated in hospital based dip- loma schools (Cockerham, 1978:151). A problem with nursing education that detracts from professionalism is the fact that practically anyone can gain admission to some sort of nursing program (Cockerham, 1978:153). This creates prob- lems for both the aspiring nursing student as well as for the institution. For example, having taught a one year sequence in psychology to nursing students enrolled in an 62 LPN program, the effects of a consistently high dropout rate from the entire program in the neighborhood of 25%, have been evident. Warnecke (1973:153) cited a national attri- tion rate from collegiate nursing programs of 40%. The source of this situation seems to be largely related to relaxed standards for admission, which unfortunately admit some students with reading levels of about eighth grade. Very few of these individuals are able to compete, although remedial courses are offered in order to provide a chance for success. NursingfiStudents Studies of student nurses suggest that most desire to be needed and to be engaged in personal helping relation- ships (Cockerham, 1978:153). They may find, however, that some nursing faculty do not reinforce the image of the nurse as mother-surrogate, and tend to de-emphasize an inti- mate nurse-patient relationship (Cockerham, 1978:153). Studies of the socialization of nurses by Davis (1972), Davis and Olesen (1963), and Psathas (1968), have all con- cluded that students experience a transition from a state of idealistic innocence to a kind of unemotional interna- lized recognizance of the routinized tasks ahead. This contributes to an eventual lack of commitment to the actual practice of nursing among many (Cockerham, 1978:157). The major stresses experienced by the novice during this transi- tion come from difficulties in psychologically integrating 63 the identities of student nurse role with the concurrently emerging identity as an adult female (Davis and Olesen, 1963:94). This leads to disenchantment with career choice, and more realistic perceptions and outlooks (Psathas, 1968:52). Nursing students generally seem unsure of themselves and passive, though there is some indication that as they enter the profession, those with grossly inadequate person- ality traits are excluded (Osipow, 1973:215). Surveys of nursing students reveal that most desire and expect mar- riage, and plan to give motherhood time priority over nur- sing work (Glaser, 1967:25-35). There are divergent views as to when a professional self-image develops among medical students. Some feel it develops during schooling, while others such as Becker, et. a1. (1963) feel it develops after graduation from medical school (Becker, et. al., 1963:419-420). Despite the lapse in logic when comparing medical doctor's educa- tion to the education of nurses, it is perhaps of some heuristic value in this instance. Having had experience in teaching licensed practical nursing students for over five years, I tend to agree with the view that a profes- sional self-image develops during schooling. Perhaps this process is different for doctors and nurses. During the field experience of nurses, an integral part of their education, they begin to think and act as nurses, as evi- denced by their classroom and lunchroom conversations. 64 Near the end of their educational program, however, the transitional effects of socialization into the role of nurse, have been assimilated. Structural features of nursing Relating to nursing as an occupation, Strauss (1967) has cited some of its structural features, which have emerged historically. The field of nursing is currently almost wholly occupied by women who seem to work in sub- ordination to physicians (Loomis and Loomis, 1960:308). It is predominantly a salaried occupation whose workers are openly recruited. Nurses have great geographical mobility due to a relatively open market for skills that are spa- tially transferrable. The occupation is embedded within a hierarchy of authority. Some specialize in teaching or administration, yet traditionally also do conventional bedside nursing. There is a "curious melange of educa- tional institutions and nursing degrees" with clinical specializations that parallel medicine itself (Strauss, 1967:62-63). Having gone through training rotations of surgical nursing, pediatric nursing, obstetrical nursing, etc., nurses have accumulated a nursing identity definable primarily in medical terms (Magraw, 1966:181). Nursing: occupation or profession? Is nursing a genuine profession, or an assisting occu- pation? (Strauss, 1967:102). Many nurses themselves do not know the answer to this question. Nursing has come to 65 be greatly concerned with finding a new, independent posi- tion in the division of labor in medicine (Friedson, 1970: 63). There has been a substantial amount of literature de- voted to debating the familiar argument over whether nur- sing should be considered an occupation or a profession (Devereux and Weiner, 1962; Wilensky, 1964; Corwin, 1965; Davis, 1972:10). Sociologist William Goode, having estab- lished criteria for professions, excluded nurses from con- sideration as professionals, viewing nursing education as a lower-level of medical education (Goode, 1957:1960). Using criteria established by Merton (1957), Fottler (1976) notes that nursing is a segregated occupation, as a large majority of workers are female, and there is an asso- ciated normative expectation that this is how it should be (Fottler, 1976:98). In contemporary publications, however, there is seen an increasing emphasis on association of nursing with the title "profession" (Rodin, 1978:32). Thus, the debate has no resolution, as yet. It seems nurses write and feel like professionals, as they strive to profession- alize (e.g., Corwin, 1965:355), while sociologists tend to relegate the practice of nursing to an occupational status (e.g., Goode, 1960; Collins, 1977). Sociologists are averse to bestowing the encomium of profession upon nursing, since nurses lack the right to control their own work (Friedson, 1970:71; Davis, 1972:10). Amitai Etzioni (1964) feels that nurses are "semi-pro- fessionals" who tend to adopt the full fledged profession 66 as their reference group and View themselves as full-fledged professionals who feel they should be given more discretion and be less controlled, particularly with regard to the young intern or the older supervisor (Etzioni, 1964:89). Friedson (1970:57) has also referred to nurses as "semi- professional." Davis (1967) cites several paradoxes that characterize nursing. Two of these relate directly to the professional status of the nurse. Tacitly acknowledging that nursing indeed is a profession, Davis states (Davis, 1967:vii— viii): - It is a paradox that despite the consider- able responsibility assumed by professional nurses for the treatment and care of patients, their organizational role in hos- pitals and elsewhere is so lacking in the autonomy and authority characteristically associated with professional status. - It is a paradox that, whereas other occupa- tions in America accorded the prestigious title of profession have long since estab- lished the bachelor's degree as a minimum prerequisite for practice, profeSSional nursing continues, despite historic and bitterly fought battles, to rely over- whelmingly on the services of persons who have not received a college education. The first "paradox" is valid and may be related to an overreaching paradox as Davis notes, such as "modern woman's social role" (Davis, 1967:viii). The second "paradox" is invalid for at least two reasons. First, there is no minimum educational prerequisite for the sta- tus of professional athlete in America; all one needs to do is accept money for athletic performance to be 67 considered "professional." Second, to say that nurses are persons who have not received a college education discounts any college education under the artificial standard implied by Davis, of the bachelor's degree. Davis does, however, realize one could endlessly dwell on the conundrum of what "really is" or "really isn't" a profession (Davis, l967:x). An underlying assumption in the preceeding discussion has been that there indeed exists certain true professions. Taking the view that a "profession" should be considered as a folk concept, Becker (1962:32) regards professions: . . . simply as those occupations which have been fortunate enough in the politics of today's work world to gain and maintain possession of that honorific title . . . there is no such thing as the "true" pro— fession . . . There are only those work groups which are commonly regarded as pro- fessions and those which are not. Status of the role of nurse The licensed R.N. ranks second in status to the phy- sician in the United States health care system (Cocker- ham, l978:147). The practice of nursing occurs within a system that is highly stratified by sex, with the nurses having internalized attitudes of subordination projected by both physicians and hospital administrators (Cockerham, 1978:157-158). Goffman (1967) alludes to the status differential be- tween nurses and physicians in his observational study of mental patients (Goffman, 1967:47-48). Examples given by Goffman included both verbal and nonverbal cues. Verbally, 68 doctors gave medical orders to nurses, but nurses did not give such orders to doctors (Goffman, 1967:53). And, doc- tors tended to call nurses by their first names, yet nurses responded with "polite" or "formal" address (Goffman, 1967: 64). Nonverbally violating the nurses' territorial rights, doctors had the right to walk into the nurses' station and lounge on the dispensing counter (Goffman, 1967:79). Per- haps even more significantly, doctors engaged in asymmetri- cal touch relations with nurses, with a tacitly acknowledged mutual understanding that it would be presumptuous to recip- rocate a doctor's touch (Goffman, 1967:74). Other aspects of the nurse role Johnson and Martin (1965:31) contend that in the doctor- nurse-patient social system, there is a clear division of labor from which emerges the nurse in the primary role of expressive specialist or social-emotional expert, and the doctor as instrumental specialist or task leader. Johnson and Martin (1965) mention that nurses also perform an instru- mental role function, and doctors an expressive role func- tion, but that they do so secondarily. Skipper (1965) has argued that it is most useful to view the nurse's role as a combination of instrumental and expressive functions, with- holding sociological emphasis on one or the other. Habenstein and Christ (1963) characterized the role opinions of professionalizer, traditionalizer, and utilizer. The professionalizer is a self-descriptive role. The 69 traditionalizer is committed to a personal role, and the utilizer is in nursing, primarily as a contractual means of earning money. It has been said that the public health nurse's willingness to work with a client is contingent primarily upon liking him or her (Zuckerman, 1977:52). This would place the public health nurse in the role of utilizer. Perhaps the role options suggested by Habenstein and Christ (1963) have overlapping capabilities. In this case the public health nurse might have the qualities of the other roles to a limited extent. Leonard Stein (1967) has described the interaction between physicians and nurses as "the doctor-nurse game." In this game, the nurse attempts to give the doctor recom- mendations without appearing to do so, and the doctor attempts to ask for recommendations, similarly, without appearing to do so. As a non-zero sum game, rewards and punishments may be shared by both players (Stein, 1967:700). A successful game creates a doctor-nurse alliance with social rewards, while an unsuccessful game has negative social consequences as penalties, such as being thought of as a "clod" (Stein, 1967:700). Sociological perspective on nursing and shiftwork A theoretical distinction derived by consideration of sociological contributions to medicine, has been made by Strauss (1957). He makes a distinction between sociology in medicine and sociology of medicine, that is of particular 7O relevance for this dissertation (Kendall and Reader, 1972: 3). Sociology in medicine means the application of socio— logical concepts, knowledge, and methods to clarify medical and social-psychological problems of interest to medical professionals. Herein sociological knowledge adds to medi— cal knowledge to attempt to solve medical problems. Socio- logy of medicine, on the other hand, asks questions about medical workers, their institutions and organizations, and their relations with others in pursuit of essentially socio- logical inquiry. The present study is primarily concerned with questions about nurses and how they are affected by pervasive institutionalized shiftwork, within a multidisci- plinary theoretical framework. Admittedly, this has neces- sitated examination of certain social—psychological aspects, but only insofar as they relate to the qualitative differ- ences of shiftwork experiences. No attempt is made at detailed medical assessment, nor a study restricted to sociology in medicine. . Eckland (1972) notes the emergence of a new multi- disciplinary field that takes as its central problem the coactions of social and biological variables, which is called "social biology" (Eckland, 1972:109). It is at this point one wonders whether the distinctions between academic disciplines are real or illusory. Analogous to the question as to the nature of time itself, the correct answer seems to favor the latter View of distinctions. 71 This may be difficult for most scientists to accept, par- ticularly those with vested interests in maintaining aca- demic disciplinary distinctions. As a function of their role, nurses bear the full, immediate, and concentrated impact of stresses arising from patient care (Brown, 1967:196). Nurses are confronted with the reality of suffering, incurable disease, and death; they must carry out tasks generally regarded as distasteful and frightening; the work sit- uation arouses in them strong and mixed feel- ings, which may include libidinal and erotic impulses, pity and compassion, guilt and anxiety, hatred and resentment of patients who arouse these feelings, and even envy of the care given the sick person. In addition to these stresses, nurses often face long hours as do many factory workers. Under the bureaucrati- cally reformed nursing service and English hospital system created by Florence Nightingale, nurses typically lived in a hospital dormitory and were expected to give their total attention to nursing (Glaser, 1967:5-6). The dedication today is theoretically the same. The long hours exist only when a nurse works two consecutive shifts, or changes shift schedules over a relatively short period of time, as is often the case with rotating shiftworking nurses. In this regard, nursing in hospitals could be said to resemble shiftwork in factories. 72 Shiftwork and leisure There are severe temporal consequences for the shift- worker in terms of the available ways to use leisure (Berry, 1965). Vroom (1964) suggests that the dislike some people have for shiftwork depends on how much their leisure and family activities are disrupted, and on how much these acti- vities are valued. In comparison to shiftworkers who must work specific hours, self-employed people may work extre- mely long hours, longer than most shiftworkers, and are highly satisfied with their work (Argyle, 1974:231). It seems, therefore, time worked per se is not the disruption causing factor. Rather, change of time, incompatible times for a given individual's constitutional makeup, and times that conflict with other valued activities, are the dis- satisfying qualities that shiftwork imposes upon people. Studies of the relationship of life changes in roles and routine activities, to psychological distress as mea- sured by Langner (1962), such as would be caused by shift- work, have raised unresolved questions of casual direction (Wildman and Johnson, 1977:179). One possibility is that a threshold exists, above which negative consequences begin to occur. In this case, causal direction is not a factor for consideration. Another approach suggests that both very large and very small amounts of life change have ad- verse affects on the individual. It is with this approach that the question of causal direction arises. From the available literature specifically relating to shiftwork, it 73 seems more plausible that the second approach is applicable. With regard to the lifestyle of the nurse, the rotating shift would seem to be the least monotonous, and the night shift the most monotonous. Yet, these two extremes are postulated to correlate more highly than day or afternoon shiftwork, with indicies of holistic disturbance. It has been seen that undesirability, as a characteristic of life events, relates closely to stressfulness (Mueller, Edwards, and Yarvis, 1977:307). Taking a logical step in reasoning, the more holistic disruptions of an undesirable nature a person experiences, whether in the direction of greater or lesser activity, the greater the likelihood there will be an increase in life change. Admittedly this point has yet to receive empirical verification, however, it does seem plausible in light of the present theoretical framework. Shiftwork studies References to shiftwork appeared in the records of European guilds as far back as the thirteenth century, as complaints by craftsmen that nightwork reduced their effi- ciency and the quality of their output (Hedges and Sekscen- ski, l979:l4). Guilds were able to prohibit nightwork for the most part, until the Industrial Revolution. As fac- tories emerged, and as certain manufacturing processes developed in the late nineteenth and early twentieth cen- turies, shiftwork became widespread. Currently, in the United States, about ten million nonfarm wage and salary 74 workers who usually work full time, work other than daytime shifts. This means about one employee in six works on a shiftwork schedule. This ratio has remained stable in the United States labor force since 1973 (Hedges and Sekscenski, 1979:15). Worldwide, it is estimated that the number of shiftworkers has doubled in the last twenty years (Zabrusky, l978:2). Formerly, a six-day workweek and a workday from sun up to sun down had been basic societal patterns, enduring for most of recorded history (Mann, 1965:111). The social and economic forces within the Industrial Revolution that pro- vided the initial impetus toward changes in hours of work, continue to demand examination and research as to the opti- mum allocation of time to work (Mann, 1965:112; Rutenfranz and Knauth, 1976:333). However, the allocation of time to work that is found to be optimum for the society, or for bureaucratic managerial ends, may not be optimum for the workers. On the contrary, it is likely to be less than optimum for the workers. There are certain relative costs and benefits applicable to different work hour patterns. Such schedules affect the well-being and effectiveness of society and its individual members. When these costs and benefits are more thoroughly understood, the study of shiftwork variation and effects will have provided insights at two levels of analysis. One level is that of the organi- zation, and holds implications for managerial decision- making concerning hours of work. The individual worker's 75 quality of life can be significantly improved through the intelligent use of psychological and sociotechnical inter- vention to realize innovative solutions to shiftwork prob- lems (Prien, et. al., 1979:98). A second level is that of society. The study of shiftwork will provide insights at this level with regard to societal functioning (Mann, 1965:112). As has been noted, there are social, technological, and economic factors that contribute to the situation of management deciding to schedule work according to shifts in order to optimize time and facility usage (Rutenfranz and Knauth, 1976:333). Various social services operate around the clock, e.g., hospitals, restaurants, police, fire and rescue, airlines, railways, etc. Some technolo- gical manufacturing processes of long duration necessitate shiftwork, e.g., iron and steel production. And, from an economic standpoint, some types of expensive machinery, such as computer hardware, can be used profitably only if in constant operation. People have had to adjust to work schedules in such services and industries, to the extent that their bodies and social commitments would allow. It has been noted by sleep and biological rhythm researchers that peOple have fairly distinct physiological clocks (Kowinski, 1975:46; Telekey, 1975:46). In addition, a range of peaks at dif- ferent times around the clock, have been found for numerous bodily functions in humans. As a result, it has been 76 acknowledged that the ideal time of day for peak work effi- ciency varies from person to person (Kleitman, 1963). Most persons tend to work better during the day, yet some work best at night (Breithaupt, et. al., 1978:767). A question- naire has been developed by Horne and Ostberg (1976), that can be used to make this distinction by self-assessment. Workers have typically been labeled as 'day' or 'night' people, according to their peak work efficiency times. Other sources in the literature have mentioned a similar dichotomy, identifying day people as "larks," and night people as "owls" (Kowinski, 1975:46; "Rx for Shift Workers," 1979:36). No researcher has found that shiftwork, which involves changing from one shift to another, is good for the worker, although some individual workers may think they thrive on it for the short term (Zalusky, l978:5). There are a number of viable reasons for some people to select night work in preference to day work. These rea- sons apply to physiological, psychological, and social areas of people's lives, and to the interactive effects of 'such areas. Physiologically, some "night" people logically prefer night work because it is compatible with their general biological rhythms (Kowinski, 1975). They have historically performed both physically and mentally better at night. Socially, night work has permitted an adult to be home more hours of the day for child care purposes, thereby eliminating the necessity and expense of a baby— sitter (Sheridan, l973:34; Houston, 1973). And, in a study 77 of 270 men and women in the hospitality industry, many found nightwork socially "convenient" (Gilmer, 1961:273). Nightwork has been used for moonlighting by those desiring to supplement their income (Houston, 1973:39). Such work is often better paid and therefore preferred (Wojtczak- Jaroszowa, 1977:43). In addition, it has provided the opportunity for workers to engage in daytime activities more frequently, such as outdoor sports or shopping. In many cases, nightwork is not deliberately selected, but is the only work available in a no choice situation. There are many unresolved questions that have arisen from reviewing the available literature, concerning disrup- tions caused by shiftwork. Little research has been done using female subjects, in particular. This is a particu- larly noteworthy factor, in light of the evidence that a large number of women engage in shiftwork. In fact, the proportion of women on the late shiftwork schedules, equals or exceeds that of men in some industries (Hedges and Seks- censki, 1979:15). Previous shiftwork research (male-oriented) Previous shiftwork research has been monopolized by a disproportionately large number of male-oriented studies. Locations of such male shiftworkers studied have ranged from factories (Mott, et. al., 1965: Koller, et. al., 1978), to taxi companies (Sakai and Takahashi, 1975), to air 78 traffic control towers (Saldivar, et. al., 1977) to rail- roads (Cottrell, 1939; Akerstedt and Theorell, 1976; Aker- stedt, 1977). The existing shiftwork research has been either social- psychologically oriented or medically oriented (Agervold, 1976:185). Within the medically oriented research, some studies are prevailingly biological-psychologically ori- ented, while others are clinically medically oriented (Ager- vold, 1976:185). The present study attempts to present a multidisciplinary picture of shiftwork disruptions by con- sideration of both orientations. In addition to the social- psychological orientation, there is a biological-psychologi- cal orientation. And, encompassing each of these orienta- tions, analysis of the cultural context of the research is provided. The Mott, et. al., (1965) study One of the most, if not the most comprehensive male- oriented studies of the social psychological effects of shiftwork was conducted by Mott, et. al., (1965). The research team used numerous indices to examine such factors as family role, friendship patterns, organizational parti- cipation, anxiety, self-esteem, conflict-pressure, and physical health. For controls, this study used age, educa- tion, number of children at home, and worker's desire to change shifts (Mott, et. al., 1965:141). Although this study tended to emphasize social psychological variables, 79 it did provide the beginning of a methodological framework for a multidisciplinary analysis of shiftwork disruptions. In the Mott, et. al., (1965) study, shiftwork was seen to increase the experienced difficulty of the individual with his major life roles. Men working the afternoon shift were more likely to report difficulty with their role as father and in the performance of miscellaneous household functions. Men working the night shift were more likely to report difficulty with their role as husband, including the sexual relationship and the providing of adequate pro- tection to their wives and families. Men working rotating shift patterns described all of the above difficulties, and also reported that the rotating shift pattern interfered with the formation of friendships and with their opportuni- ties to see friends (Kahn and French, 1970:260). Mott and his colleagues found reduced integration of the shiftworker in a number of social relationships. They reported less functional integration in marriage, in terms of the adequacy of coordination of activities, problem solving in family affairs, and sharing of responsibilities. The amount of strain and tension in marriage was reported to be greater among shiftworkers than day workers. Findings about the integration of the individual in the community showed a similar pattern. The shiftworker was less likely to be a member of community organizations, less likely to be an active participant in the organizations to which he 80 did belong, and also less likely to be a leader in such organizations (Kahn and French, 1970:260). Male shiftworkers, especially those who reported diffi- culty with the shiftwork pattern, were commonly bothered by problems of the time-oriented bodily functions such as sleep, appetite, and elimination (Kahn and French, 1970:261). They were also more likely to report colds, headaches, in- fectious diseases, ulcers, and rheumatoid arthritis. Of all workers surveyed, the rotating shiftworkers were found to be the most bothered by disruption of time-oriented bodily functions (Mott, et. al., 1965:234-282). The psychological effects of shiftwork appeared to be strongly mediated by the extent to which the shiftworker felt that the shiftwork pattern interfered with other life activities (Kahn and French, 1970:261). Where such felt interference was high, the shiftworker was also likely to experience low self-esteem and high anxiety. All the findings on the reported effects of shiftwork upon males, were mediated by additional factors of person- ality, family relations, and background, although not always in obvious fashion. For example, neuroticism appeared to mediate inversely the relationship between shiftwork and experienced difficulty. People who score high on the neuroticism measure reported themselves to be less bothered by shiftwork than people who scored low (Kahn and French, 1970:261). 81 The attitudes and behaviors of the wives of shift- workers were seen to be particularly important as mediating factors. For example, those shiftworkers whose wives made substantial adjustments in scheduling meals, sleep, quiet time, and social life, were much less affected themselves in the adverse ways previously described. It seems that the fact of shiftwork presented the wife with a great deal of additional power over the husband, the stereotyped male breadwinner. She was able, for example, to exclude him from a great deal of the family and marital relationships if she wanted to, without exposing herself to general social sanc- tion or criticism. There is also the suggestion, that in some of the interview material, wives and husbands were able to use the fact of shiftwork in a collusive fashion to "hide" from each other in time, in a way that is analogous to people hiding from each other in space (Kahn and French, 1970:261). Melbin (1978, 1979) has viewed nightwork from a theoretical standpoint based upon this View of the use of time. In critiquing the Mott, et. al., (1965) study, the following point deserves consideration. That is, the study did not provide an integrated picture of the effects of shiftwork, due to its lack of an explicit holistic theoreti- cal framework, and also to its omission of female shift- workers as subjects. 82 Previous shiftwork research on nurses Few studies of shiftwork have been carried out on fe- male shiftworkers (Folkard, Monk, and Lobban, 1978:786). As an example of the lack of consideration given to females in this regard, one study of the sociological disruptions of shiftwork by Banks (1956), surveyed the wives of male shiftworkers, and totally neglected to study female shift- workers. This was a problem noted with the methodology of the Mott, et. al., (1965) study, as well. A limited amount of previous shiftwork research on nurses, was found to give only partial coverage to the issues raised by the theoretical framework guiding the pre- sent research. Most studies of nurses used only females as subjects, as the nursing profession contains few males. Each study tended to focus on specific aSpects of shiftwork, leaving a holistic understanding of the effects to be obtained mainly by laborious cognitive synthesis of the results of each. A multidisciplinary understanding of shiftwork has been recommended, to surpass monocausal con- ceptualizations, but prior to the present study has been unobtained (Agervold, 1976). As specific examples of single aspect studies of nurses on shiftwork, Felton (1973), Hildebrandt and Stratmann (1979), Folkard, et. al., (1978, 1979), and Costa, et. a1. (1978), foCused on physiological correlates of shiftwork. The study by Costa, et. a1. (1978), used only male nurse subjects (n=18). A study by 83 Strilaeff (1976), emphasized turnover rate differences among female nurses across shifts. In studies of the sleep patterns of nurses, the pos- sibility was noted that general malaise and fatigued awakening found in shiftworkers could have been related to insufficient repayment of sleep deficits which accumulated in the daytime sleep of night shift workers (Bryden and Holdstock, 1973:37); Felton, 1975:19). In another purely physiological study of 39 female nurses who rotated shifts, it was found that their biological clocks were disrupted in ways similar to those of air travelers who experience the phenomenon known as "jet lag" (Felton, 1975:19). Another study revealed the combined effects of shiftwork with those of actual jet lag, but did not specify the effects of shiftwork alone. In this particular study, 444 United States Air Force active duty female flight nurses responded to a questionnaire survey pertaining to flying physiological and psychological changes associated with flying duty (Farrel and Allen, 1973). The findings inclu- ded such effects as irregular menstrual cycles, disrupted sleep patterns, disrupted bowel habits, increased bruising tendencies and decreased weight (Farrel and Allen, 1973: 31-36). A problem in interpretation of these particular results is whether to attribute them to shiftwork, to jet lag, or to the interactive effects of both. Other studies have corroborated the finding that nightwork alone can cause unhealthy weight loss in females 84 (Telekey, 1943:746). Both sleep loss and circadian sleep- wake disruptions were found to have psychosomatically con- tributed to increased negative psychological moods among nurses in another study by Taub and Berger (1974:164). Two studies of nurses were located that have direct implications in their findings, for the present research. A study by Pilon and Zang (unpublished) looked at both physiological and psychological variables among 17 female nurse subjects, in order to provide the basis for a mas- ter's thesis. The other study was a three-year comparative study of nurses and food processers, directed by a psycho- logist (Tasto and Colligan, 1978; "Rx for Shift Workers," 1979; Slade, 1979). The Pilon and Zang (unpublished) study In a study written to fulfill some of the requirements for an M.S. degree in Psychiatric/Medical-Surgical nursing, at the University of Michigan in 1976, Pilon and Zang looked at some selected physiological and psychological effects of shift rotation among 17 volunteer female regis- tered nurse subjects, aged 21 to 29 years, from a large midwestern university hospital. The effects that were studied involved: (1) performance of a mathematical task; (2) quantity and subjective quality of sleep received: (3) response to the Speilberger (1970) SelfeEvaluation Question- naire/State Trait Anxiety Inventory or STAI; and (4) uri- nary sodium and potassium excretion rhythms. Each subject 85 served as her own control, as data were collected for two three day periods. The study found that subjects work efficiency (as determined by a mathematical task), and sodium excretion rhythms were initially disturbed by shift rotation, but began a trend towards adaptation by the second night of shiftwork. Potassium excretion patterns partially inverted immediately after rotation to night shift. Sleep patterns were similarly disturbed. Stress levels were found to be highest when subjects worked days. A study by Segal (1965:385) revealed a corroborative finding for this effect, as night work minimized interward communication thus minimizing differences and overall stress levels. These levels increased when the subjects rotated to nights from days (Pilon and Zang, unpub1.:28). The re- searchers concluded that it would be desirable to study the stress variables in the future, using a larger sample. Based on the theoretical framework for stress research pro- vided by McGrath (1970), it is questionable whether the technique of administration of a mathematical task to mea- sure stress levels is of much value. In addition, two salient limitations are lack of male subjects and a very small sample size. Rather than analyze this study for scientific rigor, it is considered fruitful to simply note the implications of their research for the present study. First of all, it was demonstrated that research on shift- work among nurses is a necessary and desirable area of scientific pursuit. Secondly, preliminary verification of 86 some of the results that appeared in previous studies of male shiftworkers, was achieved by this study of female nurses. And third, attention was paid to selected factors that are, in theory, holistically related to the effects of shiftwork, although this relationship was not explicated by the authors. The Tasto and Colligan (1978) study of nurses and food processors According to a large scale three-year project conduc- ted by the Stanford Research Institute in Menlo Park, Cali- fornia, under the direction of clinical psychologist Donald Tasto, for the National Institute for Occupational Safety and Health in Cincinnati, Ohio, rotating shiftworkers were found to be prone to more severe health and safety dis- orders than their fixed shift colleagues (Tasto and Colli- gan, 1978). Looking first at health and safety records of 2,400 shiftworkers (half nurses and half food processors) it was determined that people who rotate shifts visited medical clinics more often, gave more serious reasons for taking sick days, and had more accidents than fixed shift workers. Second, based upon a 2,000 questionnaire response from 3,500 questionnaires mailed to shift employees in both groups, it was learned that rotators fared worst, with night workers coming in second, on an array of items inclu- ding fatigue, nervousness, digestion problems, colds and chest pains, alcohol consumption, difficulty with sleep, and happiness of marriage ("Rx for Shift Workers," 1979:36). 87 Tasto related his findings to individual differences in adaptability to shiftwork - the phenomenon of day people vs. night people - and in changing from one shift to another too quickly. His study concluded that working unconven— tional hours presents a distinct health hazard for some workers, particularly those who work on rotating shifts (Slade, 1979:107). Shiftwork, role conflict, and nursing One type of role conflict that has been extensively studied concerns conflict between the expectations Of a single role, i.e., nurse. The nurse is in a state of role conflict because the position itself carries conflicting demands. The nurse must balance individual physicians' orders against the independent demands of the patients while managing an aggregate of cases in an administra- tively acceptable manner (Friedson, 1970:126). In man- aging cases, nurses are expected to administer "tender loving care" around the clock, as an integral part of their role (Devereaux, 1950:63). Some nurses are shocked at the experience of role conflict and leave the field of nursing because of it (Kramer, 1974). Another source of role conflict involves the life roles of the individual. Shiftwork is likely to affect the opportunity and ability of the individual to perform other major life roles; for example, those of husband and father or wife and mother, citizen, and friend (Kahn and 88 French, 1970:260). It will be recalled that the Mott, gt. 31. (1965) study of male factory-workers, showed that shift- work increased the experienced difficulty of the individual with his major life roles. As hospitals resemble factories in many ways, there is every reason to expect that nurses are not exempt from this effect found among factory workers. In fact, nurses are likely to not only face this type of inter-role conflict, but the first type of intra-role con- flict is likely to tend to compound their difficulties. March and Simon (1958) made the following prediction which is relevant to shiftwork and role conflict. The greater the congruence of work time patterns with those of other roles, the greater the compatibility of the job and other roles (March and Simon, 1958:97). Based upon earlier studies of labor turnover, March and Simon have stated that the perceived desirability of movement to another job will be greater among night shiftworkers than among day shift- workers (March and Simon, 1958:97). Previous research relevant to the theoretical rationale In this section, each of the statements in the theoret- ical rationale is considered in light of available evidence in the literature. Support for each of the assumptions is provided, and specifications of hypotheses to be tested by the present study are presented. (1) The sociocultural trend toward time optimization stimulates shiftwork scheduling of workers. 89 A sociocultural trend toward time optimization on the part of administrators was seen to have had a historical development, according to a multidisciplinary analysis of the use of time. Administrators have found that a good way to make optimum use of labor and facilities, has been to schedule work around the clock. In this way, facilities and equipment are seldom, if ever, idle (Gilmer, 1961:422). (2) Shiftwork stimulates biological disruptions. There is much scientific evidence to support this contention. The human body harbors a number of "clocks" that regulate physiological functions (McConnell, 1978:23). Thus far, competing hypotheses have been proposed to ex- plain or identify the site(s) of these clocks. One hypo- thesis maintains, for example, that these clocks are located in cells throughout the body (Richter, 1960, 1965). Some other locations suggested by the hypotheses of other researchers, have been in cells found in the joints, the endocrine glands, the brain (Richter, 1960:1526; l965:4), and in the central nervous system (O'Dell, 1975:46; Shep- herd, 1978:98). Periodicity in different functions emerges at varying times during the first year of life of the human infant (Mills, 1966:133). The human then undergoes a process of gradual entrainment or adjustment and regulation to a twenty-four hour day (Mills, 1966:1964). The circadian rhythm of waking and sleeping is among the various periodic 90 functions found (Aschoff, 1965). Additional periodic functions that have been identified, include body tempera- ture (Benedict, 1904), urine flow, urine sodium and potas- sium excretion (Pilon and Zang, unpubl.), grip strength, secretion of human growth hormone (Kahn, 1974), pulse, respiration, blood sugar, hemoglobin level, blood pressure, and amino acid level (Zabrusky, 1978:5). The term "circa- dian" refers to an approximate twenty-four hour rhythmic pattern of waking and sleeping (Dement, 1974:148). This pattern is believed to be regulated by the most primitive of our biological clocks (Richter, 1960:1526). The circa- dian cycle suffers a most serious disturbance, called "desynchrony," when a worker changes from one work shift to another (Bunning, 1973:23). A similar disruption of body clocks also occurs when humans cross a number of time zones, as in transcontinental airplane flight, or when they become subjects in psychological time isolation experiments (Conroy and Mills, 1970:121). Numerous attributes believed to be dependent upon circadian rhythms include brain wave patterns, psychomotor performance, instrument reading ability, mental performance efficiency, and other indus- trial performance activities (Mills, 1966:135: Colquhoun, et. al., 1968a, 1968b). From the evidence available, it seems that people do not perform their best in work situations when there is disruption of their physiological rhythms due to shiftwork schedules (Blakelock, 1967: Rutenfranz, et. al., 1974:224, 91 1976; and Bryden and Holdstock, 1973:36). In addition, it takes up to a month or more for some persons to regain satisfactory sleep patterning following disruption (Taylor, 1967:93; Wyatt and Mariott, 1953:164). Even with satisfac— tory sleep patterning, the total amount of sleep time shift- workers receive is less than the norm for non-shiftworkers. There are other factors, besides sleep patterning, that remain in a state of disruption. For some prOportion of shiftworkers, completely satisfactory physiological adjust- ment is never obtained. A Swedish experiment concluded that approximately 28 percent of the work force cannot adapt to shiftwork (Zalusky, l978:5). A minority of shift- workers are, therefore, continually bothered if on fixed shift, or intermittently bothered if on rotating shift schedules, by physiological disruptions that defy reconcili- ation. Although the majority of shiftworkers seem able to adjust to a fixed afternoon or night shift physiologically, they are still influenced by concomitant psychological and sociological disruptions. And, those workers who work on rotating shift schedules, are in constant flux in this re- gard. (3) Shiftwork stimulates psychological disruptions. The psyche of the individual is adversely affected by shiftwork. For example, people have a range of possible emotions and feelings about their work, as well as different motivational levels. These qualities directly contribute to 92 job satisfaction. And, job satisfaction has been identi- fied as a major predictor of life satisfaction and longe- vity (Tanner, 1976). If people are generally satisfied with their work, they are seldom likely to feel bored, desire to change to a different work schedule, or have lack of moti- vation to "get going." It is hypothesized that since most people are "day" people, the majority of satisfied workers will be found on day, or first shift. Satisfaction will be considered as absence of psychological strain, based upon the index provided by Gillis (1977). Workers whose sched- ules deviate from the first shift it is further hypothe- sized, will experience less satisfaction on the average, in direct relationship to the amount of deviation. (4) Shiftwork stimulates sociological disruptions. Social relationships of the individual are affected by shiftwork (Zalusky, l978:5). In considering social fac- tors as causing human psychological strain or stress, the influence of the individual's role, in addition to biologi- cal and psychological factors, is of concern (Zola, 1972: 491). A person is ultimately responsible for the social situation in which they participate, and is affected by this aspect of individual responsibility (Zola, 1972; Gir- dano and Everly, 1979). It is hypothesized that as a person becomes less of a "day" person, because of the restructuring of lifestyle caused by shiftwork, (s)he will experience greater socio— logical disruptions, because the person will be relocated 93 further from the mainstream of social activities and rela- tionships of societal members. One aspect of this is disruption of social integration patterns. For example, when a married couple work during incompatible hours, the ramifications are largely deter- mined by social factors such as attitudes of reference groups. If the group's attitudes are negative, feelings of alientation from the reference group may emerge. Diver- gent findings have been reported with regard to social in- tegration patterns of shiftworkers. One study found no clear-cut differences between shift and day workers in social integration or leisure activities (Blakelock, 1967: 2335A). In other studies, shiftwork was found to have had disruptive effects on social integration patterns. An extensive factory-oriented study by Mott, et. al., (1965), described earlier, contained several replications of this disruptive effect. Similar findings were reported by Tasto and Colligan (1978). Another aspect is disruption of family and personal relationships (Schneider, 1957:455). The way this would occur would depend primarily on each individual actor's situation, yet some generalizations can be made. For the present research, it is hypothesized that more reported disruptions will arise the further one proceeds away from day shift, as most families and institutions in society are not set up to meet the demands of a person whose participa- tion is limited to "off" or irregular hours (Rutenfranz, 94 et. al., 1977). In a study by Wyatt and Mariott (1953), a higher divorce rate among shiftworkers appeared. And in a study by Banks (1956), interviews with the wives of shift- workers showed that they were displeased with the negative impact of rotating shift schedules upon leisure time and family activities. Workers on shiftwork also report that they feel their relationship with their children suffers (Zalusky, 1978:6). If a person is thus affected by his/ her shift schedule, (s)he is hypothesized to be more likely to feel alone in the world, be missing out on social interactions with friends, and in general feel that the world is an unfriendly place in which it is diffi- cult to find new friends. There are exceptions, as successful adaptation to alternative social lifestyle patterns may occur in some cases. Divergent findings have been reported with regard to optimum scheduling of shiftwork to meet social demands. Colquhoun (1970) has stated that the optimum theoretical solution for reducing shiftwork associated social adjust- ment problems has been to use a "fixed" night shift for some workers (Colquhoun, 1970:560). Surprisingly, other studies have suggested frequent shift rotation as the solution to adjustment problems (Maurice, 1975:45; Zalusky, 1978:6). In practice, fixed night shiftwork has tended to maximize social disruptions so most future shiftwork is likely to be of the rapidly rotating type (Colquhoun, 1970: 560). Whether this is desirable, has yet to be determined. 95 The present study is expected to contribute evidence con- cerning this question. It is hypothesized that greater social adjustment problems will appear among rotating shiftworkers, than among other shiftworkers. Fixed night shift has tended to be difficult for workers to adjust to socially, because society is struc- tured in such a way as to progressively limit opportunities for conventional social activities, such as adult educa- tion, as the early morning hours approach (Pantzar, 1977). Several contextual factors might intervene in this instance. If, for example, a worker has a high percentage of friends on night shift, (s)he might view such hours as sociologically favorable. Or, some single persons might find social opportunities for meeting other singles to be enhanced by nightwork. If the community in which the shiftworker resides is small, or if the shiftworker has children to consider, nightwork may present several social problems that could be avoided by daywork. The following matrix has been constructed to hypothetically illustrate the manner in which sociological factors identified would tend to be affected among workers, on each of the four shiftwork schedules studied: 96 BAX AFTERNOON NIGHT ROTATING Modal cultural Normal Unusual, but Unusual and Accep- expectations an acceptable weird with table but alternative trend to- tiring ward grea- ter ac— ceptance Impact on Not af- Affected if Alterna- Affected group member- fected meetings are tive affil- if meetings ship status missed iations are missed likely Community Normal Appears to Absent Erratic participation be normal from main- stream Social oppor- Normal Normal Alterna- Eclectic tunities tive social patterns likely (5) Biological disruptions stimulate psychological disrup- tions and vice versa. Biological disruptions can stimulate psychological disruptions in several ways. When the chemical balance of the body is disrupted because of an improper diet, the re- sult may be emergence of such psychological symptoms as depression and nervousness (Davis, 1970). Disruptions of biological "clocks" contribute to periodic pain and psychological discord in a wide range of pathological conditions (Richter, 1960). A subtle form of circadian pathology results from desynchronization when the convenient association between low urine flow and the usual time of sleep is altered (Mills, 1966:159). The abnormal time routine is not only inconvenient and uncomfortable, but causes loss of sleep and disruption of dreams, both of 97 which are known to adversely affect sound psychological health. Increased rhythm dissociation as shiftworkers get older, may also lead to mental disturbance in a cumulative manner of effects (Cahn, et. al., 1968:610). Circadian rhythm disruptions as occur in shiftwork, are likely to contribute to accidents. A greater number of accidents occur when biological efficiency is low, and inversely, the number of accidents decreases as biological efficiency increases (Noguiera, 1971:30). Error proneness is probably highest at night (Sollberger, 1965:286). In nursing, it is probable that medication errors, and errors in problem solving for example, happen when physical and psychological functions of nurses are at low resting levels (Felton, 1975:19). These low levels, which normally occur during sleep, are artificially induced during work hours among nurses who have not completed their biological adjustment to shift changes. Pilon and Zang (unpubl.) obtained experimental verification for increased problem solving errors among rotating shiftwork nurses. Psychological disruptions can stimulate biological dis- ruptions. Evidence for this conjecture is found in the theory of psychosomatics. Many human illnesses and dis- orders begin with stressful life situations which channel the stress through bodily processes (Cannon, 1939; Mangus, 1955:163-4; Selye, 1956; Girdano and Everly, 1979). If a person is psychologically disrupted and experiences depres- sion, (s)he is likely to have such biological symptoms as 98 trouble with sleeping, loss of appetite, weight loss, head- aches, stomach aches and intestinal difficulties, etc. (Lewinsohn, et. al., 1978:13). The aforementioned are some of the indicators of the psychological strain scale as used in the present study. The entire index consists of ques— tions 23 through 37 which appear in Appendix 1. Negative emotions are associated with unnecessary disturbances of physiological mechanisms, proportional to the duration and intensity of the negative emotional state (Ellerbroeck, 1978:95; Blanchard and Epstein, 1978). (6) Psychological disruptions stimulate sociological dis- ruptions and vice versa. If a person is mentally disrupted, it can have a nega- tive effect on that person's social situation. For example, some psychologically depressed persons report reduced interest in sexual activity (Lewinsohn, et. al., 1978:13). Depression can also impede friendships and family harmony. Research has been done on the presumed causes of lone- liness and related mental states. The underlying cause, in much of the literature, has been labeled as alienation (Siassi, et. al., 1974:265). The social system has been held accountable for this psychological phenomenon (Robin- son and Shaver, 1973:245). It was noted earlier, that workers will feel somewhat responsible for their life situation, yet they face an uncaring society, according to their perceptions. It is therefore hypothesized, that the further from the mainstream of daytime activities the 99 shiftworker lives, the greater will be the incidence of feelings of loneliness and isolation, and in general, of alienation from others and from work, as measured by the Dean (1961) index of social isolation. In order to mea- sure alienation, Dean (1961) used scales comprising three separate components of powerlessness, normlessness, and social isolation. Dean found each subscale to be reliable after testing (Robinson and Shaver, 1973). For the present study, one subscale was selected from Dean's overall alienation scale, in order to facilitate administration in the field. The entire index consists of questions 38 through 46 which appear in Appendix 1. The most powerful predictive index was selected. It had a reliability coeffi- cient of .84, and correlated with the total alienation scale with a coefficient of .75 (Robinson and Shaver, 1973: 275). Sociological disruptions may stimulate psychological repurcussions. Shiftwork enhances the likelihood that social patterns of eating will be disrupted. When this occurs, people often do not receive adequate nutrition, and are consequently subject to suffer fatigue, depression, etc. (Davis, 1970). And when, for example, a person does not meet social commitments due to scheduling problems created by shiftwork, the reaction is often negative psycho- logical assessment of such a person, by others and/or the person himself/herself. Liem and Liem (1978) have reviewed 100 research that links social structures and processes to psychological dysfunction. (7) Biological disruptions stimulate sociological disrup- tions and vice versa. A reliable positive correlation between feelings of fatigue (often found in shiftworkers with disturbed sleep patterns), and decreased working efficiency, has been found by numerous investigators (Cason, 1931:126; Bryden and Holdstock, 1973; Felton, 1975). A person who works on other than day shift will probably want to sleep at times other than those during which his/her family sleeps. This situation could create social incompatibility or dis- ruption of relations. In their study of female nurses, Bryden and Holdstock (1973) indicated that a fruitful extension of their research would be to consider the effects of napping. If night duty nurses were "napping" during the day, rather than sleeping, it may indicate they attempt- ed to reserve some day time for socially integrated behavior. It also may indicate that they had difficulty in sleeping, and therefore resorted to napping. Most chronobiologists have maintained that the social routine of man has been the primary synchronizer of his biological clocks (Burns, 1975:168). In this way, socio- logical disruptions are likely to affect the synchronization of biological processes. 101 (8) Biological disruptions contribute to psychological strain and social isolation. Because of the interrelationship between body and mind, it is proposed that part of the hypothetical construct known as psychological strain, is derived from biological disturbances of a physiological nature such as imbalances caused by sleep disturbances. Other indicators of psycho- logical strain, of an essentially biological nature, in- clude fatigue, headaches, and feeling nervous. Considering the relationship of biological disruptions to social isola- tion, a study by Rockwell, et. al., (1978) found the relationship relevant to the cause of suicide. (9) Psychological disruptions contribute to psychological strain and social isolation. It is axiomatically proposed that some elements of psychological strain are psychologically induced. Indica- tors of psychological strain which are of an essentially psychological nature, include emotions, feelings, and motivation. Psychological forms of occupational stress have been increasingly implicated in the etiology of psycho- somatic illness and poor mental health (House, et. al., 1979). It is also proposed that psychological disruptions will contribute to social isolation, as the shiftworker will find it difficult to maintain normal social relationships with non-shiftworking friends, acquaintances, and family members. And, the rotating shiftworker will have difficulty in maintaining any social relationships. 102 (10) Sociological disruptions contribute to psychological strain and social isolation. Since (wo)man is a social animal, disruptions of social patterns are likely to contribute to psychological strain and to social isolation, in particular, when relationships become difficult if not impossible to maintain (Aronson, 1976). Even disruptions alone would tend to remove a person from the "normal" pace of life. Therefore, social isolation is proposed as an indicator of such an eventuality. Cocker- ham (1978) notes that sociologists generally prefer des- cribing illness as a social, rather than as a biological event, because the condition of suffering denoted by ill- ness is a subjective experience that usually results in a modification of the individual's behavior (Cockerham, 1978: 88). Thus, an illness can be regarded as a social entity definable in terms of social functioning, e.g., the "sick role" (Parsons, 1951; Mechanic and Volkart, 1961; King, 1972:139-142). (ll) Shiftwork induced disruptions contribute to psycho- logical strain and social isolation, in direct relation to the amount of deviation from normal daytime scheduled work demanded by the shiftwork schedule. This is a major aspect of the proposed relationships between shiftwork and psychological strain, and between shiftwork and social isolation, to be explored by the present research. Evidence that this pattern occurs in male factory-worker subjects is available (Mott, et. al., (1965). Whether this pattern is also present among female 103 nurses is the focus of the topic for investigation. Some studies have implicitly suggested that this pattern will be found (Pilon and Zang, unpubl.; Tasto and Colligan, 1978). Replacement of a scientific search that uses separate levels of analysis, with a holistic system of pursuit, is considered desirable (Geertz, 1973:44). Such an approach is necessitated by consideration of shiftwork (Zalusky, l978:3). It is well within the purview of the social scienti- fic analysis of work, to consider the impact of a person's job on his/her behavior in nonjob situations as well as on the job itself. A dominant, basic hypothesis is this line of endeavor, is that various aspects of the job affect the worker's attitudes, behavior, mental health, and entire lifestyle (Mott, 1965:76). For the purposes of clarifica- tion, consider the following hypothetical situation. A husband works during the traditional day schedule. His wife, who has been home during the evenings, begins an afternoon or night shift as a nurse. Their network of social relations is disrupted because of the wife's work, and both experience stress. A vicious cycle of impact is likely to result, in which the couple's health, inter- personal relations, relations with friends and other family members, and general psychological well-being, are adversely affected by the differences in work schedules. Taking a holistic, systems analysis frame of reference, there are 104 interrelated physiological, psychological, and sociological factors to be accounted for. Previous research on the influences of shiftwork was found to be lacking in information about female shift- workers, such as the nurse in this example. Studies of fe- males that were identified were lacking in theoretical pers- pective. Some studies were physiological in orientation. Others were studies of the combined effects of shiftwork and jet lag, or of combinations of nurses as subjects with other types of workers. Lack of the comprehensive theoret- ical orientation holism provides, was considered an important limitation of the previous research. Most of the literature on shiftwork had focused upon a male, factory-oriented popu- lation of subjects. It was not certain whether the results of these studies would apply to a predominately female population of nurses. In order to place the present study within the context of existing shiftwork research, the following description is offered. The present study attempts to pinpoint the severity and incidence of psychological strain and social isolation, among nurses who engage in shiftwork, while taking control factors into account. Such information appears to be missing from the current body of available literature on the subject. In keeping with the multidisciplinary nature of the present study, biological-psychological factors, as well as social-psychological factors were considered. Instruments were selected from a review of the previous 105 literature, on the basis of their applicability to the problem for study, established scientific merit, and exped- iency for use in the field. It may be mentioned that a clinical-medical orientation was not included for several reasons. A good deal of information has already appeared in the literature from this perspective. Such an orienta- tion falls outside the traditional boundaries of multi- disciplinary social science research. And, although clini- cal-medical information might have supplemented the findings of the present study, it would have been impractical and prohibitively expensive to conduct such research on the large number of subjects in the study. Summary Previous research relevant to the theoretical rationale was reviewed. A theoretical framework for stress research was described, and related to the present study. The social organization of work and the cultural values which frame it, were considered in relation to nursing and shiftwork. A social science perspective on health and illness as,a major social phenomenon, was discussed in relation to the present research. Arguments as to whether nursing should more appropriately be called an occupation, or a profession, were presented. Shiftwork research results from studies in several disciplines, found by a review of the available literature, were considered in relation to the theoretical perspective adopted for the present research. 106 Having reviewed previous research on the subject of interest, specific problems for research were formulated. Based upon the literature review and theoretical frame- work, it is hypothesized that the data will demonstrate the following: (1) Increasing amounts of psychological strain will appear in measurements across shifts in the following sequence: day, afternoon, night, and rotating. (2) Increasing amounts of social isolation will appear in measurements across shifts in the following sequence: day, afternoon, night, and rotating. CHAPTER III METHODOLOGY AND PROCEDURES Type and design of study A field-study approach was used in the present re- search. The questionnaire used (Appendix 1), was construc- ted for use as a guide in structuring interviews with nurse subjects. The interview and questionnaire are powerful instruments for social science research, as they provide information about individuals' past experiences and- behavior that is virtually unobtainable by other means (Cannell and Kahn, 1966:331). The effects of psychological strain and social isola- tion were computed for each shift. It was originally intended that the differences between male nurse subjects and female nurse subjects would be examined for all vari- ables under study. Upon realization that the sum of all male nurses in the five institutions surveyed realized a meager seven subjects, the males were excluded from the final data analysis. It might also be mentioned that al- though supervisory nurses were interviewed, they too were later discarded as subjects in order to improve the homo— geneity of the sample. It would have been ideal, perhaps, to have studied a sample of workers under a variety of shiftwork conditions, giving each a chance to subjectively assess the differences of working each shift schedule (Wyatt and Mariott, 107 108 1953:164). For example, each nurse would have worked day, afternoon, night, and rotating shift schedules for one-year periods. No study has been found that has attempted such a longitudinal technique. This type of study would have been difficult to conduct, because it would have required major disruption of an institutionalized routine. In addition, it would have been excessively costly and time consuming. Even if such a method had been attempted, the different effects of prolonged shift changes would somehow have to have been accounted for. The present study used the methodological approach of directly entering selected institutions at random inter- vals, and finding out who was or was not experiencing psychological strain and social isolation, on the various shifts. Thus, the study was characterized by structured field interviews (Tooraen, 1972:404). It was decided at the outset of the research that questionnaires were not to be distributed by mail, or by interhospital distribution systems. The decision by the investigator to assist the nurses in completing the question- naires, was prompted by what seemed to be good reasons as specified below, considering the alternative survey research techniques: (1) Increase "N". The investigator had used a direct mail survey technique combined with personal Open-ended inter- views, for data accumulation in a survey of 250 U.S. police departments. It was learned that: 109 (a) a disappointingly small number of responses were returned; (b) individual perception as to the purpose and/or use of research data would inhibit responses (several questionnaires were returned lacking important information, yet containing statements which demonstrated this inhibition); (c) more revealing information was obtained by face- to-face interviews. (2) Increase likelihood of accuracy and responses. The investigator has taught Introductory Psychology and Social Psychology to L.P.N. students for over five years. From this unique academic experience, it was learned that roughly 20-25 percent of those graduates working as L.P.N.'s had barely passed many of their college courses. In fact, some had done so with surprisingly low eighth and ninth grade reading comprehension levels. It seemed reasonable to assume, therefore, that some significant number of respon- dents would have difficulty in comprehending the question- naire if administered by mail. The interviewer expected to facilitate comprehension of questionnaire using the approach exemplified by Hetherington's (1972) study. A sustained effort was made towards achievement of scientifically accurate results. The interviewer was parti- cularly conscious of sources of experimenter bias, and tried to avoid such bias consistently. For example, care was 110 taken to dress for all interviews in a professional, yet nondescript fashion. While the experimental method might have yielded more certain results with regard to shiftwork, had there been a way to control shifts, the field study interview technique afforded the advantage of studying and important phenomenon that cannot legitimately be controlled by a researcher. For a comprehensive discussion of the strengths and weak- nesses of alternative survey techniques, see Nachimas and Nachimas (1981), chapter 8. A question arose as to whether the effects of primacy in beginning shiftworkers would have a significant impact on the results of this study. Taylor (1973) felt that shiftwork continued for any lengthy period of time did not significantly affect health for those subjects who remain on shift. His research was limited to two factors: sick- ness absence and cohort mortality analysis figures (Taylor, 1973:18-19). Other researchers have seen the early days after the onset of shiftwork as the most troublesome for the worker, for reasons other than those mentioned by Taylor (1973). For example, the early days are markedly influenced by altered social and physiological rhythms of life (Foret and Benoit, 1974:343). And in another study, it was pointed out that shiftworkers have often faced the problem of working overtime, or of working two consecutive shifts, which has exacerbated the impact of disruptions (Cottrell, 1939:196-197). It is concluded that the 111 importance of primacy in studying beginning shiftworkers is not so great as Taylor (1973) implied, since shiftworkers are periodically subjected to irregular schedule interrup- tions which continue for years after the onset of their shiftwork routines. In order to avoid the potential spurious results of primacy effects in shiftworking nurses beginning their employment, all subjects who had worked less than one month were excluded from the research sample. Three such cases were encountered. If a nurse was interviewed while working overtime, it may have become a problem for analysis of the results, should this have occurred too frequently. On only two occa- sions did this occur. This factor was therefore considered an atypical occurrence that would not significantly influ- ence the overall results. In addition, the random nature of enlisting subjects was expected to control for such exraneous factors. In considering the design of the study in relation to the problem for research, the field-study strategy which was used did not pose any particular problems as applied to stress research, beyond those intrinsic to that strategy (McGrath, 1970:43-44). There does not currently exist a multidisciplinary stress area theory sufficiently broad as to encompass all aspects of the problem, or sufficiently Operational so as to guide the development of manipulation and measurement operations and predict their relationships 112 so all results can be placed within a unified network of concepts and relations (McGrath, 1970:48-49. The present theoretical development attempts to fix the t0pic of interest - nurses and shiftwork - within the currently available level of theoretical sophistication. It is expected to provide the nucleus for future develop- ment of a broad theory for multidisciplinary stress re- search, by concentrating on the subtopics within such a theory of psychological strain and social isolation. Site of study The study was conducted in a rural section of upper New York State, in the counties of Delaware and Otsego. Geographically, the area is mountainous. The two counties are socioeconomically similar, as both are relatively poor in terms of median annual household income. They are inhabited by residents who are predominantly engaged in agricultural and light industrial work activities. In addition, there are three colleges in the area, two of which have nursing programs. The cooperation of five different private health care institutions was secured. A code number for data analysis purposes was assigned to each institution. The five insti- tutions ranged from small to large (Spitzer, 1970). The size of the institution tended to directly correspond with the size of the town or city in which it was situated. The smallest institution had only 34 beds and was located in a 113 town with a population of 2,500. The largest institution had 205 beds and was located in a city with a population of 18,000. Three of the institutions were general hospitals, including the largest and the smallest, and two were nur- sing homes. Certain expectations about differences due to the sizes of the institutions might be specified. The larger the institution, the greater the expectation of stress re- lated disruptions. However, this relationship is only tentative as there may be administrative and/or structural- functional features of each site that would inhibit finding this proposed expectation to be true in the small number of institutions surveyed. Expectations about differences due to the nature of the institution - hospital vs. nursing home - might also be specified. It would seem logical that hospitals might be more stressful places for nurses, than would nursing homes, since they accommodate such a diverse cross-section of the population and attend to such a wide array of medical needs. Yet, one could also argue that nursing homes are more stressful places for nurses, due to the tendency for physicians to be less frequently available, creating feelings of greater responsibility for nurses when they respond to crisis situations. 114 Subjects The total number of subjects was 162. At a later point in this data analysis, 12 supervisory nurse subjects and seven male nurse subjects were discarded from the sample. Table 1 shows a breakdown of the distribution of subjects in each institution by sex. The desired goal of obtaining a large enough number of male subjects for meaningful com- parative statistical purposes, was not realized. There was a much greater lack of male nurses in the five institutions surveyed than was originally anticipated. All male nurses employed by each of the field sites volunteered to serve as subjects, yet the total was too small at the end of data collection. In addition, there were fewer rotating shift subjects available than had been originally expected. Only eleven such subjects were found in the survey. In assessment of the total number of nurses employed by each of the institutions visited, estimates were necessi- tated for two reasons. First, most of the institutions were reluctant to reveal the exact number of nurse employees, because of possible violation of employee's rights and fear of possible reprisal from union representation. Second, even if an institution's administrator was willing to risk such a violation of rights, the figures given were only temporarily accurate, due to the relatively frequent turn- over. Turnover was found to be more frequent in the two hospitals which had a teaching orientation, and were also affiliated with local colleges. 115 Procedures for gathering data and instrumentation The sampling procedure was as follows. After having obtained the official approval and sanction of each hospi- tal administrator, meetings were arranged with supervisory staff nurses. Each of the twelve supervisory staff nurses encountered, agreed to serve as subjects, and facilitated the acquisition of additional subjects. The twelve super- visory staff nurses were eventually excluded from the data, so as to provide a more homogeneous sample. The supervi- sors approached each potential nurse subject with a request to participate in a doctoral dissertation study of nursing, on a strictly voluntary and anonymous basis if desired. Requests were made during random visits at random times, to each of the institutions noted, at a frequency of one institution per day. Most of the interviews were conducted in meeting rooms, conference rooms, or reading rooms. Some of the interviews had to be conducted at the posts of nurses who could not leave such locations while on duty, such as those working in an emergency ward or in an inten- sive care unit. Supervisory nurses were not only instrumen- tal, but particularly receptive in assisting with the scheduling of interviews of consenting subjects. Once preliminary contacts were made and the project objectives explained to the administrators, data collection proceeded smoothly with only a few interruptions for nurses 116 attending to emergencies. In such cases of interruption, all interviews were eventually completed during the same visit. The chronological time of selection of subjects, was during the months of June, July, and August, 1978. As may be seen in Table l, the subjects from hospital number 1 which was the largest facility, dominated the original sample. The implications of this will be discus- sed in the analysis of the results. The administration of the survey began by giving each respondent a copy of the questionnaire to read, while the interviewer asked for their responses to each of the questions. The subject's responses were coded by the interviewer on data sheets. As for controls, the day shift acted as a control against the other patterns of shiftwork. This approach fulfilled the expectations developed in the theoretical framework, as the study is essentially an examination of variations from the norm of day shiftwork. The focus of the present study was upon assessment of psychological strain and social isolation among nurse shiftworkers, who had been working for at least four weeks. This minimum amount of time was specified in order to con- trol for any unusual effects accompanying the early days of job adjustment. It should be mentioned that there was some unavoidable error of measurement with the use of the psychological strain and social isolation indices, as there 117 NGH a mmH o HH m ms N me m mm m ..I m .... w w M H H M M 2 . mm H mm o o o m o m H m mm s sH o «H o m o s o m o s Hm m 4H 0 sH o H o N o s o a mH N mm 4 mm o a H am H am N mm omH H .mIHMflVM m w. m m a m m m m M fxoummfi g mmmmmm mmmmmm mmmmmmmm m m m mmmuzz H0 6600 mmmmmmmm muHHnm HH< mmmmm .mmlmmmmm ammmmmmm mHmEmm mo wnmfifism H mqmg 118 is with any such measurement devices (Thurstone, 1928:532). The instruments used had been thought to fulfill desirable standards of evaluation, as had been documented by Robinson, et. al., (1974:1—15) and Gillis (1977). A discussion of the characteristics of the indices used shall follow. Psychometric characteristics of Gillis (1977) and Dean (1961) scales The scale used by Gillis (1977) was used as part of the questionnaire for the present study. This scale is a shorter version of the index developed by Indik, et. al. (1964). And, as mentioned earlier, the index developed by Indik, et. a1. is yet a shorter version of the index develOped by Gurin, et. a1. (1960). The Gillis (1977) instrument is comprised of items which are substantially similar to those in the more widely used, but longer scale constructed by Langner (1960). In the Gillis study, all interitem correlations were positive with over 95 percent significant beyond the .05 level. A factor analysis of these items revealed that a single factor accounted for 69 percent of the variance. The Gillis scale was used in the present study as it was presen- ted in the Gillis (1977) study. Fifteen items were coded with five categories: never - l, unsure - 2, occasionally - 3, frequently — 4, nearly always - 5, in a Likert-type scale. Possible scores ranged from 15 (low psychological strain) to 75 (high psychological strain). Actual scores in the Gillis study covered the full range, with a mean score of 24.97 and a standard deviation of 8.57. 119 In the present study, 91 percent of the interitem cor- relations for the psychological strain items were positive, with 41 percent significant beyond the .05 level (Table 2). Actual psychological strain scores in the present study ranged from 15 to 63 with a mean score of 27.4097, and a standard deviation of 6.4487. The psychometric characteristics cited for the Dean scale in a previous study were 89 percent positive interi- tem correlations, with 52 percent significant beyond the .05 level. In the present study 92 percent of the interitem corre- lations of the Dean scale items were positive, with 36 per- cent significant beyond the .05 level (Table 3). Actual score in the present study ranged from nine to 43 with a mean score of 27.000, and a standard deviation of 3.8431. Both scales were used exactly as they had been construc- ted in the referenced studies from which they were derived. It was expected that the present study would therefore con- tribute information relating to the psychometric properties of both scales. The Statistical Package for the Social Sciences (SPSS) computer program system was used to facilitate statistica calculations (Nie, et. al., 1975). *NmNH. mono. «NmmH. mmNH. *NGHH.NOHNH. omso. same. HOHH. mmmH. mmoH. mmmH.«mmNm.gomNN. hm ammH. NHso..ommH. heme. mNmH. mNso. «Hmo.«NmHN. «NNHH. *HoHH. ommH. NNGH. mmHo.-om ammo. NHso. ammo. ammo. mmoo.usmmo. Navo.n ammo. HNHo. ammo. NNNo. ammo. mm NNNo. Heoo.-vao. mmsc.usoso. sHmo. NNHo.-*mmmm. ammo.«mm¢N. ONQH. em «HAHN. mhmo.*NNNN.«GmNH. «mmH. *GNNN. «NomN. smvN. HNNH. mama. mm snmmN.smeN.*Nvom. hone. NGNON. NNNNN. stN.«oomN. mHmH. Nm «ommN. mmHo. mesa. NosNH. NGNNN. NNmH.«omHm.«qo¢N. Hm NNNGN. NmNo.- mmmH. smNHH. NHNH.NomNH. msoo. om NHoo.- NomH. mssH.«vaH.*oHHH..omsH. NN m NNNo.- mmNH.*mva. Homo. mmoo.umN 1 mmwa.¥Hmmm.«HHom.«whmH. hm *NHNN.*mssm.*HONN. GN «ommm. mmoo. mN *HHNN. 4N mm mm am mm Nm Hm om mN NN_[ NN mN mN «N NN OHQMfiHMNV mo.hv as mEmuH :Hmupm Havamoaonowmm mo xmocH mnu mo xwuumz coflumawuuoohmucH N Mdmdfi 121 mo.v a... mama. NHmo.I momo. movo.l hammm. mmoo. ammvm. mmmo.l ow *NvHN. *momm. «hmvm. mmmH. mmbo. mvwo. mmoa. mv mmma. voma. mane. mmno. ammo. «omma. vw *momw. avoam. mama. onmo. ovmo. mv whoa. «omma. «hwma. *mwma. we {sva. mmoo. mmvo.| av omHo. memo. ow «Havm. mm mv we mv mo Hv ow mm mm wannanm> mEmuH coaumHOmH Hmfloom mo meGH map «0 xflnumz cofiumamunoouwucH m mflmde 122 Shiftwork was viewed as a kind of division of labor which led to anticipation of certain detrimental results (Blakelock, 1967). Boredom and alienation may be caused by "straightjacket scheduling" in any job (Kowinski, 1975). Presumably there would be some elements of alienation or anomia for nurses due to a variety of reasons, including the lack of adequate opportunities for socializing when "normal" patterns were disrupted by shiftwork. Based on previous literature, the manifestations of anomia were reflected in the social isolation index used in the present study (Dean, 1961). The sources of data consisted of 144 questionnaire res- ponses, and some additional observer notes. The question- naire employed indices of psychological strain (Gillis, 1977) and social isolation (Dean, 1961), as well as various demo- graphic characteristics. The questionnaires were administered verbally in interview fashion, and responses were coded by the researcher, in order to enhance consistency and under- standing of the data sheets. The respondents were instructed using the following statement: The following questionnaire is part of a research project designed to assess a variety of conditions having an adverse effect on the nursing profession. The information obtained will provide data for a doctoral dissertation on this topic. Please try to answer all ques- tions. All responses will be kept strictly confidential and anonymous. 123 The present study was geared toward a population of predominantly female nurse subjects. Guided by the theo- retical proposition that a cultural trend toward time opti- mization has led to increased shiftwork scheduling, and that such scheduling causes holistic disruptions of well—being that contribute to psychological strain, the Gillis (1977) index was applied to this question. It was predicted that the lowest amounts of psychological strain would be found among day shift subjects, and that increasing amounts of psychological strain would appear in afternoon, night and rotating shift subjects in that order. The Gillis (1977) index basically covered a combination of biological and psychological factors. In keeping with the holistic theo- retical orientation to the problem, sociological factors were also of interest. Three sets of sociological factors were used, derived from Gillis (1977): social isolation, confine- ment, and household composition. The Social isolation factor was examined by Dean (1961). It was predicted that social isolation would appear in the same pattern among subjects across shifts, as would psychological strain, since this is the pattern of detrimental effects that seemed to emerge from previous studies of shiftwork. A preliminary analysis of the data computer run was performed using analysis of variance techniques, to see if there were any significant relationships between the index of psychological strain across the various shifts, and 124 between the index of social isolation across the various shifts. The results of this preliminary analysis suggested that support for one of the two main hypotheses had been found statistically, and that further analysis of the data was warranted. Table 4 is provided so that the means from the preliminary analysis of the data may be inspected. T- tests were used to identify significant differences in psychological strain between specific shifts. For the sake of consistency in data analysis, t-tests were also run to examine differences in social isolation between specific shifts. In order to test the significance of post hoc compari- sons, a Scheffé'test was run. And, multiple regression techniques were performed on the data to see how the other variables related to psychological strain. TABLE 4 Preliminary Analysis of the Data: Mean Scores from AOV of Psychological Strain and Social Isolation Mean Psychological Strain Mean Social Stitt §22£2 Isolation Score First 25.2373 26.9492 Second 26.2889 26.9111 Third 29.7447 26.7660 Rotating 32.0909 28.7273 125 Strengths and limitations of the methodology A study by Tessler and Mechanic (1978), revealed that despite variations between different studies of population characteristics, mode of data collection, and specific ques- tions used to measure psychological distress, distress was seen to be a statistically significant correlate of per- ceived health status (Tessler and Mechanic, 1978:254). In short, people are able to express their own psychological stress via questionnaire responses, therefore the approach taken in the present study is viable. An underlying assump- tion of the present study is that the extent to which indi- viduals can successfully cope with changes in their lives will be reflected in their responses of distress or strain. This assumption is presently being tested by McFarlane, gt. gt. (1980), and it appears that this assumption is valid on the basis of their preliminary report (McFarlane, et. al., 1980:124). Currently, there are numerous self-report schemes available for predicting psychiatric symptomatology (Ross and Mirowsky, 1979). Another strength of the methodology was that first hand data was acquired, and no second hand data analyses using data obtained from other research studies, were used (Firth, 1970:32). The method of field interviews located at or near actual working areas, realized a more natural, directly job- related set of responses, than could have been realized by a laboratory research study. The interviews were all conducted Iby one researcher, which contributed to increased likelihood 126 of a common perception on the part of the subjects. This would not have been the case had several interviewers been used. The researcher attempted to remain alert to non- verbal body cues, so that bias of responses along this dimension was minimized. The study included biological, psychological, and sociological factors, which gave it a holistic theoretical orientation. Some limitations of the methodology were as follows. Since the interviews did not take place in a laboratory setting, it was not a highly "controlled" study in the scientific sense of the word. There was involvement of individual subjects in data collection that may have resul- ted in distortion or omission of certain desired informa- tion (Cannell and Kahn, 1966:330-331). The administration of the questionnaires by personal interview was an attempt at reducing such distortion and omission, yet did itself constitute a methodological limitation. However, much social science research shares such limitations. Some form of unobtrusive measure might have been used, but would probably have complicated things unnecessarily. For example, non-verbal indicators of psychological strain might have been obtained by rating the unobtrusively recorded, filtered speech of the nurses. Such a technique ‘was used in a study of doctor-patient communication by Hall, Roter, and Rand (1981). However, it would have made the jpresent study unnecessarily complicated and prohibitively expens ive . 127 Both male and female subjects were interviewed for com- parative purposes. This feature of studying both male and female shiftworkers, was found to have been lacking in most of the previous research surveyed. Although an attempt was made to acquire male subjects for the present study, the attempt was considered unsuccessful as only seven males were found. Since there were too few male subjects acquired for meaningful statistical analyses to be made, this element turned out to be a research limitation. The study could only provide correlations, rather than direct identification of causal relationships. Only inferences as to causality were made. Another limitation concerned the time period for data collection. Although data collection took three months, the research design was not longitudinal. The method was time consuming, because there were distances of up to fifty miles between research sites, and because the study was directed at subjects work- ing around the clock. The time and distance factors con- tributed to make the method selected somewhat expensive in terms of travel costs. The present study was also limited with regard to the generalizability of the findings, as one hospital dominated the sample. Furthermore, the subjects were from a single, rural geographical area, and may not therefore be represen- ‘tative of the total population of nurses (Fottler, 1976:107). 'Ihe demographic figures fortunately indicated that the 128 subjects were fairly heterogeneous with regard to their geo- graphical backgrounds. Therefore, they were not expected to be atypical of nurses at comparable institutions in other parts of the U.S. Any subjective report measure, such as the one used in the present study, is particularly vulnerable to reactivity effects (McGrath, 1970:71). The respondent knows (s)he is being "tested" and is therefore likely to attempt to alter his/her behavior to suit the social-psychological demands of the testing situation (Orne, 1962). The specific objectives of the research were deliberately kept vague, so as to attempt to minimize such effects. It is not, and probably cannot be known whether the steps taken were successful in this regard. We may simply acknowledge that personality characteristics act to increase or reduce the impact of subjectively appraised stress (Kessler and Cleary, 1980: 464). A central methodological problem raised by the theo— retical orientation of Hough, Fairbank, and Garcia (1976), applies to the theoretical orientation of the present study. Specifically, it is difficult to measure the degree of disruption of routine life patterns experienced by indi- viduals (Hough, Fairbank, and Garcia, 1976:71). Such dis- ruption was examined by statistical as well as the key concepts for this study, of psychological strain and social isolation. 129 As a final comment on the viability of the research methodology used in the present study, a statement by Eller- broek (1978), will be discussed. He wrote about the puzzles of human illness and the connection between psychological states and physical diseases, and stated some basic defini— tions and postulates that relate to stress research and interdisciplinary social science in general (Ellerbroek, 1978:94). These underlying assumptions apply not only to the present study, but to any research effort: There is no such thing as a fact: any verbal statement is an opinion, no matter how labeled. For example, any statement can be called either an opinion or a fact. If you call it an opinion, you bear in mind the possibility of error. If you call it a fact, you are neurotically expressing a belief that the statement is gold—plated, never to be questioned, and, more important, you are turning off your thinking machine as to that item. Objective knowledge is a myth: all "knowledge" being based on biases in "percep- tion" and "cognition," is subjective and emotionally determined (Ellerbroek, 1978:94). Based on the theoretical rationale and framework developed in the present study, certain items of information emerged from a field-study, that are potentially useful for expan- sion of the theoretical basis and for applications in the sites studied. This is possible because of a sharing of subjective biases between two or more individuals. Summary Five health care institutions, which ranged in size from small to large, served as research sites for the pre st} 'm 0.! (n 130 present study. The Gillis (1977) index of psychological strain, and the Dean (1961) index of social isolation, were incorporated into a questionnaire used to assess effects of shiftwork on male and female nurse subjects within a multi- disciplinary theoretical framework. The questionnaire also had items relating to confinement, household composition, socioeconomic and demographic factors. Subjects were inter- viewed at the research sites on a random, voluntary basis. The subjects worked either day, afternoon, night, or rotating shift schedules. Using appropriate statistical techniques and computer technology, the data was analyzed. CHAPTER IV RESULTS AND DISCUSSION Background Variables An analysis of the major background or demographic variables, as related to shift schedule and psychological strain is shown by Table 5. There were significant cor— relations (pw<10001) between shift schedule and psycholo- gical strain (as hypothesized), age and marital status, and income and education. It appears that the background variables were not significantly related to different shift schedules. The relationship that did occur as significant were not surprising. In addition, none of the background variables significantly related to psycho- logical strain. 131 132 Hooo.uv m4 mono.| HH~0.I mmHH. ammo.| mmvo.n moma.l «mamm. magnum HMOflmoHoaommm *ovmm. Hmmo. mamo. mmmo.| nmno.| hmmo.| newvmospm ammo.| mnmo.| ammo. mmwo.| maao.| meoocH Nmmo.| OHvo.| mmmo.| mono. cowumwaflmmfi msowmflamm mmmo. nmmo. Nmmo.| muflowcgum msumum *mvvv. mmmo. Hmuflumz vao.| mag cofiumosom mEoocH coaumHHHmmfi mufloflcnum msumum mod masomsom msonHHmm HmpHumz HHHHm manwfinm> wanpm Hmowmoaonommm cam .mmHQMHHm> 0H£mmumofimo .masomsom #mwnm mo xwuumz coaumamhnooumuaH m mnmga 133 Analysis of variance The first finding that emerged from the analysis of variance, was that shiftwork was significantly related to psychological strain (p‘<100001). This finding was hypo- thesized to occur, prior to research data collection, based upon the theoretical framework. Having noted this finding, t-tests were used to help understand the pattern of differences in means, of psychological strain across shifts (Table 6). The second hypothesis which was formulated at the out- set of the research, that social isolation would be related to shiftwork, did not receive empirical verification (Table 6). It should be mentioned, however, that a trend toward such verification did appear in the data. When the index of social isolation was later analyzed for variation across shifts, it was not seen to have realized statistically significant differences. 134 TABLE 6 Analysis of Variance of Psychological Strain by Shift Schedule Shift Mean Psychological Strain Score First 24.9020 Second 26.3000 Third 30.2857 Rotating 32.0909 Source of Variation gt Mg 3 Between Shifts 3 319.479 8.966* Within Shifts (Error) 140 35.631 *P < .00001 135 TABLE 7 Analysis of Variance of Social Isolation by Shift Schedule Shift Mean Social Isolation Score First 26.9804 Second 26.7250 Third 26.8333 Rotating 28.7273 Source of Variation gt Mg F Between Shifts 3 12.343 .833 (NS) Within Shifts (Error) 140 14.821 136 TABLE 8 Analysis of Variance of Desire to Change Shift by Shift Schedule Shift Mean Score of Desire to Change Shift First 1.8431 Second 2.1500 Third 3.2857 Rotating 3.4545 Source of Variation gt Mg F Between Shifts 3 20.915 13.122* Within Shifts (Error) 140 1.594 *p < .00001 137 A fourth finding emerged from a hypothesis formulated during the collection of data, after a preliminary computer- assisted analysis of the data. This analysis of variance computer run, which is shown by Table 8, warrants some background explanation. Admittedly, there are numerous reasons to avoid "data snooping," however, in a study of this nature, there is a strong exploratory element present. Justification for the formulation of a hypothesis during the middle of the data collection process should, there- fore, be permitted. It was from such a search of prelimi- nary data, that the analysis of the desire to change shifts variable, was noted as a strong indicator of this feature of shiftwork. During the intermediate stages of data collection, while testing the efficacy of the SPSS program instructions, a discriminant analysis was performed. One result of this analysis was the identification of the vari- able of desire to change shifts as a strong predictor of shift schedule worked. The analysis in Table 8 shows that as subjects were interviewed across shifts, from day shift through rotating shift schedules, a progressive desire to change shifts was found. This desire was strongest among the rotating shiftworkers. Post hoc comparisons A Scheffé procedure was run at the .05 level of signi- ficance to test for shift group differences. The results obtained are noted in Table 9. From Table 9 it may be seen 138 that the pairs of significantly different groups for the psychological strain variable, are day-night shift, day- rotating shift, afternoon-night shift, and afternoon- rotating shift groups. This test substantiates the argu- ment that there are differences between day and afternoon shift groups when compared with night and rotating shift groups, for the variable known as psychological strain. TABLE 9 / Scheffe Procedure to see Differences Across Shift Groups in Psychological Strain Group Group Group Group 01 02 . 03 04 Mean gtgtp 24.9019 01 26.3000 02 30.2857 03 * * 32.0909 04 * * (*) Denotes pairs of groups significantly different at the .05 level. T-tests According to Kennedy (1977:174-175), the choice of comparisonwise t-tests for multiple comparisons, such as appear in Table 10 is justified, as the specific compari- sons to be made were specified well in advance of the data collection and were the product of "strong interference" 139 as to specific directional operational predictions. As a priori comparisons, they were based upon careful considera- tion of the theoretical framework that guided the research, and the empirical and experiential foundations of the prob- lem. The comparisonwise t-tests which appear in Tables 11 and 12 are perhaps more difficult to justify on these grounds, but are nevertheless considered valuable in light of the theoretical objectives of the research. Relating to the first hypothesis, t-tests were run to help explain the differences in means of psychological strain across shifts (Table 10). No significant differences in psychological strain emerged, when day and afternoon shifts were compared. Similarly, no significant differences were found when night and rotating shifts were compared. These results were not considered at all surprising, as the combinations of shifts previously mentioned were predic- tably similar in the effects they had on the subjects, based upon the results of previous research efforts. When com- parisons were made between afternoon and night shifts, and between afternoon and rotating shifts, significant dif- ferences in psychological strain emerged. The most signi- ficant differences in psychological strain occurred between day and night shifts, and between day and rotating shifts. The general trend of these differences was hypothesized prior to field data collection. Significantly greater psychological strain appeared among night and rotating shiftworkers, for these two highly significant comparisons. 140 TABLE 10, Differences Among Shifts in Psychological Strain (t-tests) Shift 1 Shift 2 Shift 3 Shift 4 (N=51) (N=40) (N=42) (N=ll) Shift 1 -1.20 -4.63a -4.76a Shift 2 - .40 —2.57b Shift 3 - .80 Note: all tests two-tailed