Physical activity of graduated nurses in one-and multiple-shift work

Introduction: Physical activity enables nurses to better control their mental and physical strain at work, which is important for ensuring quality patient treatment. The aim of the research was to study differences in graduate nurses' physical activity in terms of their working hours, motives and obstacles to regular, free-time physical exercising. Methods: A quantitative survey with two-stage random sampling included 349 graduate nurses employed in the secondary or tertiary levels of healthcare institutions in Slovenia who work one shift (41 %) or multiple shifts (59 %). The data were collected with a questionnaire in 2012 and analysed with a chi-square test, a t-test for independent samples and discriminant analysis. Results: Graduate nurses with one shift perform physical activity more often (p < 0.001) and are more involved in organised physical exercise (p < 0.001) than those who work multiple shifts. The motives for oneshift graduate nurses to engage in physical activity are to control stress, a better mood, along with the desire for exercising, moving and relaxation, whereas nurses who work several shifts encounter obstacles due to not exercising regularly, such as work absences, the fact the effects of exercising are not immediately seen, and the lack of free time (p = 0.025). Discussion and conclusion: The research showed that graduate nurses are not sufficiently physically active. Especially those who work multiple shifts are in danger due to the less organised and lower frequency of activities. It is important to promote health in the workplace in various forms, such as active breaks during work hours and sports games for employees and their families.


Introduction
An ever greater share of the population associates physical activity with a higher level of health as well as with the improvement and maintenance of health (Sila, 2010), regarding it as one of the main recommendations for developing and upholding a healthy lifestyle (Villarruel & Koniak-Griffin, 2007;Atkinson, et al., 2008).Physical activity encompasses various types of body movements that positively affect a person's health and energy consumption (Doupona Topič, 2010).The types that benefit health include sports recreation, work-recreational activities and transport-related movements (Zaletel-Kragelj, 2006) that are intended for the broad population regardless of age, gender, knowledge level and motor abilities (Berčič, et al., 2007).The sufficiency and suitability of physical activity depend on the frequency (number of days per week), intensity (e.g.light, moderate), duration (length of a training unit) and type of motor activity (e.g.aerobic activities, power exercises, flexibility exercises) (Berčič & Sila, 2007).
About two million deaths a year can be attributed to physical inactivity (World Health Organization, 2010).Regular physical activity changes a human body in morphological and functional terms, and this can prevent or slow down the occurrence of some illnesses and ageing as well as increase physical ability.Evidence suggests that an increased level of physical activity can benefit the health of every person, even after a long period of physical inactivity and regardless of their age (Smernice EU o telesni dejavnosti, 2008).
Regular and systematic physical activity is associated with employees' health since it improves their psychophysical abilities, and these in turn increase productivity at work (Karpljuk, et al., 2009).People who are concerned for their health and work performance organise their lives in such a way that they have enough time for free-time activities, helping them to lead a healthy lifestyle (Mlinar, 2007).The better health condition of employees correlates with high productivity and low absence from work (Popham & Mitchell, 2006).Over a period of 4 years, Ravnik and Kocjančič (2015) conducted three gradual ergonomic interventions among industrial workers so as to reduce musculoskeletal disorders and improve their ergonomic status.The study showed a decline in absenteeism, greater satisfaction at work and milder musculoskeletal pain in the employees who participated in the interventions.Important factors for reducing locomotor problems included active breaks during work hours, following the instructions on the manual lifting of loads, carrying out of physical exercises for the spine and employees' higher awareness of their health.In their study Zapka and collegues (2009) highlighted that the employer should also provide for the physical activity of nurses.Namely, the work of nurses is psychologically and physically strenuous and they frequently work in multiple shifts.To be able to counteract all the strains of their work, it is important for a nurse to lead a healthy lifestyle and regularly engage in physical activity (Mlinar, 2007).
Mere knowledge that physical activity maintains and improves health does not suffice for regular physical engagement.The fact that people undertake physical activity in their free time is largely a consequence of lifestyle and the related set of personal views and external factors that influence it (Doupona Topič & Sila, 2007).Compared to nurses who work one shift, nurses with a multiple-shift work schedule report their working hours affect the continuity and frequency of their physical activity as well as their social and family lives (Han, et al., 2011).Mlinar (2007) reports that only 31.5 % of nurses with a secondary-school education in the Ljubljana University Medical Centre's intensive care units were regularly physically active.Similar findings were reported by foreign studies conducted in Europe and the USA (McElligott, et al., 2009;Tucker, et al., 2010;Blake, et al., 2011;Malik, et al., 2011), emphasising that nurses' physical activity failed to meet the World Health Organization's recommendations (2010).

Aim and objectives
Based on the findings presented in the theoretical premises, it was established that physical activity is extremely important for nurses' health and work.It can be assumed that an important factor in nurses' physical activity is their working hours; especially a multipleshift work schedule can be an influential factor leading to less frequent physical activity.The purpose of the empirical study was to investigate the physical activity status of graduate nurses in terms of their working hours and to find methods to motivate graduate nurses to overcome the obstacles and, in line with the World Health Organization's recommendations, devote more attention to regular physical activity (World Health Organization, 2010).The following hypotheses were verified in the study: H1: There are statistically significant differences in physical activity, in terms of frequency, between graduate nurses working in one or multiple shifts.H2: There are statistically significant differences in physical activity, in terms of organised physical activity, between graduate nurses working in one or multiple shifts.H3: Graduate nurses working in one or multiple shifts can be distinguished in terms of the motives for and causes of their physical activity/inactivity.

Methods
A descriptive non-experimental methodology was applied in the study.The data were acquired using the survey technique.

Description of the research instrument
The survey technique was employed to collect the data.The research instrument was a structured written questionnaire.The questionnaire's structure was based on the substance of two studies: "Health-related behavioural style 2008", which was developed and implemented by the CINDI (Countrywide Integrated Noncommunicable Disease Intervention) Ljubljana organisation (Hlastan Ribič, et al., 2010), and "Sport activity and lifestyle of nurses employed in intensive care units of the Ljubljana University Medical Centre", conducted by Mlinar (2007).The questionnaire consisted of a demographic part and 21 questions divided into nine thematic sets: 1) sociodemographic characteristics of the sample; 2) frequency and duration of physical activity; 3) organisation of physical activity (organised training, non-organised training); 4) content and/or type of physical activity; 5) way of spending free time; 6) causes of physical inactivity and motives for movement; 7) assessment of the effects of physical activity on health, well-being and behaviour; 8) opinions about physical activity; and 9) assessment of own health and stress management with physical activity in the workplace.The article presents the results of the first, second, third and sixth thematic sets of the questionnaire.The respondents' socio-demographic characteristics were established by means of relational and ordinal variables.The second thematic set, the frequency of physical activity, was established using ordinal variables with five answers offered in advance.The measured variables in the third and sixth thematic sets of the questionnaire were expressed in the form of statements and assessed based on a 5-point scale, as follows: 1 -never, 2 -very rarely, 3 -occasionally, 4frequently, 5 -always.
Before its implementation, the questionnaire was pilot tested on a sample of graduate nurses (n = 22) from the Novo mesto General Hospital.To establish the measurement instrument's reliability, we used the Cronbach alpha coefficient which ranged from 0.710 to 0.876 in some thematic sets of the questionnaire and thus exceeded 0.700, which the literature states is the appropriate reliability level of a measurement instrument (Cencič, 2009).

Description of a sample
The statistical population included graduate nurses employed in public secondary or tertiary healthcare establishments (27 institutions) of the Republic of Slovenia.Two-stage random sampling was employed.In the first stage of the sampling, 15 institutes were randomly selected from among all participating healthcare establishments, and 12 institutes gave their consent for the research.In the second stage of sampling, a sample was created of all graduate nurses employed in healthcare establishments with only one or two intensive care departments.In those healthcare establishments that have several intensive care departments, two intensive care departments were randomly selected, i.e. by drawing lots, from the list of all departments with a multiple-shift work schedule, and two departments with a single-shift work schedule.The research included all graduate

Description of the research procedure and data analysis
The surveying was conducted from May 2012 to August 2012, after the participating health-care establishments had given their written consent for the research.The first author of the article conducted the entire data collection, using a personal written approach.The data collection respected the ethical aspects of research involving human subjects, in accordance with the principles of the Helsinki-Tokyo Declaration (World Medical Association, 2013) and the Slovenian Nurses' Code of Ethics (Kersnič & Filej, 2009).Participation in the research was anonymous and voluntary, with an option to withdraw without any consequences.All of the presented results are based on the anonymity of the participating graduate nurses.
The data were processed using the SPSS version 18.0 (SPSS Inc., Chicago, IL).A chi-square test and a t-test for independent samples were applied to establish differences in terms of physical activity between graduate nurses working one shift and graduate nurses working multiple shifts.The multivariate discriminant analysis method was used to explain the differences between the abovementioned groups of graduate nurses regarding the motives for and causes of physical activity/inactivity.Differences at a 5 % and lower risk level (p < 0.05) were considered statistically significant.

Results
The study showed that graduate nurses employed in secondary and tertiary healthcare establishments in Slovenia engage irregularly in physical activity in their free time in one-half of the cases, i.e. on weekends (22.9 %) or only a few times a month (20.3 %), or are not physically active at all (3.4 %) (Table 2).One-half of the nurses are physically active at least twice a week (53.3 %), but only 15.2 % of graduate nurses meet the criterion of recommended daily physical activity.
When verifying the first hypothesis, namely that there are statistically significant differences in physical activity, in terms of frequency, between the discussed groups of graduate nurses, the chi-square test confirmed the differences were statistically significant As regards the organisation of physical activity (Table 3), the graduate nurses most often indicated they engage in physical activity alone or in a nonorganised way ( = 3.4).Organised physical activity was on average reported very rarely ( = 2.2).In the assessment of the types of physical activity, the respondents' opinions differed considerably as the standard deviation value exceeded 1 in all types.
The t-test for independent samples was used to verify the second hypothesis, namely that there are statistically significant differences in physical activity, in terms of organised physical activity, between graduate nurses working in one or multiple shifts.The t-test revealed the statistically significantly higher inclusion of graduate nurses with a one-shift work schedule in sports clubs, sports associations or fitness centres compared to graduate nurses who work multiple shifts (p < 0.001).Employees with a one-shift work schedule were statistically significantly more involved in nonorganised physical activities with their family members (p = 0.019).Graduate nurses with a multiple-shift work schedule prevailed in individual physical activity (p < 0.001).No statistically significant differences were established between the studied groups of nurses in terms of engaging in physical activity in the company of friends.
Table 4 shows that the discussed groups of graduate nurses differ most distinctively in terms of their motives for physical activity, which include: to reduce or manage stress (0.671), to improve mood and unwind (0.547), a desire for movement (0.497) and relaxation (0.452).The causes of physical inactivity that clearly distinguish the two groups of graduate nurses include not enough time due to work (-0.583), absence of an immediate visible effect (-0.497) and absence of free time (-0.456).The first four relations are positive while the next three are negative, meaning  The current job does not allow me to engage in physical activity.
-0.583 Physical activity helps improve my mood and I am more relaxed.0.547 I engage in physical activity because I have a desire for movement.0.497 I am physically inactive because the effect is not immediately visible.
-0.497I am physically inactive because I do not have enough free time.
-0.456I engage in physical activity to relax.0.452 Legend/Legenda: p -statistical significance/statistična značilnost; * -the share of correctly classified units is 63.5 %/delež pravilno uvrščenih enot je 63,5 % the importance of the motives for physical activity increases with the performance of one-shift work, whereas the causes of physical inactivity decrease; in the case of a multiple-shift work schedule the causes of physical inactivity increase and the motives for physical activity decrease.
The third hypothesis, in which it was assumed that the groups of graduate nurses differ in terms of their motives for and causes of physical activity/inactivity, was verified with the canonical correlation coefficient (0.356).The coefficient is medium-high and shows that the investigated motives for physical activity and the causes of inactivity distinguish the graduate nurses who work one or multiple shifts with a 63.5% probability.The groups differ statistically significantly (p = 0.025) in terms of their motives for and causes of physical activity/inactivity in their free time.

Discussion
It was established that more than one-half of all graduate nurses in our research engaged in physical activity from twice a week to every day.Only onefifth of them meet the World Health Organization's recommendation (2010), namely, at least 150 minutes of moderate to intense aerobic training per week for adults, with an uninterrupted duration of at least 10 minutes (e.g.50 minutes three times a week).Less than one-half of the graduate nurses in our research were irregularly physically active, i.e.only on weekends or a few times a week.Conducted in Great Britain, the study by Blake and Harrison (2013) included 540 nurses.They found that, in view of the World Health Organization's recommendations (i.e. at least 30 minutes of moderate to intense physical activity five or six times a week for a positive effect on health), nearly one-half of the nurses were insufficiently physically active, which is comparable with our research.Tucker and collegues (2010) established in a study conducted in the USA that slightly less than one-half of the surveyed nurses were physically active and that most did not meet the recommendations concerning regular movement.In the abovementioned study, 6 % of those surveyed were completely physically inactive, which was slightly higher than the share of physically inactive subjects in our research (3.4 %).
A comparison of the results for frequency of physical activity showed statistically significant differences between the graduate nurses working one or multiple shifts, whereby graduate nurses with a multiple-shift work schedule dedicate less time to physical activity than graduate nurses working a single shift.The data showing that slightly less than one-third of the graduate nurses with a one-shift work schedule find time for physical activity every day are encouraging.On the other hand, occasional or irregular physical activity prevails among graduate nurses working multiple shifts.Our results differ from those of the study by Díaz-Sampedro and collegues (2010), conducted in a Spanish hospital among nurses working multiple shifts.They found that nearly threequarters of the surveyed nurses were engaged in regular physical activity.Given the obtained results, the first research hypothesis "There are statistically significant differences in physical activity, in terms of frequency, between graduate nurses working in one or multiple shifts" can be accepted.
The graduate nurses in our research most often exercise in the framework of non-organised independent physical activity or with their family members.They rarely take part in organised trainings, and those who do are statistically significantly more often those who work one shift.One-shift nurses are more frequently physically active in the company of their family members, whereas those who work multiple shifts rank independent physical activity in first place.Statistically significant differences between the groups were expected because a multiple-shift work schedule is related with absence from home and thus fewer possibilities for spending family free time together or for engaging in organised physical activities with a fixed timetable.Hypothetically, it may be concluded that the differences between the studied groups stem from the characteristics of the working environment, the available recreational physical activities in connection with working hours, and the place of residence in the case of those deciding to engage in an organised or non-organised type of physical activity.Similar results were reported by Mlinar (2007) whose study revealed that nurses with a multiple-shift work schedule participated statistically significantly less often in organised physical activities than nurses working one shift.Given the results, the second research hypothesis "There are statistically significant differences in physical activity, in terms of organised physical activity, between graduate nurses working in one or multiple shifts" can be accepted.
Research shows that, in terms of the effects on a person's physical and mental health, organised physical activity led by a qualified expert is the highest in quality (Zurc, 2008).An unsettled issue to be answered in future studies is how to encourage nurses with a multiple-shift work schedule to engage in organised physical activities or how to adjust the latter to them.Special attention should be paid to exploring nurses' internal and external motives for engaging in organised physical activity.
The purpose of the third hypothesis was to identify the strongest motives for and causes of physical (in)activity that distinguish between graduate nurses working in one or multiple shifts.Based on the findings, it can be predicted with a 66.6 % level of reliability that, in terms of the causes of physical inactivity, those graduate nurses who work multiple shifts will differ from those working a single shift in the following views: the current job does not allow them to engage in physical activity, the effect of the physical activity is not immediately visible, and they do not have enough free time.Similar causes of the physical inactivity of nurses working multiple shifts were reported in the study by Mlinar (2007), namely the differences compared to nurses with a one-shift work schedule were seen in the following statements: "multiple-shift work does not permit me", "overfatigue", "lack of leisure time", "the effect is not immediately visible", "I don't feel the urge to engage in physical activity" and "there are no sports facilities in the vicinity".In a study by Han and collegues (2011), nurses with a multiple-shift work schedule reported that their working hours influenced the low frequency of their physical activity.Similar findings were reported by Malik and collegues (2011) in a study conducted in England among graduate nurses and nurses with a secondary-school education where the main obstacles to physical activity included a lack of time, overfatigue, a lack of financial resources, and nurses' non-motivation.Given the results obtained from the discriminant analysis, the third research hypothesis "Graduate nurses working in one or multiple shifts can be distinguished in terms of the motives for and causes of their physical activity/inactivity" can be accepted.
The measurement instrument for studying the graduate nurses' physical activity in view of the working hours, which was composed based on previous research, proved to be appropriate for our study in terms of the data collection, while also offering opportunities for improvements in further research on graduate nurses' physical activity.The result of this study is only nurses' descriptive selfassessment of their movement-related behavioural style and not an objective measurement of their actual physical activities.This can serve as a basis for future research that could objectively measure the performed physical activity.The research offers starting points for deliberating on the status of the studied population's physical activity and for considering the possibility of including physical activity in regular working hours with the aim of encouraging nurses, especially those working multiple shifts, to be more physically active so as to maintain and improve their health.

Conclusion
The study found that graduate nurses, particularly those with a multiple-shift work schedule, engage insufficiently in physical activity.As physical activity is necessary to maintain health and ensure the highquality work of nurses, employees in nursing care should be appropriately motivated, empowered and educated to adopt a more positive attitude to regular physical activity.
Based on the results of our study, we propose preventive trainings on the importance of physical activity for the health of employees in nursing care, especially nurses with a multiple-shift work schedule.
Attention should be paid to adjusting the timetables of organised physical activities for nurses who work multiple shifts.Given the fact that graduate nurses are aware of the importance of physical activity but encounter certain obstacles in their attempt to regularly engage in such activity, it would be worth considering introducing an active break for employees during their working hours as well as different sports events for employees and their families; health institutions would thus boost the level of interest and offer their employees various possibilities for regular and continuous engagement in physical activities.Physical activity in the workplace improves employees' well-being and health and should be an indispensable part of the annual work plan.Physical activity only achieves its purpose when implemented regularly.As our research results show, in the case of nurses this is only feasible if the specifics of their working hours are considered.

Table 2 :
Frequency of graduate nurses' physical activity and related differences due to their working hours Tabela 2: Pogostnost ukvarjanja diplomiranih medicinskih sester z gibalno aktivnostjo in razlike

Table 3 :
Organisation of graduate nurses' physical activity and related differences due to their working hours Tabela 3: Organiziranost ukvarjanja z gibalno aktivnostjo diplomiranih medicinskih sester in razlike glede na delovnik

Table 1 :
Socio-demographic characteristics of the sample

Table 4 :
Discriminant analysis of motives and causes for physical activity/inactivity of graduated nurses who work one shift and more shifts