Worker perspectives on the impact of non-standard workdays on worker and family well-being: A qualitative study

Background Non-standard work schedules (NSWSs), occurring outside of regular and predictable daytime hours, may negatively affect worker and family health. This qualitative study sought to understand worker perspectives on the health and well-being impacts of NSWSs among full-time, transportation maintainers, correctional, and manufacturing workers. Methods Forty-nine workers participated in 8 focus groups. Data were transcribed and analyzed with ATLAS.ti, using the constant comparative method to identify themes and sub-themes. Results Workers reported that long work hours and irregular and unpredictable schedules posed the biggest obstacles to their well-being. Workers reported that NSWSs were associated with behavior impacts (poor family and social connections, poor eating, poor sleep, lack of exercise recovery), physical health impacts (exhaustion, weight gain) and extended work exposures (increased stress, increased accidents). Conclusions This highlights the importance of developing and implementing effective workplace interventions to address these barriers to health and health behaviors.


Background
Non-standard work schedules (NSWSs), characterized by work schedules occurring outside of the traditional 9 AM to 5 PM workday, Monday through Friday pattern are common and increasing in the US workforce. While NSWSs have long been commonplace for workers in some sectors such as public safety (e.g. police), healthcare, and retail, the expansion of NSWSs to a broader range of work sectors is new. Historic estimates suggests that 90% of Americans have worked a NSWS at some point in their life [1,2], although given recent disruptions in work schedules due to the COVID-19 pandemic, the prevalence of NSWSs is likely even higher.
In addition to being characterized as standard or nonstandard, time at work can be described through a number of characteristics. "Shift work, " is one type of NSWS, defined as work scheduled outside the typical daytime work period that may extend beyond a typical 8 to 9 hour schedule, in order to meet the staffing needs of organizations that operate continuously over 24 hours [3]. It may include on-call work, compressed work schedules, rotating shifts, weekend work and many other shift arrangements. One comprehensive framework put forth by Harma and colleagues [4] characterizes work based on seven domains that include (1) shift length, (2) time of day, (3) shift intensity, (4) schedule control, (5) schedule predictability, (6) free time, and (7) variability of working time. While NSWSs help to meet the societal and economic demands of a 24/7 society, there are implications for workplaces, workers, as well as families and communities [5].
It is hypothesized that NSWSs, and shift work more specifically, impact workers through three mechanisms: circadian rhythm disruption, fatigue, and social rhythm disruption [6]. Circadian rhythm disruption occurs when a worker's sleep schedule is outside of the natural day/ night, wake/sleep pattern. With continued disruption, circadian rhythm misalignment can lead to cell proliferation, increased inflammation, and immunosuppression, putting workers at increased risk for breast cancer, cardiovascular disease, gastrointestinal and metabolic disorders, and possibly other cancers, mental health and reproductive problems [6]. Circadian rhythm disruption can occur when workers are working in the late evening and early morning hours as can be the case with shift work.
Fatigue occurs when there is insufficient time for recovery and sleep, which increases the risk of injuries and accidents [7] and may lead to a cascade of inflammatory responses implicating numerous chronic diseases including metabolic disorders, cardiovascular disease, cancer and diabetes [6]. Long work hours, including long work weeks (>55 hours worked per week), as well as shift work can all disrupt sleep patterns and lead to fatigue.
Social disruption occurs when workers are unable to participate in the stable social rhythm of evening and weekend activities that are consistent with western industrialized societies [8]. In addition to impairing social life, social disruptions can precipitate work-life conflict [8] and may also play a role in the link between poor work schedule characteristics and depression [9]. Working in the evening or the early morning hours, work on the weekend, long work hours, and irregular and unpredictable work hours have all been linked to social disruptions [8]. NSWSs have also been linked to reduced family well-being including increased risk of separation or divorce and poorer emotional and developmental outcomes for children whose parent works shift-work [5,8].
The mechanisms by which working hours impact worker and family well-being help to inform our understanding of the harmful characteristics of work schedules [10,11]. However, the characteristics of work schedules and the mechanisms by which they have effects tend to overlap. Long work hours can extend into the evening and early morning hours with fatigue and circadian disruption simultaneously affecting worker well-being while producing stressors on personal life adding social disruption.
Previous occupational research examining the effects of work schedules on worker and family well-being have primarily relied on quantitative methods. However, a qualitative research approach, driven by participants' interpretation of their environment and assessment of their well-being allows researchers to gain an in-depth understanding of complex relationships and has been successfully applied among other workers [12][13][14].
The purpose of this study was to better understand the range and depth of well-being effects of work schedules in workers who experience a combination of both long and irregular work hours. The study cohort included bluecollar workers from a variety of industry sectors including transportation, corrections, and manufacturing. Workers from these populations were employed full-time with access to benefits, yet had varied exposures to working time characteristics. These blue-collar workers were also similar in their financial situation and geographical location. In addition to exposures to NSWSs, blue-collar workers are often times also exposed to additional hazardous work organization exposures such as monotonous and repetitive work and low levels of work control [15].

Study design
This was a qualitative study that used focus groups to assess worker perceptions on how time at work impacts worker and family well-being. It was the first phase of the larger mixed-methods, cross-sectional, WorkTime study, based on a participatory research approach involving workers from three sectors: transportation, corrections, and manufacturing. Focus groups (n=8) were performed with a subset of workers from these sectors to understand how their experience of NSWSs impacts the health and well-being of themselves and their families. The study was approved by the UConn Health's Institutional Review Board and written informed consent was received from all research participants.

Focus group participants and recruitment
We provided work sites with recruitment flyers, briefly describing the study and purpose of the focus group that were handed out to potential participants ahead of time. All workers who were willing to share their NSWS experiences were recruited through convenience sampling at their work site. Within the transportation sector, we recruited transportation maintainers or "maintainers" who perform maintenance and repair of roadways. Within the corrections sector, we recruited both correctional officers and supervisors. We recruited manufacturing workers from a privately owned, small manufacturing company. We continued to recruit participants until no new themes emerged i.e., data saturation was reached across a broad range of NSWS experiences across industries. Focus groups included representatives from only one industry at a time.

Focus group script
A semi-structured focus group script was designed by the research team to understand work hours and schedule concerns at different work sites, characterize how work hours and schedules acted as barriers to worker and family well-being, and consider ways in which work hours or schedules could be beneficial to worker wellbeing ( Table 1). The script was pilot tested and refined before use in the field. The research team included experts in occupational health, industrial hygiene, occupational health psychology and industrial and organizational psychology. The focus group script was guided by the framework of NSWSs put forth by Harma et al. [4], the mechanisms by which NSWSs effect worker and family well-being [8], as well as initial conversations with workers who experience NSWSs. Consistent with the U.S. National Institute for Occupational Safety and Health (NIOSH) Total Worker Health ® approach [2], we took a broad view of well-being which in addition to being associated with good health, included health behaviors, mental health, and social connections. This concept of well-being was described to the workers during the focus group.

Focus group procedure
We conducted the focus groups at the worksites, with only the research team (consisting of the facilitator and one research assistant) and the participants in attendance. Participants took a brief demographic survey, administered electronically, before the focus groups commenced. Focus groups were audio recorded with the knowledge and permission of the participants, while the research team took detailed notes to provide context of non-verbal expressions. Participants were asked to use only first names to assure confidentiality. Eight focus groups were conducted separately among a total of 49 workers (25 from transportation, 17 from corrections, and 7 from the manufacturing company). Each focus group had on average 6 participants with focus group size ranging from 4 to 8. A member of the research team facilitated the focus groups using the focus group script with question guides, and probes were used where appropriate (Table 1). Each focus group lasted about 1 hour (median 35 minutes) and were conducted over a 4-month period (April 2018 to August 2018).

Data analysis
We computed descriptive summary statistics of demographic data, including means, standard deviations, and frequencies using SPSS version 25. The audio-recording from the focus groups were professionally transcribed and reviewed for accuracy. Transcripts were imported into Atlas.ti version 8 qualitative software package for analysis. Analysis of the transcribed data was done using the constant comparative method of qualitative data analysis [16] to generate meaningful concepts and theories through identifying common themes and sub-themes which were quantified across all focus groups, until no new themes emerged. Data from each of the eight focus groups was coded, and then reviewed as a combined dataset.
Coding used the inductive approach, which was driven by the available data [17]. One of the members of the research team completed the initial coding by reading through the transcripts line by line, to identify significant words or phrases (quotations) to generate codes. Sub-themes and themes were subsequently identified from the emerging codes and codes groups by grouping common quotations and codes into codes and code groups, respectively. The team continually discussed and reflected on the emerging sub-themes and themes to ensure validity. A final code structure evolved based on continuous review by two of the researchers, and also from input from worker teams consisting of a subset of the initial focus group participants. Based on the final sub-themes and themes, two members of the research team independently re-coded the data, and calculated the inter-coder agreement (ICA), which was at 87 percent agreement. A third member of the team served as the tiebreaker in cases where there were code discrepancies. Sub-theme frequencies were derived from code densities.
When workers were asked about the aspects of their work hours and schedules that were the biggest obstacles to their health and well-being, 9 sub-themes emerged, leading to 3 main themes: well-being behavior impacts, physical health impacts and extended exposures from work.

Results
Forty-nine workers participated in the focus groups ( Table 2). The participants on average were 46 years old (SD = 10). The majority of workers were male (92%), White (51%), with more than a high school diploma or its equivalent (51%), married (70%), and had either a child or adult dependent (81%). Most of the participants were transportation maintainers (51%), worked the first shift (84%), and had no supervisory responsibilities at work (71%).
Workers were asked to describe their work, typical work hours and schedules, and how their work hours and schedules change (Table 1). Maintainers reported that their job involved highway/road maintenance -patching potholes, paving, repairing guardrails, mowing grass, flagging, brush cutting, picking-up litter, masonry and wood chipping in the summer and snow plowing in the winter. They described working long, irregular and unpredictable schedules mostly during winter storms, typically about seventeen to twenty-one hours per day, with short breaks. Schedules also often changed with short notice and calls-in during the winter. A maintainer described his work hours below: "So after the 14 th hour, if you rested three hours and say we were staying, you would go another 17 hours. Your second rest break would be four hours, which we've only done maybe once or twice this whole winter. We didn't have too many four-hour rest breaks

this year. " (Male transportation maintainer)
Correctional officers (CO) reported that their work involved monitoring inmates' daily activity inside the correctional facility to ensure their safety, health and welfare. They work different eight-hour shifts -first, second and third, often with rotating schedules and a lot of voluntary and mandatory overtime. Correctional supervisors were assigned to supervise the different shifts and were responsible for many administrative duties. They also work long, unpredictable hours with changing schedules and on-call work. A CO described his work hours below: "…my shift is eight to four regularly but other than that it's either eight to ten, so it's 14 hours… And I do swaps also, so it could be a 14-hour day, then a 16-hour day followed by another 14- Themes, sub-themes and sub-theme frequencies for worker-identified barriers of work hours and schedules to health and well-being are summarized in Table 3. Each theme and sub-theme with quotation examples are detailed below:

Theme 1: Well-being behavior impacts
Workers reported numerous ways that their extended time at work affected the behaviors used to maintain their well-being. These pertained to physical and mental health, and family, social, and community connections. (We present sub-themes in order of descending frequency).

Sub-theme 1.1 Strained family connections (n=83)
Workers reported strained family relationships as a result of missing important and routine events with family due to long work hours, irregular schedules and shift work.

Sub-theme 1.2 Poor eating (n=76)
Workers indicated changing and irregular eating patterns as well as unhealthy eating due to lack of access to healthy food from working extended/irregular hours and night work.

Sub-theme 1.4 Poor social and/or community connections (n=34)
Workers reported missing everyday social activities, opportunities to volunteer in the community, and also educational opportunities due to long work hours, irregular schedules and shift work.

Theme 2: Physical health impacts
Workers identified several ways that long and irregular work hours and schedules affect their physical health and well-being including exhaustion and weight gain.

Sub-theme 2.1 Exhaustion (n=29)
Workers reported that long work hours resulted in physical exhaustion.

Theme 3: Extended exposures at work
Workers identified ways that their health and well-being were affected by extended exposures to work hazards, including increased hypervigilance, stress and anxiety and increased chances of accidents or mistakes on the job.

Sub-theme 3.1 Increased hypervigilance, stress/anxiety (n=17)
Due to extended work hours in a dangerous and/or stressful work environment, workers reported increased psychological symptoms of hypervigilance, stress and anxiety. The majority of comments (n=13) in this category were from workers in corrections with the remainder (n=4) from transportation workers.

Sub-theme 3.2 Increased accidents at work/mistakes on the job (n=6)
Due to physically demanding work over long hours, workers reported sustaining injuries or making mistakes on the job. Of the 6 comments, 5 came from corrections workers and 1 from a transportation maintainer.
"… I've seen people now that -normal guys,…if they work one shift, they're good. But…I see how many hours they're workin' . There's a correlation. The more you work, the more chances you make mistakes. " (Male correctional officer) "…sometime driving too many hours, and we have to be safe, no accidents…" (Male transportation maintainer)

"…I work a lot of overtime… I've run to a couple of codes, injured my knee, tore up my rotator cuff, my bicep, my hand's still not, some days it's real rough…" (Female correctional officer)
Despite the long and irregular hours these workers spend at work, focus group participants identified some aspects of their work hours and schedules that gave them schedule control and were benefits to worker health and well-being. Six sub-themes emerged from the main theme: Well-being behavior impacts (Table 4). Sub-theme frequencies, sub-themes and the main theme for worker-identified benefits of work hours and schedules to health and well-being are summarized in Table 4. Each theme and sub-theme with quotation examples are detailed below:

Theme 1: Well-being behavior impacts
Workers identified some ways in which their long and irregular schedules benefited their ability to maintain well-being behaviors including financial benefits, time for themselves, getting more sleep, work social connections, time for family connections and reducing stress levels.

Sub-theme 1.1 Financial benefits (n= 31)
Workers reported earning more money as a result of longer hours spent at work due to overtime and differentials. They spent the extra money earned on behaviors which helped to maintain their health and well-being such as taking vacation, paying bills, paying for children's education and buying things.

Sub-theme 1.4 Social connections at work (n=7)
Workers reported building social connections with coworkers due to the long hours they spent together at work. "… you kinda build a family with the people that you work with because sometimes you're at work when you're at home. " (Male correctional supervisor)

Sub-theme 1.6 Reduced stress (n=4)
Workers recounted some ways that aspects of their long work hours and schedules reduce their stress levels, due to reduced exposure from work, or the benefits they get from working long hours such as the extra money which reduces stress.

Discussion
Full-time workers with NSWSs reported numerous ways in which their work schedules impacted personal and family well-being. Consistent with the literature, workers reported NSWS affects across health-related outcomes in the domains of physiological, psychological and health behaviors, personal/family-related outcomes as well as work-related outcomes [5]. The work schedule impacts reported by workers were supported across three themes -well-being behaviors, physical health, and extended exposures at work. Impaired social connections through strained family connections and poor social and community connections were most frequently noted as being impacted by work schedules. Along with increased hypervigilance, stress, and/or anxiety, these factors have the potential to precipitate mental health effects. Direct impacts on physical health were noted through exhaustion and weight gain along with indirect physical health impacts through health behaviors including poor eating, poor sleep, and lack of exercise. To a small extent, workers reported work outcomes including increased accidents at work. Despite different industry sectors and job titles, the workers in this study were similar in that all were fulltime employees who experienced NSWSs. Extended work hours through overtime was characteristic for workers in all three sectors, as was irregularity and little notice of extended work. However, workers reported variations in other characteristics and patterns of the work. The transportation maintainers consistently worked first shift and experienced seasonal variation in work shifts due to storm work. While the correctional officers and correctional supervisors worked rotating shifts with mandatory overtime consistent throughout the year. In addition to mandatory overtime in the form of double shifts, correctional officers also reported swapping shifts with colleagues in order to get some time off of work which contributes to increased schedule length and irregularity. The manufacturing employees worked varied shift configurations, based on the production line and machinery that they were assigned with overtime being driven by production schedules.

Social connections
Consistent with the proposed mechanisms by which shift work impacts health [6], we observed social disruption as a major threat to worker and family well-being. Social disruption was expressed by workers in all industries. Strained family connections was the most frequent well-being impact cited by workers. Related, poor social and community connections were also cited as a barrier to well-being. Research supports how NSWSs affect the balance between work and non-work domains including social participation [8]. Working and living patterns that are asynchronous with the community rhythms of family, community and recreational activity can precipitate work-life conflict, especially in women where work stress in combination with high family responsibilities leads to increase in psychological distress [18]. While the majority of the current population was male, the majority (81%) also had child and/or adult dependents. Yet, within the current population, the effects of work schedule on social consequences were also reported by single workers who reported missing engagement with friends. In fact, workers noted the difficulty of missing out on important as well as routine family and social events ranging from weddings to children's sports events, due to work schedule challenges.

Healthy eating, exercise and weight
The next most frequently mentioned barrier of schedules to well-being was in the category of physical health and health behaviors including healthy eating and exercise. This qualitative finding was in line with previous quantitative research among corrections officers. In a cross-sectional survey of 157 correctional supervisors, we found a high prevalence of obesity with 38% categorized as overweight and 51% obese [19]. Furthermore, health supporting behaviors in the population were likewise low with 27% reporting often or always meeting recommended fruit intake and 42% often or always meeting physical activity guidelines [19]. Worker perspectives confirmed the role of work schedules in influencing poor health and health behaviors among correctional workers. Similar perspectives were echoed among transportation maintainers where weight gain increased over the winter months due to long hours of sitting (driving), lack of physical activity and poor eating choices and patterns. The effect of NSWSs on poor eating behaviors includes irregular eating behaviors, heightened food cravings, and increased food and fat intake [5,20]. Poor eating habits in combination with circadian disruption [21] and sleep debt [22] may contribute to the increased obesity associated with shift work [23,24]. The lack of exercise among workers with NSWSs may also contribute to obesity risk. Night work has been shown to be associated with less exercise in assisted living caregivers [25], although not in nurses [26]. The link between NSWSs and exercise is not fully explored.

Sleep and fatigue
Poor sleep and exhaustion were noted by workers. The role of sleep and exhaustion resulting from lack of recovery is well explored in our understanding of work schedules and health [5]. While recognized as being impacted by work schedules, sleep and fatigue were not as frequently mentioned as other factors. In a qualitative study of transit worker stress, workers reported putting family before sleep [12]. In fact, night shift workers often choose the shift to better balance family responsibilities, despite the trade-off in terms of sleep [27].

Increased exposures at work
Workers, especially those in corrections, reported increased exposures at work. Importantly, the workplace exposures vary by sector. Transportation workers have physically demanding jobs with numerous physical and over-exertion hazards. Whereas corrections workers may have increased exposure to psychosocial hazards from extended exposures to dangers and stressors at work and may be at increased risk for hypervigilance, stress and anxiety. While fatigue and its related consequences such as increased risk for accidents is a wellknown consequence of extended exposures at work [28], it is important to recognize that additional risks may be relevant based on job-hazards as well as worker characteristics [29].

Financial benefits
Across all work groups, financial rewards were cited as the most important benefits of their work schedules. Workers reported a wide range of financial expenditures ranging from household items, to children's college costs, to family vacations, to luxury items such as cars. From a worker's perspective, incentives of US workers for long work hours, and more broadly NSWSs, are largely financial with increased pay and often times advancement by accepting the employers' overtime or work shift requests. Corrections workers in the state where the data was collected report a common belief within the organization that health must be sacrificed to maximize present and future income [30]. Overtime pay provides a substantial boost to current income and enables workers and their families to attain a very high standard of living, which they become accustomed to. Moreover, the retirement policy enables workers to retire after 20 years of service, with their payout being based on the highest 3 years of earnings. Thus there is a great deal of pressure to maximize earnings through overtime work, especially late in one's career. However, it is important to remember that NSWSs are a benefit to the employer as well. In fact, long work hours, can be a result of increased production demands where employers seek to minimize costs through overtime, rather than paying employee benefit costs that are incurred with hiring additional employees [29].

Strengths and limitations of qualitative study design
Through qualitative research methods, we identified a breadth of well-being impacts due to work hours and schedules. From a worker perspective, social connections were deeply affected by NSWS. While prior work suggests that working on weekends impacts worker wellbeing [8], based on worker perspectives indicate that missing important events, which may or may not be on weekends, has impacts on worker and family well-being.
As with many qualitative research studies, there are limitations to the generalizability of our results to other populations. Importantly, we engaged full-time workers with long and irregular work hours. Their experiences are likely different from workers with precarious schedules who may also experience irregular and extended hours without the benefit of stable full-time work or benefits. The majority of focus group participants were men, which is a reflection of the male-dominated transportation, corrections and manufacturing industries. The threats of work schedules to the well-being of women are likely different as women face additional responsibilities inside the home. Likewise while workers were recruited based on their self-reported experience of NSWS, the majority of workers who were interviewed worked first shift and more detailed information about NSWS shift characteristics were not collected. Workers who experienced the most deleterious effects of work schedules may leave the workforce and their perspective is not likely captured in this cross-sectional study.

Future research directions
The worker perspectives from these focus groups informed the development of survey items that captured the full breadth of worker impacts as well as schedule characteristics. The worker perspectives made evident that a broader definition of well-being, which, in addition to encompassing physical and mental health, should also include social connections and financial security, is needed when assessing the impacts and benefits of NSWSs. This is consistent with the Total Worker Health approach that recognizes worker well-being is influenced by a set of expanded domains which, in addition to considering the workplace physical environment and culture, also considers workers health status, evaluation of work and home experience, community and societal engagement, and satisfaction [2]. Consistent with the NIOSH Total Worker Health framework, work schedules had impacts across health status, social relationships, and within the workplace itself [2]. In fact, recognizing and addressing work organization impacts, which includes work schedule characteristics, has been suggested as a defining element of Total Worker Health approaches [31].
With respect to work organization, future interventions (including work schedule changes), should address prevention across the spectrum from primary to tertiary prevention. For example, in a multi-level approach for managing workers' sleep-related fatigue, primary prevention may include providing sleep opportunity through limiting hours of service and adding rest breaks. While tertiary prevention may include reducing fatigue-related incidents [32]. Primary through tertiary prevention approaches may also be relevant for mental and physical health and health behavior consequences. A multi-level perspective should also be considered with respect to the target of interventions; in addition to interventions on the individual level, it is also imperative to intervene at the job/task level, the employer/organization level and the legislative/policy level [33]. For example, interventions to address the increased hypervigilance and stress reported by workers with NSWS may include primary prevention at the organizational level that adds more schedule control and increased staffing to reduce long work hours while also providing tertiary prevention at the individual level by educating workers about stress and hypervigilance and providing best practices for stress reduction.

Conclusion
This qualitative study was part of the larger Work-Time project focused on understanding the effects of nonstandard work schedules on worker and family well-being. Worker perspectives highlighted social disruptions as a salient hardship of NSWSs in this full-time, blue-collar work force.