European Working Time Directive and doctors’ health: a systematic review of the available epidemiological evidence

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Abstract

Objective

To summarise the available scientific evidence on the health effects of exposure to working beyond the limit number of hours established by the European Working Time Directive (EWTD) on physicians.

Design

A systematic literature search was conducted in PubMed and EMBASE. Study selection, quality appraisal and data extraction were carried out by independent pairs of researchers using pre-established criteria.

Setting

Physicians of any medical, surgical or community specialty, working in any possible setting (hospitals, primary healthcare, etc), as well as trainees, residents, junior house officers or postgraduate interns, were included.

Participants

The total number of participants was 14 338.

Primary and secondary outcome measures

Health effects classified under the International Classification of Diseases (ICD-10).

Results

Over 3000 citations and 110 full articles were reviewed. From these, 11 studies of high or intermediate quality carried out in North America, Europe and Japan met the inclusion criteria. Six studies included medical residents, junior doctors or house officers and the five others included medical specialists or consultants, medical, dental, and general practitioners and hospital physicians. Evidence of an association was found between percutaneous injuries and road traffic accidents with extended long working hours (LWH)/days or very LWH/weeks. The evidence was insufficient for mood disorders and general health. No studies on other health outcomes were identified.

Conclusions

LWH could increase the risk of percutaneous injuries and road traffic accidents, and possibly other incidents at work through the same pathway. While associations are clear, the existing evidence does not allow for an established causal or ‘dose–response’ relationship between LWH and incidents at work, or for a threshold number of extended hours above which there is a significantly higher risk and the hours physicians could work and remain safe and healthy. Policymakers should consider safety issues when working on relaxing EWTD for doctors.

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Most cited references 42

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The impact of overtime and long work hours on occupational injuries and illnesses: new evidence from the United States.

A Dembe (2005)

To analyse the impact of overtime and extended working hours on the risk of occupational injuries and illnesses among a nationally representative sample of working adults from the United States. Responses from 10,793 Americans participating in the National Longitudinal Survey of Youth (NLSY) were used to evaluate workers' job histories, work schedules, and occurrence of occupational injury and illness between 1987 and 2000. A total of 110,236 job records were analysed, encompassing 89,729 person-years of accumulated working time. Aggregated incidence rates in each of five exposure categories were calculated for each NLSY survey period. Multivariate analytical techniques were used to estimate the relative risk of long working hours per day, extended hours per week, long commute times, and overtime schedules on reporting a work related injury or illness, after adjusting for age, gender, occupation, industry, and region. After adjusting for those factors, working in jobs with overtime schedules was associated with a 61% higher injury hazard rate compared to jobs without overtime. Working at least 12 hours per day was associated with a 37% increased hazard rate and working at least 60 hours per week was associated with a 23% increased hazard rate. A strong dose-response effect was observed, with the injury rate (per 100 accumulated worker-years in a particular schedule) increasing in correspondence to the number of hours per day (or per week) in the workers' customary schedule. Results suggest that job schedules with long working hours are not more risky merely because they are concentrated in inherently hazardous industries or occupations, or because people working long hours spend more total time "at risk" for a work injury. Strategies to prevent work injuries should consider changes in scheduling practices, job redesign, and health protection programmes for people working in jobs involving overtime and extended hours.

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Prognostic factors for duration of sick leave in patients sick listed with acute low back pain: a systematic review of the literature.

Ivan A Steenstra, P Bongers, J. Verbeek … (2005)

The percentages of patients with acute low back pain (LBP) that go on to a chronic state varies between studies from 2% to 34%. In some of these cases low back pain leads to great costs. To evaluate the evidence for prognostic factors for return to work among workers sick listed with acute LBP. Systematic literature search with a quality assessment of studies, assessment of levels of evidence for all factors, and pooling of effect sizes. Inclusion of studies in the review was restricted to inception cohort studies of workers with LBP on sick leave for less than six weeks, with the outcome measured in absolute terms, relative terms, survival curve, or duration of sick leave. Of the studies, 18 publications (14 cohorts) fulfilled all inclusion criteria. One low quality study, four moderate quality studies, and nine high quality studies were identified; 79 prognostic factors were studied and grouped in eight categories for which the evidence was assessed. Specific LBP, higher disability levels, older age, female gender, more social dysfunction and more social isolation, heavier work, and receiving higher compensation were identified as predictors for a longer duration of sick leave. A history of LBP, job satisfaction, educational level, marital status, number of dependants, smoking, working more than 8 hour shifts, occupation, and size of industry or company do not influence duration of sick leave due to LBP. Many different constructs were measured to identify psychosocial predictors of long term sick leave, which made it impossible to determine the role of these factors.

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Health and safety problems associated with long working hours: a review of the current position.

A Spurgeon, J. Harrington, C Cooper (1997)

The European Community Directive on Working Time, which should have been implemented in member states of the European Community by November 1996, contains several requirements related to working hours, including the right of employees to refuse to work more than 48 hours a week. The United Kingdom government attempted to oppose the Directive, arguing that there is no convincing evidence that hours of work should be limited on health and safety grounds. Much of the research in this area has focused on the problems of shiftworking and previous reviews have therefore tended to emphasise this aspect of working hours. However, there is much less information about the effects of overtime work, which is a central element of the terms of the Directive. This paper reviews the current evidence relating to the potential effects on health and performance of extensions to the normal working day. Several gaps in the literature are identified. Research to date has been restricted to a limited range of health outcomes--namely, mental health and cardiovascular disorders. Other potential effects which are normally associated with stress--for example, gastrointestinal disorders, musculoskeletal disorders, and problems associated with depression of the immune system, have received little attention. Also, there have been few systematic investigations of performance effects, and little consideration of the implications for occupational exposure limits of extensions to the working day. Existing data relate largely to situations where working hours exceed 50 a week and there is a lack of information on hours below this level, which is of direct relevance to the European Community proposal. Finally, it is clear from investigations relating to shiftwork that a range of modifying factors are likely to influence the level and nature of health and performance outcomes. These include the attitudes and motivation of the people concerned, the job requirements, and other aspects of the organisational and cultural climate. It is concluded that there is currently sufficient evidence to raise concerns about the risks to health and safety of long working hours. However, much more work is required to define the level and nature of those risks.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Open

Journal ID (iso-abbrev): BMJ Open

Journal ID (hwp): bmjopen

Journal ID (publisher-id): bmjopen

Title: BMJ Open

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2044-6055

Publication date Collection: 2014

Publication date (Electronic): 7 July 2014

Volume: 4

Issue: 7

Electronic Location Identifier: e004916

Affiliations

[1 ]Catalan and Spanish Societies of Occupational Medicine, Barcelona, Spain

[2 ]Department of Medical Sciences, School of Medicine, Universitat de Girona, Girona, Spain

[3 ]MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK

[4 ]Healthy Working Lives Group, Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK

[5 ]CiSAL—Centre for Research in Occupational Health, Universitat Pompeu Fabra, Barcelona, Spain

[6 ]Occupational Health Department, Epsom & St Helier University Hospitals NHS Trust, Surrey, UK

[7 ]Clinical Institute of Occupational, Traffic and Sports Medicine, University Medical Centre, Ljubljana, Slovenia

[8 ]College of Occupational Medicine, Portuguese Medical Association, Lisbon, Portugal

[9 ]Helsinki City Occupational Health Centre, Helsinki, Finland

[10 ]Occupational Health Service, Parc de Salut MAR, Barcelona, Spain

[11 ]CIBER of Epidemiology and Public Health, Spain

[12 ]UEMS Section of Occupational Medicine

Author notes

[Correspondence to ] Dr Evangelia Demou; evangelia.demou@ 123456glasgow.ac.uk

Article

Publisher ID: bmjopen-2014-004916

DOI: 10.1136/bmjopen-2014-004916

PMC ID: 4091509

PubMed ID: 25001394

SO-VID: b7ad5d11-08a7-482d-abf2-c5a584ecdb9d

License:

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 3.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/3.0/

History

Date received : 24 January 2014

Date revision received : 12 June 2014

Date accepted : 16 June 2014

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European Working Time Directive and doctors’ health: a systematic review of the available epidemiological evidence

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Abstract

Objective

Design

Setting

Participants

Primary and secondary outcome measures

Results

Conclusions

Related collections

Sex and gender-sensitive medicine

Most cited references 42

The impact of overtime and long work hours on occupational injuries and illnesses: new evidence from the United States.

Prognostic factors for duration of sick leave in patients sick listed with acute low back pain: a systematic review of the literature.

Health and safety problems associated with long working hours: a review of the current position.

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Cited by 25

Most referenced authors 589