Silva AA, Marqueze EC, Rotenberg L, Fischer FM, Moreno CRC
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ORIGINAL ARTICLE
Shift workers in electrical systems control rooms:
job satisfaction and work ability
Trabalhadores em turnos de salas de controle de sistema elétrico: satisfação e
capacidade para o trabalho
Amanda Aparecida Silva1, Elaine Cristina Marqueze1, Lúcia Rotenberg2, Frida Marina Fischer1, Claudia
Roberta de Castro Moreno1
ABSTRACT
Objectives: The objectives of this study were to analyze the relationship between job satisfaction and work ability and to identify
factors associated with job dissatisfaction. Methods: This is a cross-sectional study of 101 shift workers from electrical systems control
centers conducted in 2009. Two procedures were performed for
data collection: 1) distribution of a questionnaire that included the
Work Ability Index (WAI) and the Occupational Stress Indicator
(OSI) to assess job satisfaction, a General Health Questionnaire
(GHQ-12) to identify psychological disorders, and an International
Physical Activity Questionnaire (IPAQ-8); and 2) group interviews.
Tests of association, correlation, and logistic and multiple linear
regression models were used to analyze the data. Results: The population (97% males) had an average age of 38.5 years (SD= 11.8).
The average OSI score was 90.8 (SD= 17.4), and the average WAI
score was 42.5 (SD= 3.9). Although most workers indicated satisfaction with the items assessed, the likelihood of being dissatisfied
at work increased almost three-fold among those who had worked
for more than eight years at the company and more than eight-fold
for those who were not satisfied with the time devoted to family.
For each point increase in the WAI score, there was an average
increase of one point in the work satisfaction score. Conclusions:
The results reveal a clear association between job satisfaction and
work ability. The high demand placed on mental resources is the
main factor causing the reduction of work ability, and it also negatively affects job satisfaction.
Keywords: job satisfaction, occupational health, shift work, work
capacity evaluation, work/psychology.
RESUMO
Objetivos: Analisar a associação entre satisfação no trabalho e
capacidade para o trabalho, e verificar fatores associados à insatisfação no trabalho. Métodos: Estudo transversal realizado em
2009 com 101 trabalhadores em turnos dos centros de operações
de sistema elétrico. Foram realizados dois procedimentos para a
coleta de dados: 1) aplicação de questionário, incluindo escalas de
índice de capacidade para o trabalho (WAI), satisfação no trabalho
(OSI), presença de distúrbios psicológicos (GHQ-12), atividade física (IPAQ-8) e 2) realização de entrevistas coletivas. Para a análise
dos dados, utilizaram-se testes de associação, correlação, modelos
de regressão logística e linear múltipla. Resultados: A população,
majoritariamente do sexo masculino (97%), tinha idade média de
38,5 anos (DP= 11,8). O escore médio do OSI foi 90,8 (DP= 17,4)
e do WAI foi 42,5 (DP=3,9). Embora a maioria tenha referido satisfação nos itens avaliados, a chance de estar insatisfeito no trabalho
aumenta em quase três vezes entre aqueles que trabalhavam há mais
de oito anos na empresa e mais de oito vezes quando o trabalhador não estava satisfeito com o tempo dedicado para a família. A
cada ponto acrescido no escore do WAI, aumenta-se em média um
ponto no escore da satisfação no trabalho. Conclusões: Os resultados revelaram de forma inequívoca a associação entre satisfação
no trabalho e capacidade para o trabalho. A elevada exigência do
uso de recursos mentais, além de ser o principal fator de redução
da capacidade para o trabalho, impacta negativamente na satisfação
no trabalho.
Descritores: avaliação da capacidade de trabalho, satisfação
no emprego, saúde ocupacional, trabalho em turnos, trabalho/
psicologia.
INTRODUCTION
Continuous shift work is in itself an important organizational stressor. Because it counters biological and social
interaction principles, it is associated with increased cardiovascular, gastrointestinal and psychological morbidity(1). In addition to affecting the physical, mental and social well-being of workers, it may also increase the risk of
workplace accidents, particularly when long working days
or work during irregular hours are combined with other
unfavorable environmental and/or psychosocial work
stressors(2). Unfavorable factors linked to working and living conditions can lead to early onset of functional disability(1,3).
Preventing functional disability has become a
prominent concern because of demographic transitions
and changes in the workplace, such as technological advances and the organizational changes that follow them.
Regarding occupational health and safety, concerns about
functional aging have become increasingly more relevant.
Work ability has become an important indicator of early
functional aging(4). Work ability is influenced by numerous
variables, including physical, mental, and social demands
of work, the organizational culture, and the work environment. Among the organizational and psychosocial aspects
of labor associated with work ability we can mention job
satisfaction, years of service, job title, work shift, autonomy, and work control(5-9).
Departamento de Saúde Ambiental, Faculdade de Saúde Pública da Universidade de São Paulo – USP – São Paulo (SP), Brasil.
Laboratório de Educação em Ambiente e Saúde, Instituto Oswaldo Cruz, Fiocruz – Rio de Janeiro (RJ), Brasil.
Corresponding author: Amanda Aparecida Silva - Avenida Dr. Arnaldo, 715 - São Paulo (SP), Brasil - CEP 01246-904 - Tel.: 3061-7115 - Fax: 3061-7755 E-mail: [email protected]
Recceived: January 10, 2011; Accepted: August 30, 2011.
1
2
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Shift workers in electrical systems control rooms: job satisfaction and work ability
The concept of job satisfaction is also complex and
can affect both the social behavior of workers and their
physical and mental health. The relationships between job
satisfaction and these variables are not sufficiently clear(10,11).
In this study, we focused on shift workers in electrical systems control centers, a group that has received
little attention in Brazil. In electrical plants, there are sets
of processes, instruments and equipment designed for the
transmission, generation, distribution, and commercialization of electric power. The job demands are related to the
extensive range of activities that can be conducted in this
sector(12-14). The activities performed in a control room are
characterized by significant mental and psychosocial demands, such as the time pressure, responsibility, amount
of work, problem solving, decision-making, the high level
of concentration required and adjustment to new technologies. The purpose of this study was to analyze the
relationship between job satisfaction and work ability and
to identify whether there is an association between job
dissatisfaction and sociodemographic, work, health, and
lifestyle variables.
METHODS
Population
All shift workers from the control rooms of five control
centers in a Brazilian electric company were invited to participate in this cross-sectional study, which was conducted
at the request of the company in 2009. In total, 101 workers (93.5%) voluntarily agreed to participate and signed an
Informed Consent document, according to the precepts
of the ethics in research with human beings(15). There
were only three women among the participants; they were
excluded from the inferential analyses so that the results
would reflect the conditions of the majority.
Data collection
The researchers were introduced to the workers by the
shift supervisor, both at the time the questionnaire was administered and when the interviews were conducted. After
the introductions, the supervisor left the room, and only
the researchers remained with the workers; at this time,
the researchers had the opportunity to explain the ethical principles that guide research with human beings, such
as anonymity and the confidentiality of individual results.
The fact that the study was conducted at the request of the
company meant that the workers had been aware of the
study since its inception.
Data collection occurred in two stages. The operators were invited to fill out a questionnaire and then to
participate in group interviews. The protocols used are
described below:
a) A self-administered questionnaire consisting of the
following components: the Work Ability Index (WAI)(16), the
General Health Questionnaire (GHQ-12) to identify nonpsychotic psychiatric disorders(17), the Occupational Stress
Indicator (OSI) to assess job satisfaction(18,19), and the International Physical Activity Questionnaire (IPAQ-8)(20,21). The
study questionnaire also requested sociodemographic data
and information on work characteristics, health, and lifestyle.
The WAI can be used to evaluate whether the
worker is fit to perform his job, both in the present and
in the near future, based on his health status and physical
and mental abilities(16). It is composed of seven domains:
current work ability compared with the worker’s lifetime
best, work ability in relation to the demands of the job,
number of current diseases diagnosed by a physician, estimated work impairment due to diseases (refers to the
need to change work methods or rhythm, or even the total impairment of job performance, due to the disease or
symptoms), sick leave during the past year, self-prognosis
of work ability two years from now, and mental resources.
The total score ranges from 7 to 49 points and may or may
not be categorized.
The OSI can be used to analyze workers’ perceptions about their own health and performance based on
the work environment and content, organizational conditions, and the skills and needs of the workers. The scale
is comprised of 22 Likert-type questions that vary from
(1) great dissatisfaction to (6) great satisfaction(18,19). This
scale has a total score that varies from 22 to 132 points,
and there is no cutoff point. The 22 questions can also be
evaluated separately(18).
The GHQ-12 can be used to estimate the degree of
psychological dysfunction (without, however, characterizing the nature of this dysfunction) from the reporting of a
specific symptom or behavior. It is based on 12 questions
for which the answer is rated on a four-point scale indicating “no more than usual”, “same as usual”, “more than
usual” and “much more than usual”. The two last answers
were scored as “yes” whereas the first ones were score as
“no”. The total score was based on the number of “yes”,
which varies from 0 to 12. Five or more affirmative responses indicate an increased likelihood of exhibiting a
non-psychotic psychiatric disorder(22).
The IPAQ can be used to estimate the level of
physical activity of individuals and populations. In this
study, the short version of the IPAQ, which consists of
eight questions that encompass the frequency (days/
week), duration (minutes/day), and intensity of physical
activity (vigorous and moderate activities, and walking)
performed by the individual during a typical week, was
used. Only physical activities performed continuously for
at least 10 minutes were taken into account. As additional
information, the time spent seated (minutes/day), on both
weekdays and weekends, was considered (20,21). The level of
physical activity was classified as very active, active, insufficiently active and inactive according to the frequency and
time spent in each activity(23,24).
b) Collective analysis of work: This technique solicits a description of the activity performed by the workers
by asking: “What do you do in your job?” The question
is asked after explaining to the participants the objectives
and methods used for group analysis, the role of the researchers, and the guarantee of the workers’ anonymity(25).
In this study, six group interviews were conducted with
groups of operators from five centers; in one center, two
interviews were conducted at the request of the local senior management. In all of the interviews, there were two
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researchers and, on average, ten operators. The interviews
were recorded and transcribed to analyze the discourses
of these workers.
Data analysis
Relationships between the job satisfaction score and the
work ability score were analyzed.
In the first analysis, the mean of the WAI score was
determined to be 42.5. Considering this value, an association between the WAI score and the 22 psychosocial
factors on the job satisfaction scale was confirmed; each
one was classified as either “satisfaction” (ranging from
some satisfaction to great satisfaction on the Likert scale)
or “dissatisfaction” (from great dissatisfaction to some
dissatisfaction).
In a second analysis, the seven factors of the WAI
scale were considered separately. In this case, the seven
variables were also categorized in a dichotomous manner
according to the assumptions of the authors of the questionnaire (16). In this analysis, the median point of the
job satisfaction score was determined to be 92.5 for the
categories “satisfaction” and “dissatisfaction”.
Tests of association (Pearson χ2 or Fisher’s Exact
according to the proportions) and of correlation (Pearson
or Spearman according to distribution) were conducted
to examine the statistical significance of the relationships
between the variables studied.
To test other variables as predictors of job satisfaction, the association between job dissatisfaction (that is,
the negative variable) and several factors, such as sociodemographic data, work characteristics and conditions, and
health and lifestyle, were examined.
The variables showing p<0.20 in the tests of association were tested in a multiple logistic regression model. Furthermore, a multiple linear regression model was developed
in which the variables were tested according to the values of
R-Squared in the correlation matrix; only the variables for
which p<0.20 were selected. The values were considered to
be significant in the final analyses when p<0.05.
RESULTS
The study population was comprised mostly of males
(97%) and had an average age of 38.5 years (SD= 11.8
years; range= 20-61 years). The average seniority at work
was 12.6 years (SD= 10.5 years; range= 1-40 years), and
the average seniority at this company was 6.9 years (SD=
3.4 years; range= 1.1-19.9 years); 42.5% of operators reported that their regular work schedules allowed them the
highest number of consecutive days off. In the group interviews, this schedule was identified as being the best for
the recuperation of the worker.
The environmental work conditions with the highest percentage of responses to the alternatives “normal”
and “bad” were ventilation (57%), thermal comfort during
cold months (44%), lighting (42.5%), furnishing (37%),
thermal comfort during warm months (35.4%), and noise
(35%).
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Table 1 shows the main sociodemographic,
work, health and lifestyle variables that characterize the
population.
Sixty-two percent of operators characterized the
availability of mental resources to perform their particular
jobs as “high”.
Overall, the population was rated well based on the
seven WAI factors. The current work ability compared
with the lifetime best was concentrated around values 8
and 9 on a scale that had a maximum of 10; approximately
42% of the population reported a score of 10 for work
ability in relation to the job demands. The average OSI
score for the population was 90.8 (SD= 17.4), and the majority reported satisfaction in the 22 items studied. The
three items that received the most responses indicating job
dissatisfaction were the way in which changes and innovations are implemented (52.5%), the degree to which the
company takes into account the potential that the worker
deems himself to have (46.5%), and the manner in which
conflicts are solved (44.6%).
The majority of workers reported never having
smoked (80%), only consuming alcoholic beverages on
special occasions (65%), and drinking coffee daily (72%).
A total of 62% reported a weight increase after starting
shift work at the company (average of 5.5 kg, SD= 5.9).
The top diseases/symptoms reported, according to
medical diagnosis, were high cholesterol (17.8%), back injury
(13.9%), and hypertension (12.9%). Mild emotional disorders
(mild depression, stress, anxiety, insomnia) were prominent
among the symptoms/diseases reported (23.7%), but these
were unsubstantiated by medical diagnosis.
The items on the GHQ-12 that were most unfavorable were difficulty maintaining focus on the job at hand
(66%), dissatisfaction with day-to-day activities (61.4%),
and not feeling useful in most day-to-day activities (57.5%).
Analyses of the association between job satisfaction and work ability are shown in Figures 1 and 2; the first
shows the association between the 22 items from the OSI
and the categorized WAI, and the second shows the association between the seven WAI factors and the categorized OSI. In Figure 1, being satisfied with these factors
(p<0.05) was associated with optimum work ability, and in
Figure 2, a high ability to develop the activities with regard
to mental resources was associated with job satisfaction.
The following responses exemplify the result
shown in Figure 1. The associated factors refer to management issues pertaining to work, which the workers may
have considered to be problems.
(...) the work quality here is terrible, and it is not only
the shift work schedule that is a problem; it is also the quality
of work. We always feel tense while working, nervous. (...)
(...) what the company wants is for you to remain
there (…). So, you either leave the company to pursue goals,
or you stay there because there is always one mechanism or
another that does not allow you to progress.
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Shift workers in electrical systems control rooms: job satisfaction and work ability
Table 1. Descriptive analysis of sociodemographic, work, health, and lifestyle variables (n=101)
Variables
Categories
n
%
Single
25
24.8
Sociodemographic
Marital status
Married /domestic partnership
70
69.3
Separated /divorced / widowed
6
5.9
Work
Job title
Normal work schedule
Supervisor / Senior
45
44.6
Full-time / Operator
36
35.6
Junior / Trainee
20
19.8
2 mornings / 2 afternoons / 2 nights / 4 days off
43
42.6
2 afternoons / 2 nights / 1 day off / 2 mornings / 3 days off
35
34.6
3 afternoons / 2 days off / 3 mornings / 2 days off / 3 nights / 2 days off
21
20.8
Other schedules
2
2.0
Up to 8.0 years
48
49.5
Years working at the company *
Frequency of change in work schedule
Work Ability Index (WAI)
OSI job satisfaction Scale**
Satisfaction with the time devoted to family life #
Level of noise at work##
8.1 years or more
49
50.5
Less than once a month
47
46.5
Once a month
24
23.8
Every 15 days
17
16.8
Once or twice per week
10
9.9
Others
3
3.0
Low ability
0
0
Moderate ability
7
6.9
Good ability
52
51.5
High ability
42
41.6
Dissatisfied with work
49
50.0
Satisfied with work
49
50.0
Not at all satisfied
19
19.0
Satisfied to some extent
65
65.0
Very satisfied
16
16.0
Excellent
15
15.0
Good
50
50.0
Average
29
29.0
Bad
6
6.0
Inactive
5
5.3
Insufficiently active
34
36.2
Active
41
43.6
Very active
14
14.9
Underweight (<18.5 kg/m2)
3
3.0
36.6
Lifestyle, health, sleep
Level of physical activity##; §
Normal (18.5-24.9 kg/m )
37
Overweight (25-29.9 kg/m2)
45
44.5
Grade I Obesity (30-34.9 kg/m2)
14
13.9
Grade II Obesity (35-39.9 kg/m2)
2
2.0
Yes
18
17.8
No
83
82.2
Yes
13
12.9
No
88
87.1
No
68
67.3
Yes
33
32.7
Good
28
27.7
Average
54
53.5
Bad
19
18.8
Greater chances of having psychological disorders
50
51.0
Lower chances of having psychological disorders
48
49.0
2
Body Mass Index §§
Medical diagnosis for high cholesterol
Medical diagnosis for hypertension
Do you take naps regularly?
How would you describe your sleep quality?
GHQ-122
* 97 answered this question; ** 98 answered this question; # 100 answered this question; ## 94 answered this question; § Classification according to
criteria established by IPAQ - short version (20,21); §§ Classification according to criteria from the World Health Organization.
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detail, when there is trouble, there is naturally a greater increase in stress (…).
Tables 2 and 3 show the factors correlated with job
dissatisfaction.
Table 2. Factors correlated with job dissatisfaction (OSI). Multiple
linear regression model (n=93).
Variables
ß1
T
p
95% CI
Years working at the company
-1.4
-2.0
0.05
-2.8; -0.01
Work Ability Index
1.0
Adjusted by job title and married status.
2.1
0.04
0.1; 1.9
Table 3. Factors associated with job dissatisfaction (OSI). Multiple
logistic regression model (n=93).
Variables
Years working at the company
Satisfaction with the time
devoted to family life
Categories
OR
Up to 8.0 years
1
8.1 years or more
2.8
Satisfied
1
Not at all satisfied
8.7
Level of noise
Great / Good
1
Average / Bad
3.2
95% CI
1.1; 7.2
2.2; 34.8
1.2; 8.8
Adjusted by GHQ12.
Hosmer-Lemeshow= 6.0 / p=0.54.
Figure 1. Association (χ2 or Fisher’s Exact Test) between the work
ability index and the psychosocial factors of the job satisfaction scale.
According to the linear regression analysis, for each
year of work at the company, there was, on average, a
1.4-point decrease in the work satisfaction scale score, and
for each point increase in the work ability score, there was
an average increase of one point in the job satisfaction
score, regardless of job title or marital status.
The likelihood of being dissatisfied with work increased almost three-fold for those who have worked for
more than eight years at the company and increased more
than eight-fold when the worker was not satisfied with the
amount of time devoted to family. When noise was rated
as “terrible” by the participants, it was associated with approximately a three-fold increase in job dissatisfaction.
Below are some of the responses exemplifying the
results of the regression model:
I intend to work there another five or six years, of
course, and I would like for the work environment to improve, and the quality of life of shift work to improve so
that I can bear it.
(...) Give me back my time off so that I can enjoy
my quality of life with my family. Why take me away from
my family?
Too many people, too much noise. The noise is terrible.
Figure 2. Association (χ2 or Fisher’s Exact Test) between job satisfaction and the Work Ability Index.
The response below exemplifies the role of mental
resources:
(…). So, there are two different moments (…) we
have to be highly focused, and when there is trouble, we have
to be even more focused and highly concentrated. And one
DISCUSSION
Through the combined use of questionnaires and group
interviews, the analyses undertaken enabled understanding
of the work performed by this population. This revealed
their insights about what it means to work in shifts at the
company studied, particularly in terms of the benefits, difficulties, and strategies for addressing both the demands
and the hardships of this work.
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Shift workers in electrical systems control rooms: job satisfaction and work ability
Similar studies have been conducted on other populations(6), including electric power plant workers(7,14). Although work ability and the level of satisfaction at work
were high, statistical analyses and the responses of the
workers identified problems with psychosocial work factors and the organization of shift work. Some authors
argue that only a minority of workers expresses job dissatisfaction, which may lead to underestimation of the
prevalence of dissatisfaction(7,26). The profile of work ability observed in this population could be dependent on the
work content, which is predominantly mental. Work ability seems to be better preserved in this type of activity
compared to work that is predominantly physical(27,28).
The relationship between work satisfaction and
work ability showed unequivocally that work ability was
strongly associated with the perception of workers regarding the management of work, especially the style of
supervision, the way that changes are implemented, the
psychological climate that prevails in the company, and
the degree to which the company takes into account the
potential of the workers. Other studies also showed an association between job satisfaction and work ability(6-8). The
way that work is organized can affect the level of work satisfaction, which in turn has been identified as an indicator
of stress associated with ill health(29,30). Thus, job satisfaction must have indirect repercussions on work ability(6,7).
Analysis of the workers’ responses suggests that
one of the problems related to supervision style was the
inability of managers to consider the viewpoint of workers in situations where group decisions would be desirable.
This negative aspect of supervision was articulated in the
results of the job satisfaction scale, according to which the
way that conflicts were resolved constituted a significant
complaint. For a group of workers whose work schedules
impose ‘challenges’ for the body and personal life(2,31), the
ability to share decisions with those who occupy different
positions within the hierarchy of the company becomes
essential.
Supervision style also aligned with the psychological climate experienced by the studied group. For example, knowledge of and respect for the shift work schedules
(and the days off) seems to be essential to ensuring a constructive environment and dialogue between workers and
their superiors.
The recognition of potential was another factor
that was prominent in its association with work ability.
Recognition at work has been discussed by other authors
using different approaches, and its relevance has always
been related to the development or maintenance of health,
especially mental health(32,33).
Analysis of the results, especially those from the
interviews, showed that relationships at work permeated
the various psychosocial aspects of the work organization. The relationships at work mentioned here could refer to what is identified in other studies as social support
at work. Social support at work refers to the interactions
with management and co-workers and can alter the effect
of work stress on health(34). Souza et al.(12) observed an
association between social support and common mental
disorders in electric power workers.
The cross-sectional nature of this study does not
permit causal inferences about the relationships that were
analyzed. However, the mild emotional problems that
were more frequently mentioned, according to the selfassessment of responders, may suggest mental suffering.
They could be the result of poor workplace management
coupled with the shift regimen and the strong demand for
mental resources, which is one of the major features of
the work performed.
The high demand for mental resources was the
main factor in the reduction of work ability. This may
worsen with the shift work regimen, given that there are
major cognitive demands over the work shifts, especially
during night shifts, when it is harder to maintain alertness
and make decisions(2). This can lead to the development
of higher stress levels and could result in the development
of mild emotional disorders. It is important to remember that problems related to mental health have become
increasingly relevant since the end of the 1990s in Brazil,
and they could be related to the organization of work(35,36).
The mental resources necessary to perform the
work of the operators influenced job satisfaction. This
result showed that operators with higher stress levels
may become more dissatisfied, resulting in compromised
health. In a study by Martinez & Latorre(13) conducted on
electric power workers, workplace stress was an especially
relevant factor due to its association with work ability, regardless of health and lifestyle issues.
In this study, the reports from workers showed that
in contingency situations, where there is an intensification
of work demands, activities that could be considered routine became more difficult due to shift work.
Despite the satisfactory profile of this population
in relation to work ability, the results indicate that the
workers reported health problems related to their diet and
sleep. Martinez & Latorre(14) also found similar results related to the diet in another population of electric power
workers. It is possible that the present shift schedule contributed to these outcomes(31).
Analysis of factors associated with job dissatisfaction was consistent with the responses of workers during
the interviews. It was observed that the longer seniority
at the company, the greater the job dissatisfaction, which
were associated with fatigue and strain along the years of
night work and the limitations placed on social life(37,38).
This latter aspect was highlighted in the group interviews
analysis. The use of days off for job training, with a consequent reduction of leisure-family time was a serious
concern, especially when dealing with a group for whom
family life was already compromised due to shift work(2).
One subtle aspect regarding the night shifts was
mentioned by the workers: their necessary preparation to
work during the night before the work shift. The desynchronization of the biological rhythms and the outdoor
environment result in additional difficulties to have enough
rest during the day after a night of work(39). Because the
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worker must follow a daily pattern that contradicts physiological principles, as well as principles of social familylife, the effects of shift work on health and well-being of
workers are unavoidable(2). Thus, promoting actions to improve or maintain work ability and job satisfaction in this
group means implementing actions that reduce the impact
of the work schedule from a perspective that considers
the multifaceted aspects of shift work(1,2).
To address the work ability of shift workers in this
company required consideration of the specificity of the
work: the high demand for the use of mental resources
to perform work activities, combined with a regimen of
continuous shift work, which in turn creates physiological
and social difficulties. These factors, combined with issues
related to management at/of work, should lead to actions
to improve the conditions and organization of work not
only to improve work ability but also to improve the quality of life of shift workers.
ACKNOWLEDGMENTS
The research team thanks the study participants for
their cooperation.
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