Shiftwork is common in industries which require the availability or continuity of various services in 24 hours [1]. Conventionally, shift work involves working outside daytime working hours or on a schedule other than the standard working week and may involve changes in working time arrangements. In most cases, shiftwork in the workplace involves changes in areas of deployment, rotation patterns and schedule [2] [3] [4] [5]. Due to an increasing demand for healthcare services, healthcare systems have required doctors, nurses and other health care professionals to engage in shiftwork to ensure continuity of medical services in clinical settings, emergency cases and rescue operations [2] [4] [6] [7].

Shiftwork is perceived to be indispensable due to globalization as it ensures continuity of essential services. The implementation of shiftwork has been common predominantly in Western countries [8]. Currently, studies which describe the effects of shiftwork to health professionals have been explored, revealing a negative effect on their over-all well-being [3] [5] [9]. During night shifts, in particular, health care workers need to be awake during a time when behavioral inactivity is expected [10]. Most studies dealt with the effects of night shift on the short-term physical and mental well-being of health care professionals and effects on social relationships. Other studies have reported an increased propensity of individuals to develop chronic conditions such as cancer, cardiovascular diseases and diabetes [2] [4] [10] - [15].

Members of ambulance services experience a unique working environment compared to other healthcare professionals in the clinical setting. Aside from dealing with unpredictable cases which require a diverse skill set to provide prehospital interventions, the cases are usually highly stressful especially during night shift, since precise management of pharmacological interventions and clinical skills need to be ensured [16]. When individuals work at night, exposure to light and physical activity causes a disturbance of circadian rhythms, leading to decreased cognitive functions, stress and anxiety [4] [6] [9] [14] [17]. In addition to shift work, ambulance service staff have to cope with other issues such as trauma, accidents, and death, which makes them susceptible to mental health problems [16].

There have been few efforts to investigate the effects of shiftwork on ambulance service staff and personnel using physiologic parameters in other countries, but the social and psychological components remain unexplored [7] [16]. Previous studies have used single-construct questionnaires to evaluate the psychological effects of shiftwork such as the Standard Shift Work Index which measures self-report impact of work on the health and well-being of individuals and General Health Questionnaire (GHQ-28) which measures general well-being [4]. [18] However, there has been no effort to capture the perceived total effects of shiftwork on the over-all wellbeing of ambulance service staff and personnel in Saudi Arabia or other Middle Eastern countries, which has robust psychometric properties. While other countries present rich information on the various effects of shift work in Western ambulance service staff, the effects of shiftwork to ambulance staff in Saudi Arabia remains unexplored, although efforts have been done to determine the effects shiftwork on nurses in Saudi Arabian clinical settings [19].

The rules and regulations of occupational health and safety in Saudi Arabia are emerging, and the need for globalization and standardization of policies need to be addressed since there are limited literature which can support the similarities of ambulance services in Western and Middle Eastern contexts [16]. In order to capture the over-all effects of shiftwork to the ambulance service staff in Saudi Arabia, there is a need to construct a research instrument which integrates various aspects which were reported to be affected by shiftwork based on the currently available literature. Hence, this study aimed to develop a research instrument which can measure the effects of shiftwork to various dimensions of well-being among ambulance service staff in Saudi Arabia.

The primary objective of this study is to determine the factor structure of the PESQ in light of the perceived effects of a night shift to the ambulance services staff in Saudi Arabia. The present results reveal a three-factor solution for the research instrument, which generally presented a good fit to the data. The three-factor structure of the research instrument included the perceived effects on health, social relationship and career quality. With regards to the over-all internal consistency, PESQ has a satisfactory Cronbach alpha, but the dimension pertaining to “perceived effects on career quality” needs to be re-evaluated. To the author’s knowledge, this is the first attempt to develop a questionnaire which addresses the perceived effects of night shift to the over-all health, social relationship and career quality among emergency medical service staff in Saudi Arabia.

An extensive body of literature has explored the effects of a night shift to sleep quality (Farias et al.; Khan et al.; Vetter et al.), physical health (Ferri et al.; Nea et al.), mental health and psychological well-being (Ferri et al.; Khan et al.; Suminska et al.), social relationship (Grzywacz; Iskra-Golec et al.; Tai et al.), work performance (Costa; Dehring et al.; Recio-Saucedo et al.), cognitive function (Suminska et al.), and predisposition to unhealthy lifestyle (Shan et al.), certain types of cancer (Szkiela et al.; Yuan et al.), diabetes, and cardiovascular diseases (Strohmaier et al.) [2] [4] [7] [8] [10] [12] [13] [15] [16] [17] [23] [24]. Furthermore, health professionals who worked during night shifts were reported to exhibit more mental health problems such as irritability, somatization, obsessive-compulsive disorder, interpersonal sensitivity, anxiety, altered mood, and paranoid disorders. While such issues have been assessed in clinical settings, there a dearth of literature on the assessment of the perception of ambulance medical services staff in Saudi Arabia [4].

In addition, the nature of work of ambulance service staff differs from health care professionals in clinical settings as the former deal with pre-hospital or post-hospital environments [25]. Furthermore, the cases dealt with ambulance services may be life-threatening and require an extensive use of available equipment inside the ambulance van prior to the provision of medical services in hospitals. Hence, being in a night shift providing ambulance services demand high proficiency, resourcefulness, and high cognitive function to make important decisions which ensure patient safety prior to the arrival to well-equipped hospitals.

Emergency services during night shift, however, induces high levels of physical and mental stress which may be caused by traumatic experiences or failure to address distresses during work [8]. Aside from the mental effects, shift works impairs eating patterns circadian rhythms which were often attributed as causes of work-related pathologies [9] [14] [17]. The development of a questionnaire which addresses the need for determining the perception of ambulance medical services has been fueled with this gap in literature.

The exploratory factorial validity using the factor extraction strategy used in this study, pertaining to principal axis factoring with Varimax rotation has satisfactorily identified the three dimensions which can be measured simultaneously in the Perception of Effects of Shiftwork Questionnaire (PESQ), which is contextualized to the ambulance service staff of Saudi Arabia. It has been observed that the dimension “perceived effects on social relationship” has the greatest contribution to the observed variance in the study. This implies that the effects of shiftwork to social relationship such as relationship to family members, lack of time to perform social tasks and strengthen social relationships is the greatest advocacy of PESQ. This validates other studies that social relationship is a commonly affected component of a health care worker’s well-being [10] [21].

The second greatest source of variance was contributed by the dimension “perceived effects on health”. Compared to other studies, the items in the research instrument describes generic issues related to over-all health. Apparently, issues on sleeping problems, weight gain, fatigue and feelings of tiredness belong to one factor, indicating a high correlation of the identified sub-components. This supports the effect of shiftwork to previously identified components of over-all wellbeing such as sleep quality (Farias et al.; Khan et al.; Vetter et al.) and physical health (Ferri et al.; Nea et al.) [2] [4] [8] [16] [17]. One limitation of the items in this dimension, however, is the lack of support for describing the effects to mental health and psychological well-being as reported by Ferri et al., Khan et al. and Suminska et al. [4] [7] [16].

One novel finding in this study is the inclusion of the perceived effects on quality of work (Q12) and career advancement (Q15). These two items are unique as no studies so far has explored the effects of shift work in the career trajectory of ambulance service staff. However, the third dimension (perceived effects on career quality) needs to be improved due to its low internal consistency. Nevertheless, this dimension contributes to the over-all internal consistency of the PESQ, which might further necessitate future investigation.

This study has several implications to the development of policies which will protect the over-all wellbeing of ambulance service staff and address the perceived effects to over-all health, social relationship and career quality among emergency medical service staff in Saudi Arabia. Other countries can also adapt the questionnaire for cross-cultural comparisons among Middle Eastern contexts.

This study contributes to the present work related to the exploration of the effects of shiftwork on the over-all wellbeing of ambulance service staff in Saudi Arabia. The research instrument developed in this study, Perception of Effects of Shiftwork Questionnaire (PESQ), has adequate reliability to measure the perception of effects of shiftwork on over-all health, social relationship, and career trajectory. Hence, the research instrument has the potential to be used to generate policies in improving the work schedule and improve the coping mechanisms of ambulance service staff in Saudi Arabia and in other Middle Eastern countries.

The research protocol was approved by the Institutional Review Board at King Abdullah Medical City, Saudi Arabia, (ethics certificate number IRB Number 21-778). Informed consent was obtained from all participants and anonymity was ensured by assigning a code for each respondent.

The data used in this study are available and can be provided on a reasonable request by the corresponding author.

All authors involved in data collection, data interpretation, and manuscript drafting and approval.

The authors declare no conflicts of interest regarding the publication of this paper.

Albishri, F. and Zamzami, L. (2021) Perception of Effects of Shiftwork Questionnaire (PESQ) among Ambulance Service Staff in Saudi Arabia: An Exploratory Factor Analysis. Open Journal of Emergency Medicine, 9, 123-134. https://doi.org/10.4236/ojem.2021.93012