INTRODUCTION
In contemporary healthcare systems, shift work has become an indispensable scheduling model, particularly in hospitals and long-term care settings, where continuous patient monitoring and treatment are essential [1-5]. To maintain uninterrupted care over 24 hours, a substantial portion of the nursing workforce is required to engage in shift-based schedules [6-8]. Globally, approximately 20% of the workforce—including over one-third of nurses—are involved in some form of shift work, with a significant proportion working night or rotating shifts [2,9,10]. These schedules, while operationally necessary, pose significant challenges to the physiological and psychological well-being of healthcare professionals [11,12].
Night and rotating shift work are known to disrupt circadian rhythms, the body’s intrinsic timekeeping system that governs sleep–wake cycles and hormonal regulation [9,10,13]. Circadian misalignment due to irregular work hours can lead to chronic sleep deprivation, impaired alertness, and a host of psychosomatic issues [3,14-16]. Nurses who regularly work rotating night shifts are at a heightened risk of developing symptoms associated with shift work disorder (SWD), a clinically recognized condition characterized by insomnia, excessive daytime sleepiness, fatigue, and compromised cognitive functioning [17-19].
The adverse effects of shift work extend beyond sleep disturbances. Numerous studies have reported associations between night shift work and increased incidence of gastrointestinal disorders (e.g., dyspepsia, constipation, and irritable bowel syndrome), cardiovascular abnormalities (e.g., hypertension and chest pain), and psychological strain (e.g., anxiety, irritability, and depressive symptoms) [19-23]. These health issues often lead to reduced job satisfaction, higher absenteeism, and compromised patient care quality [6,24,25]. In addition, studies have shown that the risk of medication errors, workplace injuries, and burnout increases substantially among nurses working extended or poorly scheduled shifts [17,26-29].
Furthermore, the psychosocial impact of shift work cannot be overlooked. Reduced social interactions, strained family relationships, and diminished personal time are common among shift-working nurses, leading to lower morale and professional dissatisfaction [3,27,30,31]. The quick return between consecutive shifts (<11 hours), common in rotating schedules, exacerbates these effects by impairing rest and recovery time [32].
Given the mounting evidence on the health implications of shift work, there is a growing need to understand these effects in diverse clinical contexts and populations. Despite widespread concern, research exploring the direct impact of shift types—especially rotating night shifts—on psychosomatic symptoms and job satisfaction among nurses in the Indian healthcare context remains limited.
Psychosomatic symptoms—ranging from fatigue, gastrointestinal discomfort, and sleep disturbances to cardiovascular irregularities and anxiety—are often underrecognized in occupational health surveillance but may be exacerbated by irregular and night-based work schedules [33-35]. The present study aims to bridge this gap by comparing rotating shift and fixed day shift nurses in terms of both the overall prevalence of psychosomatic symptoms and the distribution of 15 specific symptoms, as identified by the Patient Health Questionnaire-15 (PHQ-15).
It is noteworthy that in India, many hospitals still operate with staffing norms well below those recommended for safe and sustainable care. Nurse staffing norms remain outdated and considerably below international standards. For example, recommended ratios suggest one nurse for six patients in general wards and stricter allocations such as 1:2 in intensive care units or 1:1 for ventilated beds, yet many facilities operate with lower coverage [36,37]. In addition, time-and-motion analyses highlight that patient dependency levels justify closer to a 1:1.2 ratio in critical care [38]. These persistent shortages, coupled with high workload and shift duties, have been linked to stress, gastrointestinal problems, musculoskeletal pain, and sleep disturbances among Indian nurses [39,40]. These contextual realities likely compound the psychosomatic symptom burden we observed, particularly among government hospital nurses, reinforcing the need for policy-level interventions.
Through this comparative and associative analysis, the study seeks to assess whether shift work is significantly related to higher psychosomatic symptom burden and which specific symptoms are most influenced by shift type. By focusing on both aggregate and symptom-level outcomes, this research contributes a nuanced understanding of how work schedules affect the multidimensional health of nurses, informing strategies for organizational planning and occupational health interventions in Indian healthcare settings.
Figure 1 provides a conceptual overview of the proposed relationship between shift work characteristics, circadian disruption, and psychosomatic symptom burden among nursing professionals, forming the theoretical framework for the present study.
METHODS
Study design and setting
This study employed a cross-sectional, comparative research design to examine the impact of shift work on psychosomatic health among nurses. The study specifically compared psychosomatic symptoms between nurses engaged in rotating shifts and those working regular day shifts.
The research was conducted across both government and private hospitals located in northern India, providing a heterogeneous sample that reflects diverse institutional work environments and scheduling practices.
Sample and sampling technique
A total of 384 registered nurses were recruited using convenience sampling. The required sample size was calculated using Cochran’s formula [41] for an unknown population proportion, assuming a 95% confidence level and 5% margin of error. Nurses included in the study were classified into two main groups: 1) shift-working nurses, including those engaged in rotating or non-rotating night shifts; and 2) non–shift-working nurses, defined as those employed in standard fixed day shifts.
Eligibility criteria required participants to be actively employed as nursing professionals for at least six months in either a government or private hospital. Nurses who were on leave or had a history of diagnosed psychiatric or chronic medical illness were excluded to minimize confounding variables.
Convenience sampling was used, which introduces the possibility of selection bias, as nurses who volunteered may differ systematically from those who declined, potentially affecting the generalizability of findings. However, this approach was chosen to ensure that nurses from different hospitals (government and private), departments, and shift schedules were included, thereby enhancing the diversity of the sample. While not a strictly purposive sampling strategy, the convenience-based recruitment facilitated purposive representation across varied work contexts.
Instruments for data collection
Data were collected using a structured questionnaire comprising two sections: 1) demographic and professional profile: information on age, gender, marital status, years of experience, type of hospital, title of job, and shift schedule was obtained; and 2) psychosomatic symptom assessment: the PHQ-15 was used to assess the severity of psychosomatic symptoms. The PHQ-15 is a validated self-report tool that captures 15 somatic symptoms commonly associated with psychological distress, including fatigue, gastrointestinal problems, sleep disturbances, pain, and cardiovascular symptoms [34]. Each item is rated on a 3-point scale (0=not bothered, 1=bothered a little, 2=bothered a lot), with higher scores indicating greater symptom severity.
Data collection procedure
After obtaining institutional permission, data were collected through face-to-face administration of the questionnaire during duty hours or break periods and through online Google Forms to ensure convenience and minimize disruption. Participation was voluntary and confidential.
Statistical analysis
After the completion of data collection, all responses were coded and entered into a Microsoft Excel spreadsheet for initial organization and cleaning prior to statistical analysis. Data were analyzed using SPSS Statistics version 22 (IBM Corp.). Descriptive statistics (frequency, percentage) were used to summarize demographic and clinical characteristics. Categorical variables were summarized using absolute frequencies and corresponding percentages. Chi-square tests were conducted to compare psychosomatic symptoms between shift and non-shift workers. Further, logistic regression analysis was used to determine the association between the type of shift and the likelihood of experiencing each of the 15 individual psychosomatic symptoms. Statistical significance was set at p<0.05.
Ethical considerations
This study was conducted as part of a PhD research project. Before data collection, ethical clearance was obtained from the Institutional Human Ethics Committee of Lovely Professional University (LPU), LPU/IEC-LPU/2024/3/5, India. All procedures involving human participants were performed by the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments.
Participants were fully informed about the purpose of the study, and informed consent was obtained from each participant before the administration of the questionnaire. Participation was entirely voluntary, and nurses were assured that their decision to participate or withdraw at any stage would not affect their professional standing. Strict confidentiality and anonymity of the collected data were maintained throughout the research process. The information gathered was used solely for academic purposes, specifically for the completion of the researcher’s postgraduate thesis.
RESULTS
Reliability analysis
To assess the internal consistency of the psychosomatic symptom scale used in this study, Cronbach’s alpha was computed for the 15 items of the PHQ-15. The reliability analysis yielded a Cronbach’s alpha of 0.867, indicating good internal consistency among the items. This suggests that the PHQ-15 scale is a reliable tool for assessing psychosomatic symptoms within the sample of Indian nursing professionals included in this study. Each item contributed positively to the overall reliability, and no single item, if deleted, improved the alpha significantly, affirming the coherence of the 15-item structure in this context.
This high level of internal consistency supports the use of the PHQ-15 for further statistical analyses, including comparisons across shift work groups and assessment of symptom-level prevalence. The reliability observed is consistent with prior studies validating the PHQ-15 in occupational and clinical populations [34].
Since the majority of the study variables were categorical, descriptive analysis was conducted using frequencies and percentages. Table 1 summarizes the demographic characteristics of the nursing professionals (n=384) included in the study.
The majority of participants were female (73.2%), and nearly half were below 30 years of age (49.0%), followed by those aged 30–40 years (35.7%). In terms of educational qualifications, 52.3% of the nurses held a BSc nursing degree, while 32.8% had completed general nursing and midwifery (GNM), and 12.5% held an MSc in nursing.
With regard to income distribution, 38.0% of participants reported earning less than ₹25,000 per month, while 24.0% earned between ₹25,000–50,000, and 22.9% between ₹50,000–100,000. A smaller proportion (15.1%) earned more than ₹100,000 monthly.
In terms of marital status, 51.6% were unmarried, and 48.4% were married. Regarding professional designation, a large majority (79.7%) were working as nursing officer, followed by senior nursing officers (8.6%), and other supervisory or administrative roles such as assistant nursing superintendent (ANS) (5.2%), nursing superintendent (NS) (4.9%), and deputy nursing superintendent (DNS) (1.6%).
Shift-related characteristics
Descriptive analysis of shift-related variables is presented in Table 2. A majority of participants were employed in government hospitals (45.8%), followed by those in private hospitals (27.9%) and other healthcare settings (26.3%). Most nurses (70.8%) reported being engaged in shift work, while the remaining 29.2% were not involved in shift-based schedules.
With regard to work schedule types, over half of the respondents (53.9%) worked three-shift rotations, 14.3% worked two-shift rotations, and 31.8% followed non-traditional or irregular schedules. In terms of shift duration, the largest proportion of nurses (44.8%) reported working 6-hour shifts, followed by 8-hour shifts (35.1%), other durations (11.5%), and 12-hour shifts (8.6%).
Distribution of psychosomatic symptom levels
As shown in Table 3, the psychosomatic symptom burden among nurses was assessed using the PHQ-15 instrument. Based on total scores, 36.7% of participants fell in the medium symptom category, while 35.9% had low symptom levels, and 27.3% reported high levels of psychosomatic symptoms. These findings suggest a considerable proportion of nursing professionals are experiencing moderate to severe somatic complaints, potentially influenced by their work schedules and shift engagement.
Symptom severity of psychosomatic complaints (PHQ-15 items)
Each of the 15 somatic symptoms assessed using the PHQ-15 was categorized into severity levels: “Not bothered at all,” “Bothered a little,” and “Bothered a lot.” Table 4 presents the item-wise distribution of symptom severity among the study participants.
Notably, the most frequently reported symptoms were nausea/indigestion (84.6%), constipation or loose bowels (83.9%), and tiredness/low energy (75.3%) in the “bothered a little” category. A considerable proportion also reported trouble sleeping (27.1%), back pain (26.6%), and tiredness (24.7%) as “bothered a lot.” Symptoms such as chest pain, fainting spells, and problems during sex were least frequently reported in the “bothered a lot” category. These findings reflect varying degrees of psychosomatic symptom burden among nurses, possibly related to occupational stressors and shift patterns.
Association between shift work characteristics and psychosomatic symptom severity
A series of chi-square tests was conducted to examine the association between shift work-related variables and psychosomatic symptom severity (categorized as low, medium, and high based on PHQ-15 scores) seen in Table 5.
Engaged in shift work (Yes/No)
A significant association was found between being engaged in shift work and psychosomatic symptom severity, χ2(2, n=384)=6.64, p=0.036. Nurses engaged in shift work were more likely to report medium (39.7%) and high (28.3%) symptom levels compared to those not in shift work (medium=29.5%, high=25.0%).
Workplace type (government, private, other)
Work setting also showed a significant relationship with PHQ category, χ2(4, n=384)=12.03, p=0.017. Nurses in government hospitals had the highest proportion of high (29.5%) and medium (42.0%) psychosomatic symptoms, compared to those in private hospitals and other settings.
Work schedule (three shifts, two shifts, other)
There was a statistically significant association between the type of work schedule and PHQ category, χ2(4, n=384)=12.56, p=0.014. Nurses working in three-shift schedules reported more medium (39.1%) and high (30.0%) symptom levels than those in two-shift or other schedules.
Duration of shift (hours worked per shift)
No significant association was found between shift duration and psychosomatic symptom severity, χ2(8, n=384)=4.66, p=0.793. This suggests that the number of hours worked per shift (e.g., 6, 8, or 12 hours) did not significantly influence symptom severity levels among nurses.
Association of individual psychosomatic symptoms among nurses in different settings
To examine which psychosomatic symptoms were more prevalent among nurses working in different settings, a series of chi-square tests was conducted between work setting (government hospital, private hospital, and other institutions) and each of the 15 individual PHQ symptom items. The analysis revealed statistically significant associations for several symptoms (Table 6).
Notably, significant associations were found for stomach pain (χ2=11.41, df=2, p<0.01), back pain (χ2=11.46, df=2, p<0.01), problems with menstruation (χ2=43.48, df=8, p<0.01), headache (χ2=30.25, df=4, p<0.01), problems during sex (χ2=13.79, df=4, p=0.01), constipation or diarrhea (χ2=7.04, df=2, p=0.03), low energy or fatigue (χ2=31.09, df=2, p<0.01), and trouble sleeping (χ2= 25.69, df=4, p<0.01). These findings suggest that nurses employed in government hospitals reported a higher prevalence of these symptoms compared to those working in private or other healthcare settings.
On the other hand, symptoms such as body pain, chest pain, dizziness, fainting spells, heart racing, shortness of breath, and nausea/indigestion did not show statistically significant differences across work settings (p>0.05).
Association between engagement in shift work and individual psychosomatic symptoms
To determine whether engagement in shift work is associated with individual psychosomatic symptoms, item-wise chi-square tests were conducted for all 15 items of the PHQ-15 (Table 6). The results revealed that nurses engaged in shift work reported significantly higher frequencies of several psychosomatic symptoms. Specifically, significant associations were found for stomach pain (χ2(1)=8.81, p<0.01), back pain (χ2(1)=12.22, p<0.001), body pain (χ2(2)=8.90, p<0.01), headaches (χ2(2)=6.21, p<0.05), nausea or indigestion (χ2(1)=10.10, p<0.01), tiredness or low energy (χ2(1)=6.38, p=0.01), and trouble sleeping (χ2(2)=9.85, p=0.01). These findings suggest that shift-working nurses are more prone to experience these symptoms than their non-shift counterparts.
However, other symptoms such as chest pain, dizziness, fainting spells, heart palpitations, shortness of breath, problems during sex, menstrual difficulties, and bowel-related issues (e.g., constipation or diarrhea) did not show statistically significant differences between shift-working and non-shift-working groups (p>0.05). This suggests that while some psychosomatic complaints are linked with shift work engagement, others may be more universally experienced or influenced by other factors.
Association between work schedule type and PHQ-15 psychosomatic symptoms
Chi-square analyses were conducted (Table 6) to examine whether different work schedule types (fixed, rotating, and night shifts) were associated with the prevalence of individual psychosomatic symptoms measured using the PHQ-15. Item-wise analyses indicated that work schedule type was significantly related to several psychosomatic complaints (Table 6).
Highly significant associations (p<0.001) were observed for stomach pain (χ2(2)=19.40), back pain (χ2(2)=13.84), headaches (χ2(4)=27.21), chest pain (χ2(4)=20.97), constipation or diarrhoea (χ2(2)=15.32), low energy/tiredness (χ2(2)=18.43), and trouble sleeping (χ2(4)=19.95). These findings suggest that irregular or non-standard work schedules may contribute substantially to gastrointestinal discomfort, musculoskeletal pain, fatigue, and sleep-related difficulties among nurses.
In addition, statistically significant associations were identified for nausea or indigestion (χ2(2)=10.56, p=0.01) and fainting spells (χ2(4)=10.41, p=0.03), whereas menstrual-related problems (χ2(8)=15.21 p=0.06) are not significant. These findings suggest that variations in work schedules may be associated with certain autonomic psychosomatic symptoms.
Conversely, symptoms such as general body pain, dizziness, heart pounding or racing, shortness of breath, and problems during sexual activity did not demonstrate statistically significant differences across work schedule categories (p>0.05), suggesting that these symptoms may be less sensitive to variations in shift patterns.
Overall, the results underscore the crucial role of work schedule organization in influencing psychosomatic health outcomes among nursing professionals, particularly in relation to symptoms such as sleep disturbances, fatigue, pain, and gastrointestinal issues.
Predictors of psychosomatic symptom severity: the role of shift work and workplace characteristics
A multinomial logistic regression was conducted to examine the effects of shift work engagement, work schedule type, shift duration, and workplace setting on psychosomatic symptom severity among nursing professionals, using the PHQ-15 symptom categories: low, medium, and high (Table 7). The low symptom category was specified as the reference group.
The overall model was statistically significant compared to the null model, χ2(18)=32.89, p=0.017, indicating that the set of predictors reliably distinguished between the levels of psychosomatic symptoms. The model explained approximately 9.3% of the variance in psychosomatic symptom categories as indicated by the Nagelkerke pseudo R2.
Likelihood ratio tests revealed that work schedule type (χ2(4)=12.05, p=0.017) and workplace setting (χ2(4)=10.59, p=0.032) significantly improved model fit, while engagement in shift work (χ2(2)=3.99, p=0.136) and shift duration (χ2(8)=4.31, p=0.828) did not contribute significantly.
In terms of predicting high psychosomatic symptoms (compared to low), nurses working under three-shift schedules were three times more likely to report high symptoms (OR=3.02, 95% CI [1.11, 8.25], p=0.031), while those with irregular or “other” shift schedules were more than five times as likely (OR=5.22, 95% CI [1.77, 15.45], p=0.003). Furthermore, nurses employed in other types of healthcare settings (e.g., NGOs, specialty clinics) were significantly less likely to report high symptoms compared to those in private hospitals (OR=0.415, 95% CI [0.19, 0.93], p=0.032).
When comparing medium symptoms to low, most predictors were not statistically significant. However, a marginal effect was found for nurses working in government hospitals, who were nearly twice as likely to report medium symptoms (OR=1.83, 95% CI [0.99, 3.39], p=0.054), suggesting a trend toward increased psychosomatic burden in that group.
Shift work engagement (Yes/No) showed a non-significant trend for both medium and high symptom groups (p=0.091 and p=0.093, respectively), and shift duration (6-hour, 8-hour, 12-hour) showed no significant association with psychosomatic symptom category in any comparison (p>0.5).
These findings suggest that the type and pattern of work schedule play a more critical role in predicting psychosomatic symptom burden than shift length or general shift engagement, highlighting the importance of schedule design in occupational health planning.
The multinomial logistic regression findings underscore the importance of work schedule design and workplace setting as predictors of psychosomatic symptom severity among nurses. While shift engagement and shift duration did not emerge as significant predictors, the strong association of irregular and three-shift schedules with high psychosomatic symptoms aligns with global evidence that erratic schedules disrupt circadian stability and exacerbate fatigue, sleep disturbances, and somatic complaints [32,42]. This finding supports the growing argument that the structure and predictability of work schedules, rather than the mere presence or length of shifts, have a more profound effect on health outcomes.
The observed trend of greater symptom burden among nurses in government hospitals also reflects the contextual challenges of Indian healthcare systems, where high patient–nurse ratios and inadequate staffing persist despite national norms. Previous studies have reported that workload intensification, especially in public hospitals, contributes to heightened psychosomatic complaints and burnout among nurses [43]. Thus, the results highlight that occupational health interventions must not only address circadian misalignment but also incorporate organizational reforms such as workload redistribution and adequate staffing.
Importantly, the non-significant effect of shift duration suggests that policies focusing solely on reducing shift length may not sufficiently safeguard nurse well-being. Instead, chronobiology-informed scheduling approaches that consider stability, forward rotation, and adequate rest opportunities between shifts may offer more sustainable benefits [13,14].
DISCUSSION
The present study provides compelling evidence that engagement in shift work, particularly rotating and night shifts, is significantly associated with elevated psychosomatic symptom burden among Indian nursing professionals. This is consistent with prior international research highlighting the detrimental effects of circadian disruption on somatic and psychological health [3,10,19]. Using the PHQ-15 instrument, our analysis revealed that nearly two-thirds of participants reported medium to high levels of psychosomatic symptoms—a prevalence that raises concern for occupational health and workforce sustainability in healthcare.
It should be noted that the PHQ-15 focuses primarily on somatic manifestations of distress, and does not capture broader psychological or behavioral domains such as anxiety, depression, or coping strategies. Future studies incorporating multidimensional tools, such as the PHQ-9 or GAD-7, may provide a more comprehensive understanding of nurses’ psychosocial health.
Our findings indicate that nurses engaged in shift work were significantly more likely to report symptoms such as stomach pain, back pain, fatigue, trouble sleeping, headaches, and nausea (p<0.05). This aligns with earlier work suggesting that gastrointestinal issues and fatigue are among the most commonly reported somatic complaints in shift-working nurses [14,15]. Sleep disturbances and low energy, both prominent in our study, have also been previously associated with irregular and night shifts due to misalignment of circadian rhythms and insufficient recovery time between shifts [9,13].
It is acknowledged that certain symptoms such as fatigue and back pain may not be exclusively attributable to shift work. Nursing is a physically demanding profession that involves prolonged standing, frequent bending, patient lifting, and extended periods of alertness during duty hours. These occupational demands themselves have been consistently associated with musculoskeletal complaints and general fatigue among nurses, independent of their shift schedules [44,45]. To address this overlap, the present study utilized the PHQ-15, which captures symptoms persisting for more than four weeks [34,35], thereby reducing the likelihood of including short-term complaints that may arise from daily workload fluctuations. Furthermore, while work ergonomics and nursing duties may explain part of the symptom burden, the higher prevalence of psychosomatic symptoms among shift-working nurses compared with those in regular schedules suggests that circadian disruption acts as an additional and significant contributor beyond the routine physical demands of nursing practice.
Moreover, chi-square analysis across various work schedules revealed that nurses in rotating shifts reported significantly higher rates of PHQ-15 symptoms than their counterparts in fixed shifts. Notably, symptoms like chest pain, constipation or diarrhea, menstrual irregularities, and fainting spells were all significantly associated with work schedule type (p<0.05), a pattern consistent with earlier studies linking shift work to autonomic dysfunction and reproductive health disturbances [4,18,20]. The influence of rotating schedules on gastrointestinal symptoms like nausea, indigestion, and constipation may reflect the disruption of digestive processes due to erratic meal timings and stress [33,46-48].
Interestingly, certain symptoms such as body pain, dizziness, and palpitations did not show significant differences across shift types, suggesting that while shift work may exacerbate certain domains of psychosomatic health, others may be influenced by individual vulnerability or environmental factors independent of shift timing [5,28]. Additionally, our findings that longer shift hours were not significantly associated with symptom severity challenge the assumption that longer shifts alone contribute to psychosomatic distress; rather, the timing and regularity of shifts may be more critical determinants.
Nonsignificant findings and their implications
While several psychosomatic symptoms showed significant associations with work schedules and engagement in shift work, a subset of symptoms did not demonstrate statistically significant relationships. For instance, body pain (item 3), dizziness (item 7), fainting spells (item 8), heart palpitations (item 9), and shortness of breath (item 10) yielded non-significant chi-square results across most comparisons. These findings suggest that not all somatic complaints among nurses are directly attributable to shift work or circadian disruption.
Previous research supports this variability. Trinkoff et al. [44] noted that musculoskeletal pain and dizziness may be more strongly linked to ergonomic demands, patient handling, and environmental stressors rather than to shift patterns per se. Similarly, Vedaa et al. [49] emphasized that individual factors such as resilience, physical fitness, and coping strategies often mediate the relationship between shift schedules and symptom presentation. The lack of association for palpitations and shortness of breath in the present study may also reflect the multifactorial nature of these symptoms, which are influenced by pre-existing cardiovascular or respiratory conditions [50] and not solely by occupational stressors.
This finding aligns with previous studies suggesting that the quality and timing of shifts may exert a greater influence on health than their absolute duration [42,51]. Nurses working in rotating or irregular shifts may experience circadian misalignment, which has been shown to disrupt sleep and metabolic regulation, whereas longer but more predictable shifts may allow for partial adaptation [19]. The lack of significance for cardiovascular-type symptoms (e.g., palpitations, chest pain) is also noteworthy. Prior research indicates that such symptoms often have multifactorial origins, including lifestyle behaviors, baseline anxiety, and underlying medical conditions, which may obscure their relationship with shift work [32,52].
These non-significant findings emphasize that not all domains of psychosomatic health are equally influenced by shift work. They highlight the importance of investigating moderating factors such as individual resilience, coping strategies, and organizational supports. Future longitudinal studies incorporating both somatic and psychological measures (e.g., anxiety, depression, coping scales) would help clarify these complex interrelationships.
Furthermore, the elevated symptom burden among nurses employed in government hospitals compared to those in private or other settings may be attributed to systemic factors such as staffing shortages, heavier caseloads, or limited institutional support [25,30]. These contextual factors can compound the impact of shift work, further exacerbating physical and mental health outcomes.
The study also reinforces the psychometric robustness of the PHQ-15 scale, with a Cronbach’s alpha of 0.867, indicating good internal consistency. This supports the use of PHQ-15 in future occupational health research in India, particularly in resource-constrained settings where brief yet valid tools are needed.
The present findings align with concerns regarding workload and staffing pressures in India. Nurse-to-patient ratios often fall short of recommended norms, especially in government hospitals where patient inflow is higher and resources limited. While guidelines propose ratios of 1:6 in general wards and 1:1–1:2 in intensive care settings, actual practice frequently deviates due to chronic shortages [37]. In addition, time-and-motion analyses highlight that patient dependency levels justify closer to a 1:1.2 ratio in critical care [37,38]. Previous surveys reveal that more than 80% of Indian nurses perceive workload as a major contributor to occupational stress, and shift-working nurses disproportionately report gastrointestinal issues, back pain, hypertension, and disturbed sleep [38,43]. These contextual realities likely compound the psychosomatic symptom burden we observed, particularly among government hospital nurses, reinforcing the need for policy-level interventions.
Limitations of the study
Despite its significant findings, this study has several limitations that warrant consideration. First, the cross-sectional design precludes any causal inferences between shift work and psychosomatic symptoms. Longitudinal or prospective cohort studies would be necessary to confirm whether shift work leads to psychosomatic distress over time, or whether individuals with higher baseline vulnerability are more likely to report symptoms. While associations were observed, the temporal direction of these relationships cannot be confirmed, and reverse causality remains a possibility.
Second, data were collected using self-reported instruments, including the PHQ-15, which may be subject to response bias, such as social desirability or recall inaccuracies. Participants may have underreported or overreported symptoms based on personal perceptions, mood at the time of survey completion, or fear of professional consequences. Although the PHQ-15 is a validated and reliable tool for assessing somatic symptom severity, it does not differentiate between psychosomatic or functional complaints and symptoms arising from underlying medical conditions [33]. Thus, some reported symptoms may reflect organic illnesses rather than occupational stressors or shift work per se. To minimize this limitation, we excluded participants with known chronic medical ailments at the time of data collection. Furthermore, the PHQ-15 identifies symptoms that persist for more than four weeks [34], thereby reducing the likelihood of capturing transient or short-term complaints unrelated to work patterns.
Third, the study relied on convenience sampling from selected hospitals, which limits the generalizability of findings. The sample, though sizable (n=384), may not fully represent the broader nursing population across India, especially those in rural or smaller healthcare settings.
Fourth, while the PHQ-15 offers a reliable assessment of psychosomatic symptoms, it does not differentiate between functional and organic causes of symptoms. Consequently, some reported complaints may stem from medical conditions unrelated to occupational stress or shift work.
Fifth, important confounding variables such as chronotype, sleep quality, coping mechanisms, and organizational factors (e.g., staffing ratio, administrative support) were not controlled in this study. Their omission may limit the depth of interpretation regarding the pathways through which shift work affects psychosomatic health.
Lastly, gender-specific health concerns, such as menstrual issues, were explored but not stratified by gender, which may dilute the interpretability of certain results—particularly as these symptoms are biologically constrained to a subset of participants.
Future research should consider longitudinal designs, stratified sampling, and multivariate models that incorporate biological, psychosocial, and environmental moderators to better understand the complex relationship between shift work and nurses’ health.
This study did not directly measure staffing adequacy, nurse-to-patient ratios, or patient dependency levels. Given that Indian hospitals often operate below recommended norms and with significant variability between government and private sectors, incorporating workload measures could have provided a more nuanced understanding of how staffing interacts with shift schedules to influence psychosomatic health. Future studies should integrate objective workload indicators to strengthen causal inferences.
Conclusion
This study provides compelling evidence that shift work significantly influences psychosomatic symptom severity among nursing professionals. A considerable proportion of participants reported moderate to high levels of somatic complaints, particularly those engaged in rotating or irregular work schedules. Key symptoms such as headaches, gastrointestinal discomfort, fatigue, and sleep disturbances were more prevalent among shift workers compared to those on fixed schedules. These findings align with prior research indicating that circadian disruption and inconsistent work patterns contribute to heightened physiological stress and symptom manifestation [32,53,54].
Furthermore, chi-square analyses revealed significant associations between specific shift characteristics—such as engagement in shift work, work schedule type, and working hours—and various psychosomatic indicators. These results underscore the urgent need for shift-sensitive health monitoring systems and institutional strategies to mitigate adverse outcomes in healthcare workers [10].
Given the critical role of nurses in patient care delivery, prioritizing their well-being is not only a matter of occupational health but also of healthcare quality and safety. Implementation of chronobiologically informed scheduling and stress-reduction programs may help reduce symptom burden and improve job satisfaction and retention [55].
In conclusion, shift work emerges as a salient occupational stressor associated with psychosomatic distress in nurses. Addressing this issue requires an integrated approach involving organizational policy reform, individualized shift planning, and continued research to explore underlying mechanisms and long-term outcomes.
This study adds to the growing literature on occupational health by documenting the significant burden of psychosomatic symptoms among nurses working in shifts. The strong associations between shift work and specific somatic complaints highlight the urgent need for organizational policies that prioritize shift design, rest periods, and supportive work environments. Future interventions should consider chronobiological principles to align work schedules with individual chronotypes, potentially mitigating the health risks associated with shift work.
Future directions
Beyond observational and longitudinal research, future investigations should examine intervention strategies that integrate chronobiological principles with staffing reforms. In the Indian context, this could include piloting flexible or chronotype-informed shift schedules alongside the enforcement of safe nurse-to-patient ratios as recommended by national guidelines [56,57]. Interventional trials assessing the combined effect of staffing adequacy and schedule design on psychosomatic health would provide stronger evidence for sustainable workforce policies.
While observational designs highlight important associations, interventional research is needed to test actionable strategies. Chronobiology-informed scheduling has shown promise in reducing circadian misalignment by aligning work hours with individual chronotypes, using forward-rotating shifts (day–evening–night), and limiting consecutive night duties [10,56,58]. Such strategies have been linked to improved sleep quality, reduced fatigue, and lower psychosomatic symptom burden. Organizational reforms are equally critical. These include enforcing safe nurse-to-patient ratios, as recommended for Indian healthcare settings [37], and implementing workload redistribution through supportive staffing policies. Institutional measures such as protected rest breaks, fatigue risk management systems, and wellness programs focusing on sleep hygiene and coping strategies may also mitigate health risks [1,51,59]. In the Indian context, pilot trials combining chronobiology-informed scheduling with staffing reforms in high-volume government hospitals would be especially valuable. Evaluating these interventions could provide robust evidence for institutional and national policy changes aimed at safeguarding nurse well-being and sustaining care quality.
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