Effects of nursing care delivery models on nurses’ fatigue: a cross-sectional study

Effects of nursing care delivery models on nurses’ fatigue: a cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of nursing care delivery models on nurses’ fatigue: a cross-sectional study Naomi Kisanuki, Sanae Oriyama This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5107994/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract A new nursing care delivery model has been developed in Japan in which all nurses, including experienced nurses, work in pairs to provide daily nursing care for multiple patients. This study aimed to confirm the effectiveness of the paired system by comparing physical changes and mental fatigue before and after work with the conventional system in which one nurse is responsible for several patients. Physical and mental fatigue levels were measured before and after for 675 nurses working at two hospitals with >400 beds. Repeated measures of two-way analysis of variance for changes over time before and after work revealed no interaction. In the paired system, self-negativity was significantly decreased after than before work. This is because, in the paired system, two workers always communicate and consult with each other while performing their work; thus, emotional stress may less accumulate. The system remains not fully established because it has only been implemented for a short time. Strengthening pair relationships was considered an innovative model. Nursing Nursing Care Delivery Model Nurse Physical Fatigue Mental Fatigue A Cross-sectional Study Practitioner points In the paired system, in which two nurses work in pairs to provide nursing care to multiple patients daily, self-negative feelings decrease after work because the two nurses always communicate and work together. The paired system remained not fully established because some mental fatigue items increased after work while others decreased, indicating that it is an innovative model of nursing care delivery by strengthening the relationship between the two nurses to respect each other. Physical and mental fatigue before and after work demonstrated no association in the paired-patient system and the conventional system in which a single nurse is in charge of multiple patients, but establishing a system and continuously verifying the effectiveness of the system remains necessary. 1. Introduction Many healthcare organizations globally are facing a nursing shortage that influences their ability to provide healthcare services. To address this issue, determining the appropriate nurse staffing and the appropriate nursing care delivery model (NCDM) required to provide quality patient care is essential (Fowler et al., 2006 ) (Prentice et al., 2021 ). The general NCDM includes the following components. Common NCDMs involve function-specific nursing, team nursing, total patient care, and primary nursing. Hospital nursing managers identify the NCDM based on the characteristics of their hospital or combine multiple NCDMs into a system to provide quality and safe nursing care (Jennings, 2008 ). Empirical evidence related to the quality of nursing care for this NCDM is limited (Hall et al., 2004) (LeClerc et al., 2008 ). Additionally, studies of systems combine skill mix with NCDM by introducing assistant nurses and nursing assistants in response to nursing shortages (Lookinland et al., 2005 ) (Harris and Hall, 2012 ). Thus, NCDM is currently sought and prepared following the characteristics of each hospital for nurses to divide labor and efficiently provide quality nursing services to patients and their families. Organizations are urged to organize their work and to consider innovative methods of NCDM due to the recent economic and human resource pressures. Regarding NDCM, studies of the association between NDCM and patient or nurse outcomes have been conducted. A survey of Canadian surgical nurses in terms of patient outcomes revealed that nurses working in team nursing demonstrated more unfinished business and a higher frequency of patient adverse events than those working in total patient care (Havaei et al., 2019 ). Additionally, an Italian hospital reported a decrease in the number of patients with urinary tract infections and venous catheter infections after introducing primary nursing, as well as a decrease in the number of patients with falls and pressure ulcers (Dal Molin et al., 2018 ). Conversely, concerning nurse outcomes, the transition of NDCM from individual patient-assigned nursing to team nursing in an Australian hospital has improved job satisfaction and substantially improved retention of key staff (Fairbrother et al., 2010 ). Additionally, no significant change was found in nurses’ job satisfaction when changing from team nursing to total patient care, although total patient care was more effective (Wells et al., 2011 ) (Tran et al., 2010 ). Thus, no NCDM has been adequately investigated, as no NCDMs produce positive outcomes for patients and nurses. In Japan, fixed-team nursing and, more recently, a system in which two nurses pair up to provide nursing care (paired system) have become widespread. A 2017 survey revealed that 24% of national university hospitals had adopted fixed-team nursing and 52% had adopted the paired system (Higaonna and Morimoto, 2019 ). The paired system, where all nurses, including experienced nurses, work in pairs to provide daily nursing care for multiple patients, differs from the traditional Japanese system in which one nurse provides daily nursing care for multiple patients (single system). The number of nurses remained in the paired system, whereas the number of patients was greater than in the single system because the number of patients was the same as that handled by the two nurses in the single system. A study that compared the mortality rate and activities of daily living status of patients in this paired system with fixed-team nursing, which is a predominant practice in Japan, revealed no significant difference in mortality rate and an increase in the number of patients with decreased activities of daily living (Higaonna et al., 2020 ). However, studies on the effectiveness of the paired system are limited, partly because of the short period since its development. The paired system is characterized by nurses complementing each other and working together and is more efficient and less physically and mentally straining. The skill mix between assistant nurses and nursing assistants is frustrating because their roles are unclear (White et al., 2008 ). They emphasize that this role uncertainty results in competition among healthcare providers, workplace tensions, lack of trust among healthcare providers, and lack of effective teamwork (Baranek, 2005 ). However, the paired system may be an innovative NCDM in which nurses with the same qualifications work in pairs, thereby reducing the burden and decreasing fatigue without any role uncertainty. Furthermore, nurses are physically and mentally fatigued due to the nature of their work and the tasks required of them. Focusing on reducing fatigue among nurses is important, considering that fatigue demonstrates a strong negative impact on the patient. A study of Spanish nurses revealed that the higher the level of such support from colleagues, the lower the mental fatigue score (Albar Marín and García-Ramírez, 2005 ). Paired systems always perform tasks with the support of their colleagues. Therefore, a paired system in which work is performed with constant support from colleagues is predicted to cause a sense of security among nurses and reduce mental fatigue from before to after work. Additionally, the high level of mental fatigue affects the quality of care (Poku et al., 2020 ) (Koy et al., 2015 ). Reducing the mental fatigue of nurses is crucial for improving and maintaining the quality of nursing care. Furthermore, pairing not only reduces mental fatigue but also reduces the amount of care provided by one person and the stress of finding a nurse to help when another nurse’s help is required. Thus, increased physical work demands and stress cause physical fatigue (Farag et al. 2022 ). Few studies on NDCM have investigated physical and mental fatigue as an outcome for nurses. However, nurses’ performance decreases when their physical and mental fatigue is high (Barker and Nussbaum, 2011 ). Therefore, confirming the association between NDCM and nurses’ mental and physical fatigue can provide recommendations for NDCM that will cause positive outcomes for patients and nurses. 2. Materials and methods 2.1. Aim This study aimed to test the following hypotheses 1. A paired system had lower physical and mental fatigue levels before work compared to a single system. 2. Paired systems were less physically and mentally fatigued at the end of work compared to single systems. 3. Paired systems demonstrated a lesser increase in physical fatigue at the end of work compared to single systems. 4. Paired systems exhibited a lesser increase in mental fatigue at the end of work compared to single systems. 2.2. Research design The study utilized a comparative cross-sectional survey design with a single system so that the effectiveness of the paired system could be evaluated. 2.3. Sample Convenience sampling was used. After confirming by telephone with the directors of nursing departments of general hospitals with >400 beds in five prefectures in the Chugoku region of Japan that used single and paired systems, a set of documents requesting research cooperation was mailed to them, and 675 nurses from two hospitals who agreed to cooperate in the study were selected as participants. 2.4. Data collection The survey was administered to the participants for only one day from March to June 2018. The survey procedure was to distribute a portion of the pre and postservice survey forms together to the participants. The paired nurses were requested to distribute a portion of the survey form with the same number on it to each of them for the paired system. The nurses were asked to fill out the “Subject’s Attributes,” “ Jikaku-sho shirabe, ” and the POMS2 survey forms before starting work. The nurses were asked to complete the “work status,” “Jikaku -sho shirabe, ” and the POMS2 survey forms at the end of work. The completed forms were collected at the hospital and mailed to the principal investigator. 2.5. Measurements 2.5.1. Participant attributes Participants’ age, sex, years of clinical experience, sleep time on the previous day, and attributes were investigated. 2.5.2. Status of work on the day of the survey The status of work on the day of the survey was investigated in terms of “work during the day (day shift or long day shift),” “number of patients in charge (patients discharged or transferred in the morning were not included),” “rest time,” “overtime hours,” and “work status during the day.” In Japan, third-shift night shift workers work 8-h day shifts, and second-shift workers work 12-h long day shifts; thus, these were determined as the work during the day. Respondents were requested to select their work status during the day as “busy,” “same,” and “not busy” compared to the usual work status. 2.5.3. Physical fatigue: “ Jikaku-sho shirabe” The Japanese Society for Industrial and Labor Research developed Jikaku-sho shirabe as a measure of physical fatigue, which is mainly used to investigate fatigue in the sense of reduced physical capacity, as in this study (Sasaki and Matsumoto, 2005) (Kubo et al., 2011). This questionnaire consists of 25 subjective fatigue symptoms that are categorized into five factors of feeling: (ⅰ) drowsiness, (ii) instability, (iii) uneasiness, (iv) local pain or dullness, and (v) eyestrain. Participants were requested to rate their fatigue for each item on the following scale: “Strongly disagree,” “Mostly disagree,” “A little agree,” “Fairly agree,” and ”Strongly agree.” Each of these five intensities were assigned a score from 1 to 5. A higher score demonstrates a greater degree of fatigue. Jikaku-sho shirabe has been validated for factorial validity and internal consistency (Kubo et al., 2008)(Nagai et al., 2011)． 2.5.4. Mental fatigue: “POMS2 (short version) (POMS2)” POMS2, as mental fatigue assessment, is sensitive to subjective stress and mood disorder levels and measures emotional state (Galantino et al., 2005) The POMS2 was used, which consists of the following five items: anger-hostility (AH), confusion-bewilderment (CB), depression-dejection (DD), fatigue-inertia (FI), tension-anxiety (TA), vigor-activity (VA), and friendliness (F). The scale consisted of five items in each of the lower five items of the scale and is rated on a five-point scale ranging from 0 (not at all) to 4 (very much). The POMS2 is characterized by its ability to measure transient emotions and moods based on the conditions in which they occur. The POMS2 calculates and evaluates the T score, which is a standardized version of the surveyed scores, and the “total mood disturbance (TMD)” score, which indicates overall mood status from items other than F. Higher T scores for TMD score and negative mood states (AH, CB, DD, FI, and TA) indicate more negative emotions and mood disorders. Higher T scores for positive affective states (VA and F) indicate a more positive affective state. The Japanese version of the POMS2 has been confirmed for standardization, reliability, and validity (Konuma et al., 2015). 2.6 Analysis Single and paired systems were compared for subject attributes, work status, physical and mental fatigue before work, and physical and mental fatigue after work using chi-square tests or paired t -tests. A repeated measure two-way analysis of variance (ANOVA) was utilized to compare single and paired systems for changes over time in physical and mental fatigue from before to after work. A t -test was conducted on the change in physical and mental fatigue before and after work in each of the single and paired systems. 2.7. Ethical considerations Written and oral explanations were provided to the facility administrators, and their consent was obtained. The participants were sent an explanatory letter and a survey form, and consent was assumed to have been obtained if they responded to the survey. The XXX University Epidemiological Research Ethics Review Committee approved the study (Approval No. XXX). 3. Results 3.1. Sample characteristics Of the 565 respondents (83.7% response rate), this study included 450 (79.6% valid response rate) with no missing values, including 40 and 410 in the single and paired systems, respectively. 3.2. Background of the participants and work status during the day The backgrounds of the participants and their working conditions during the day were compared between the single and paired systems (Table 1 ). The number of patients in charge was with 5.5 ± 11.0 and 7.3 ± 3.6 in the single-patient and paired groups, respectively, with the paired group demonstrating a significantly higher number of patients. Other items were not significantly different between the two systems. Table 1 Background of the participants and their work situation during the day Single system (n = 40) Mean (SD) or n % Paired system (n = 410) Mean (SD) or n (%) P -value Age 30.3 (7.3) 28.9 (7.7) 0.63 Sex female male female male 0.045 32 80.0% 8 20.0% 370 90.2% 40 9.8% Years of clinical experience (years) 7.9 (7.3) 6.8 (6.7) 0.54 Hours of sleep on the previous day (hours) 6.6(1.4) 6.6(1.4) 0.97 Work on the day day shift long day shift Other day shift long day shift Other 0.75 30 75.0% 10 25% 0 0% 289 70.5% 118 28.8% 3 0.7% Number of patients in charge (persons) 5.5(2.5) 7.3(3.6) < 0.01 Break time (minutes) 53.0 (11.0) 51.4 (12.9) 0.38 Overtime (minutes) 35.4 (31.2) 41.5 (45.6) 0.41 Working conditions on the day of the event busy Same as usual I am not busy. busy Same as usual I am not busy. 0.85 10 25.0% 20 50.0% 10 25.0% 110 26.8% 185 45.1% 115 28.0% [Table 1 about here] 3.3. Physical and mental fatigue before work We compared Jikaku-sho shirabe and POMS2 before working between the single and paired systems (Table 2 ) and revealed no significant differences in all items. Among the Jikaku-sho shirabe items, (ⅰ) feeling of drowsiness was higher in both systems, whereas among the POMS2 items, “F” was higher in both systems. Table 2 Comparison of single and paired systems of physical and mental fatigue before work Single system (n = 40) Mean (SD) Paired system (n = 410) Mean (SD) P -value Jikaku-sho shirabe Factors Ⅰ: feeling of drowsiness 2.09 (0.8) 2.01 (0.9) 0.40 Factors Ⅱ: feeling of instability 1.60 (0.7) 1.64 (0.7) 0.76 Factors III: feeling of uneasiness 1.57 (0.6) 1.51 (0.5) 0.83 Factors Ⅳ: feeling of local pain or dullness 1.83 (0.6) 1.75 (0.7) 0.39 Factors Ⅴ: feeling of eyestrains 1.63 (0.7) 1.64 (0.7) 0.35 POMS2 (short version) anger-hostility (AH) 42.0 (7.7) 41.5 (6.5) 0.45 confusion-bewilderment (CB) 43.1 (6.3) 44.3 (8.0) 0.11 depression-dejection (DD) 45.5 (8.5) 46.1 (7.6) 0.96 fatigue-inertia (FI) 43.2 (10.6) 42.5 (10.2) 0.91 tension-anxiety (TA) 43.8 (7.3) 45.1 (9.8) 0.10 vigor-activity (VA) 47.5 (8.2) 47.9 (8.5) 0.86 friendliness (F) 51.3 (9.5) 51.4 (8.4) 0.72 total mood disturbance (TMD) 43.4 (8.2) 43.6 (8.2) 0.82 [Table 2 about here] 3.4. Physical and mental fatigue after work We compared Jikaku-sho shirabe and POMS after working between the single and paired systems (Table 3 ) and revealed that mental fatigue “CB” was significantly higher in the single system (41.5 ± 9.0) versus the paired system (44.6 ± 9.0). The item of Jikaku-sho shirabe of (ⅰ) feeling of drowsiness” and the POMS2 item of “F” were high in both systems. Table 3 Comparison of single and paired systems of physical and mental fatigue after work Single system (n = 40) Mean (SD) Paired system (n = 410) Mean (SD) P -value Jikaku-sho shirabe Factors Ⅰ: feeling of drowsiness 2.28 (0.9) 2.28 (1.0) 0.98 Factors Ⅱ: feeling of instability 1.48 (0.6) 1.66 (0.8) 0.09 Factors III: feeling of uneasiness 1.61 (0.7) 1.69 (0.8) 0.51 Factors Ⅳ: feeling of local pain or dullness 2.15 (0.7) 2.06 (0.8) 0.50 Factors Ⅴ: feeling of eyestrains 1.93 (0.8) 1.88 (0.9) 0.79 POMS2 (short version) anger-hostility (AH) 42.7 (10.2) 41.5 (7.2) 0.44 confusion-bewilderment (CB) 41.5 (9.0) 44.6 (9.0) 0.040 * depression-dejection (DD) 45.0 (9.0) 45.4 (7.6) 0.75 fatigue-inertia (FI) 49.3 (10.9) 48.9 (11.8) 0.85 tension-anxiety (TA) 40.5 (7.7) 42.6 (9.6) 0.18 vigor-activity (VA) 44.2 (7.8) 44. 4 (9.0) 0.91 friendliness (F) 51.5 (9.4) 50.1 (9.4) 0.39 total mood disturbance (TMD) 44.3 (10.1) 45.0 (8.6) 0.62 * t -test, p < 0.01 [Table 3 about here] 3.5. Changes in physical fatigue before and after work A two-way ANOVA of the Subjective Illness Questionnaire, before and after work between the single and paired systems, revealed no associations for all items ([ⅰ] feeling of drowsiness vs. F [1,448] = 0.34; [ii] feeling of instability vs. F [1,448] = 1.79; [iii] feeling of uneasiness vs. F [1,448] = 2.08; [iv] feeling of local pain or dullness vs. F [1,448] = 0.01; (v) feeling of eyestrain vs. F [1,448] = 0.01) (Table 4 ). A two-way ANOVA was then conducted for the bottom 25 items of Jikaku-sho shirabe , and an interaction was revealed for one item, (iii) discomfort: dizziness (F =[1,448] = 7.996, P < 0.01). The single system decreased from 1.30 before work to 1.15 after work, whereas the paired system increased from 1.15 to 1.30. Additionally, t -tests were conducted before and after work in both the single and paired systems, revealing that the two items, (iv) feeling of local pain or dullness and (v) feeling of eyestrain, in Jikaku-sho shirabe significantly increased after work. The t -tests conducted before and after work in the single and paired systems, respectively, revealed that the two items, (iv) feeling of local pain or dullness and (v) feeling of eyestrain, in Jikaku-sho shirabe significantly increased after work in both systems. Items (ⅰ) feeling of drowsiness and (iii) feeling of uneasiness of Jikaku-sho shirabe significantly increased after work in the paired system alone (Table 4 ). Table 4 Change in physical fatigue from before to after work Single system P -value Pair system P -value P -value Before work Mean (SD) After work Mean (SD) t -test Before work Mean (SD) After work Mean (SD) t -test ANOVA Factors Ⅰ: feeling of drowsiness 2.09 (0.85) 2.28 (0.90) 0.17 2.01 (0.90) 2.28 (1.02) 0.000* 0.54 Factors Ⅱ: feeling of instability 1.60 (0.71) 1.48 (0.60) 0.26 1.64 (0.73) 1.66 (0.76) 0.569 0.18 Factors III: feeling of uneasiness 1.57 (0.63) 1.61 (0.66) 0.70 1.51 (0.58) 1.69 (0.77) 0.000* 0.15 Factors Ⅳ: feeling of local pain or dullness 1.83 (0.63) 2.15 (0.73) 0.000* 1.75 (0.70) 2.06 (0.80) 0.000* 0.93 Factors Ⅴ: feeling of eyestrains 1.63 (0.70) 1.93 (0.76) 0.000* 1.64 (0.79) 1.88 (0.91) 0.000* 0.68 * t -test, p < 0.01 [Table 4 about here] 3.6. Change in mental fatigue before and after work A two-way ANOVA of the POMS 2 revealed no association between the single and paired systems before and after work in the change in t score for all items (AH vs. F [1,448] = 0.58, CB vs. F [1,448] = 3.00, DD vs. F [1,448] = 0.07, FI vs. F [1,448] = 0.04, TA vs. F [1,448] = 0.40, VA vs. F [1,448] = 0.02, F vs. F [1,448] = 1.93, TMD vs. F [1,448] = 0.28). Additionally, t -tests were conducted before and after work in each of the single and pair systems, revealing that TA and VA demonstrated significantly decreased T scores after work in both systems whereas FI exhibited a significantly increased T score. Items DD and F decreased significantly, whereas TMD increased significantly in the paired system (Table 5 ). Table 5 Change in mental fatigue from before to after work POM2 Single system P -value Paired system P -value P -value Before work Mean (SD) After work Mean (SD) t -test Before work Mean (SD) After work Mean (SD) t -test ANOVA anger-hostility (AH) 42.0 (7.7) 42.7 (10.2) 0.51 41.5 (6.5) 41.4 (7.2) 0.75 0.45 confusion-bewilderment (CB) 43.1 (6.3) 41.5 (9.0) 0.22 44.3 (8.0) 44.6 (9.0) 0.46 0.08 depression-dejection (DD) 45.5 (8.5) 45.0 (9.0) 0.57 46.1 (7.6) 45.4 (7.6) 0.002* 0.79 fatigue-inertia (FI) 43.2 (10.6) 49.3 (10.9) 0.000* 42.5 (10.2) 48.9 (11.8) 0.000* 0.85 tension-anxiety (TA) 43.8 (7.3) 40.5 (7.7) 0.002* 45.1 (9.8) 42.6 (9.6) 0.000* 0.53 vigor-activity (VA) 47.5 (8.2) 44.2 (7.8) 0.000* 47.9 (8.5) 44. 4 (9.0) 0.000* 0.89 friendliness (F) 51.3 (9.5) 51.5 (9.4) 0.87 51.4 (8.4) 50.1 (9.4) 0.000* 0.17 total mood disturbance (TMD) 43.4 (8.2) 44.3 (10.1) 0.37 43.6 (8.2) 45.0 (8.6) 0.000* 0.60 *t -test, p < 0.01 [Table 5 about here] 4. Discussion 4.1. Physical and mental fatigue before work No difference was found in the physical and mental fatigue levels before work between the single and paired systems; thus, the paired or single system did not affect the fatigue level before work. Nurses experienced more fatigue than other healthcare professionals (Barker and Nussbaum, 2011 ) (Smith-Miller et al., 2014 ). In particular, nurses may experience fatigue that is exacerbated by shift work and may not recover before the next shift (Min et al., 2019 ). Under such conditions, fatigue will be stronger in the single system than in the paired system due to the effects of pressure to assume sole responsibility, but this hypothesis was not tested. Sleep disturbance due to shift work decreases recovery from fatigue (Winwood and Lushington, 2006 ) (Min et al., 2019 ). The present results revealed that both groups demonstrated the highest (ⅰ) feeling of drowsiness of Jikaku-sho shirabe before work, indicating that they had not fully recovered from fatigue from shift work. Various factors, including sleep duration and leisure time, affect recovery from fatigue between shifts (Smith-Miller et al., 2014 ) (Martínez-Zaragoza et al., 2020 ). Thus, large individual differences were found in fatigue recovery, and this survey may not have reflected the differences between the two systems. However, we believe that continuing to investigate this issue as an evaluation of NDCM is necessary, since NDCM may have some effect at the beginning of work. 4.2. Physical and mental fatigue after work In the paired system, CB after work was significantly higher and more mentally fatiguing than in the single system. Fatigue in nursing is a multifaceted problem because of its complex nature, blending factors, including personal and work system factors (Lee et al., 2014 ). In particular, work system factors can be both fatigue and preventative, depending on whether they are functioning or not (Steege and Dykstra, 2016 ). Additionally, the components of the work system include people, organization, and environment (Steege and Dykstra, 2016 ). Additionally, NDCM is part of the work system and is crucial to reducing nurses’ fatigue levels. However, nurses were usually assigned to a single system in which one nurse was in charge of multiple patients and performed tasks in daily care in Japan for many years. Nurses accustomed to such a system may not be accustomed to the newly introduced pair system, and the pair system does not fully function as an effective system. Additionally, the paired system requires two nurses to work together, so teamwork is essential. Teamwork-related tasks exhibit a significant effect on the nurses’ mental fatigue (Steege et al., 2015 ). Therefore, teamwork is a potential reason why nurses experience mental fatigue in the paired system. 4.3. Before and after work changes in physical fatigue We predicted that the paired system would enable two persons to perform patient care and other tasks together and would cause less physical fatigue than the paired system. However, no association was observed between the single and paired systems in terms of physical fatigue before and after work, and the hypothesis could not be tested. In Japan, many hospitals have a fixed-team nursing system that combines team and primary nursing (Higaonna et al., 2020 ). The results of the study revealed that the fixed-team nursing system is more effective than the primary nursing system. Fixed-team nursing involves one nurse who is basically in charge of multiple patients in her team and performs all daily care and procedures for the patients in her charge. Team members are asked to assist when care is required. The reported advantages of team nursing include the ability to share a heavy workload and to provide each other rest during breaks (O’Connell et al., 2006). In particular, even in a single system, team members can work together in a team environment. In particular, the environment is conducive to obtaining cooperation from team members, which may reduce the physical burden of the team members, even in the case of a single system. Therefore, the present study indicates that changes in the physical fatigue level before and after work were similar in both single and pair systems, with no interaction effect. However, a significant increase in “Group I sleepiness” and “Group III discomfort” as the level of physical fatigue only in the paired group. Nausea is fatigue accompanied by general malaise, whereas instability is fatigue of the head and thinking. Time and multitasking demands have contributed to nurses’ fatigue (Steege et al., 2015 ). The paired system may have affected physical fatigue levels due to the complex time and work management that occurs due to the large number of patients to be assigned and the need for coordination between the two. 4.4. Before and after work changes in mental fatigue We predicted that the paired system would cause less mental fatigue because of the constant support of colleagues. However, no association was found between the single and paired systems in the change in mental fatigue before and after work, but the hypothesis was not tested. The single system is characterized by greater nurse self-sufficiency, more control over information and care decisions, and fewer role conflicts (Fawcett, 2021 ). Thus, we believe that the single system did not impose a stronger psychological burden than the ability to control work at one’s own pace and that the pre- and post-work changes were similar to those in the paired system. The self-negative emotion DD significantly decreased after work in the paired system. Ongoing job stress causes mental fatigue and feelings of helplessness (Cordes and Dougherty, 1993 ). This stress can be reduced through effective communication (Vertino, 2014 ). The pairing system is a form of communication in which two people are always communicating with each other. Two people always communicate and consult with each other while performing their duties in the pair system; thus, emotional stress is less likely to accumulate and DD is decreased. However, F was significantly decreased and TMD was increased in the paired system, indicating that the constant action of two people decreased positive feelings toward the other after working due to their constant concern for the other. The association with coworkers is a factor that affects psychological fatigue (Farag et al., 2022 ). Another factor that contributes to psychological fatigue is teaching new nurses and other professionals (Steege et al., 2015 ). In particular, the nurses who were paired with a partner for the first time or in a position to teach or be taught experienced transient stress during the workday, which manifested itself in overall mental fatigue. We believe that establishing a relationship of mutual respect and consideration between the two partners can reduce mental fatigue and provide an effective model for delivering nursing care. 4.5 Study limitations and implications for future research First, as this was a cross-sectional study, drawing causal conclusions is not possible. Second, as the results were from two hospitals and there were 41 participants in the single regime, the number of eligible institutions and sample size must be expanded to generalize. Third, as the participants included two- and three-shift workers, the possible influence of the working pattern on fatigue cannot be excluded and should be interpreted with caution. In addition, the effectiveness of the care system must be assessed comprehensively, including patient outcomes, impact on patient safety, nurse satisfaction, and impact on overtime. 5. Conclusion We tested the effectiveness of a pair-based nursing delivery system developed in Japan based on four hypotheses. The results showed that there was no interaction between the paired system and the conventionally introduced single system in terms of physical and mental fatigue before and after work, and the hypotheses were not tested because of similar changes. In Japan, the single-pair system is combined with fixed-team nursing, so it is possible that the change in fatigue level was similar to that in the paired system because of the cooperative system in place. However, in the paired system, some items of mental fatigue increased after work and others decreased. In terms of mental fatigue, it became clear that two nurses working together could reduce the level of fatigue after work, and that the level of fatigue became stronger due to concern for the other nurse. Therefore, it was suggested that an innovative nursing care delivery system can be developed by examining ways to reduce mental stress, such as two nurses building a relationship of mutual respect and consideration. 5.1. Relevance to clinical practice This study indicated aspects in which fatigue can be reduced after work by two nurses working together in the paired system and aspects in which fatigue can be intensified based on teamwork with the partner. The reduction of nurses’ fatigue is a crucial issue in the NCDM. Reducing nurse fatigue is crucial to providing safe patient care because it increases nurse job satisfaction, retention, and nurse performance. 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Juntendo Medical Journal , 61 (5), 517–519. https://doi.org/10.14789/jmj.61.517 Koy, V., Yunibhand, J., Angsuroch, Y., & Fisher, M. (2015). Relationship between nursing care quality, nurse staffing, nurse job satisfaction, nurse practice environment, and burnout: Literature review. International Journal of Research in Medical Sciences , 3 (8), 1825–1831. https://doi.org/10.18203/2320-6012.ijrms20150288 Kubo, T., Tachi, N., Takeyama, H., Ebara, T., Inoue, T., Takanishi, T., Arakomo, Y., Murasaki, G. I., & Itani, T. (2008). Characteristic patterns of fatigue feelings on four simulated consecutive night shifts by “Jikaku-sho Shirabe”. Sangyo Eiseigaku Zasshi – Journal of Occupational Health , 50 (5), 133–144. https://doi.org/10.1539/sangyoeisei.b7008 Kubo, T., Takahashi, M., Sato, T., Sasaki, T., Oka, T., & Iwasaki, K. (2011). Weekend sleep intervention for workers with habitually short sleep periods. Scandinavian Journal of Work, Environment and Health , 37 (5), 418–426. https://doi.org/10.5271/sjweh.3162 LeClerc, C. M., Doyon, J., Gravelle, D., Hall, B., & Roussel, J. (2008). The Autonomous-collaborative Care Model: meeting the future head on. Nursing Leadership (Tor Ont) , 21 (2), 63–75. https://doi.org/10.12927/cjnl.2008.19876 Lee, K. A., Dziadkowiec, O., & Meek, P. (2014). A systems science approach to fatigue management in research and health care. Nursing Outlook , 62 (5), 313–321. https://doi.org/10.1016/j.outlook.2014.07.002 Lookinland, S., Tiedeman, M. E., & Crosson, A. E. T. (2005). Nontraditional models of care delivery: Have they solved the problems? Journal of Nursing Administration , 35 (2), 74–80. https://doi.org/10.1097/00005110-200502000-00006. Martínez-Zaragoza, F., Fernández-Castro, J., Benavides-Gil, G., & García-Sierra, R. (2020). How the lagged and accumulated effects of stress, coping, and tasks affect mood and fatigue during nurses' shifts. International Journal of Environmental Research and Public Health , 17 (19), 1–15. https://doi.org/10.3390/ijerph17197277 Min, A., Min, H., & Hong, H. C. (2019). Work schedule characteristics and fatigue among rotating shift nurses in hospital setting: An integrative review. Journal of Nursing Management , 27 (5), 884–895. https://doi.org/10.1111/jonm.12756 Nagai, M., Morikawa, Y., Kitaoka, K., Nakamura, K., Sakurai, M., Nishijo, M., Hamazaki, Y., Maruzeni, S., & Nakagawa, H. (2011). Effects of fatigue on immune function in nurses performing shift work. Journal of Occupational Health , 53 (5), 312–319. https://doi.org/10.1539/joh.10-0072-OA O'Connell, B., Duke, M., Bennett, P., Crawford, S., & Korfiatis, V. (2006). The trials and tribulations of team-nursing. Collegian , 13 (3), 11–17. https://doi.org/10.1016/s1322-7696(08)60527-2. Poku, C. A., Donkor, E., & Naab, F. (2020). Determinants of emotional exhaustion among nursing workforce in urban Ghana: A cross-sectional study. BMC Nursing , 19 (1), 116. https://doi.org/10.1186/s12912-020-00512-z Prentice, D., Moore, J., & Desai, Y. (2021). Nursing care delivery models and outcomes: A literature review. Nursing Forum , 56 (4), 971–979. https://doi.org/10.1111/nuf.12640 Sasaki, T., & Matsumoto, S. (2005). Actual conditions of work, fatigue and sleep in non-employed, home-based female information technology workers with preschool children. Industrial Health , 43 (1), 142–150. https://doi.org/10.2486/indhealth.43.142 Smith-Miller, C. A., Shaw-Kokot, J., Curro, B., & Jones, C. B. (2014). An integrative review: fatigue among nurses in acute care settings. Journal of Nursing Administration , 44 (9), 487–494. https://doi.org/10.1097/NNA.0000000000000104 Steege, L. M., Drake, D. A., Olivas, M., & Mazza, G. (2015). Evaluation of physically and mentally fatiguing tasks and sources of fatigue as reported by registered nurses. Journal of Nursing Management , 23 (2), 179–189. https://doi.org/10.1111/JONM.12112 Steege, L. M., & Dykstra, J. G. (2016). A macroergonomic perspective on fatigue and coping in the hospital nurse work system. Applied Ergonomics , 54 , 19–26. https://doi.org/10.1016/j.apergo.2015.11.006 Tran, D. T., Johnson, M., Fernandez, R., & Jones, S. (2010). A shared care model vs. a patient allocation model of nursing care delivery: Comparing nursing staff satisfaction and stress outcomes. International Journal of Nursing Practice , 16 (2), 148–158. https://doi.org/10.1111/j.1440-172X.2010.01823.x Vertino, K. A. (2014). Effective interpersonal communication: A practical guide to improve your life. Online Journal of Issues in Nursing , 19 (3), 1. https://doi.org/10.3912/OJIN.Vol19No03Man01 Wells, J., Manuel, M., & Cunning, G. (2011). Changing the model of care delivery: Nurses' perceptions of job satisfaction and care effectiveness. Journal of Nursing Management , 19 (6), 777–785. https://doi.org/10.1111/j.1365-2834.2011.01292.x White, D., Oelke, N. D., Besner, J., Doran, D., McGillis Hall, L., & Giovannetti, P. (2008). Nursing scope of practice: Descriptions and challenges. Nursing Leadership . Tor. Ont., 21 (1), 44–57. https://doi.org/10.12927/cjnl.2008.19690 Winwood, P. C., & Lushington, K. (2006). Disentangling the effects of psychological and physical work demands on sleep, recovery and maladaptive chronic stress outcomes within a large sample of Australian nurses. Journal of Advanced Nursing , 56 (6), 679–689. https://doi.org/10.1111/j.1365-2648.2006.04055.x Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5107994","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":355598954,"identity":"281b482c-6a66-40d3-b8f6-55477d9ddcd4","order_by":0,"name":"Naomi Kisanuki","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEUlEQVRIiWNgGAWjYBACCWYwlcDDwMB8AMRibIDKMBOhhS2BSC0QCqSaxwBFC04g2c7+8HNhW5oMg3TPN4kffw7L9jcA9f6oYWA3x6FFmpnHWHpmWw4Pg8zZbZK9bYeNZxzgMWDsOcbAbInDPjlmHgZp3rYKHvsbudskeBsOJzbcf2PAwNvAwGxwAJcW9se/QVoYJHKeSf75czhxPsiWv3i0SDMzmAFtyQFpYZPmYTucuAGohRmfLZLNPGbWPOfSgFrSjK1l29KNNx5gKzgsc0wCp18kzh9/fJunLNmeQSL54c03f6xl5x1g3vjwTY1NMq4QQwYsEjAW0EkSyQZEaGH+gMyzI0bLKBgFo2AUjAgAAJFdTxe/vs1xAAAAAElFTkSuQmCC","orcid":"","institution":"Yasuda Women’s University","correspondingAuthor":true,"prefix":"","firstName":"Naomi","middleName":"","lastName":"Kisanuki","suffix":""},{"id":355598955,"identity":"bc0b135e-c180-44c6-9855-7a5941946562","order_by":1,"name":"Sanae Oriyama","email":"","orcid":"","institution":"Hiroshima University","correspondingAuthor":false,"prefix":"","firstName":"Sanae","middleName":"","lastName":"Oriyama","suffix":""}],"badges":[],"createdAt":"2024-09-18 07:55:00","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-5107994/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5107994/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":64882859,"identity":"993284ed-dbf3-41ba-8666-e5a728904f81","added_by":"auto","created_at":"2024-09-20 03:54:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":842258,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5107994/v1/56340f07-e8e8-4caa-9759-dc753c690a4e.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eEffects of nursing care delivery models on nurses’ fatigue: a cross-sectional study\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Practitioner points","content":"\u003cul\u003e\n \u003cli\u003eIn the paired system, in which two nurses work in pairs to provide nursing care to multiple patients daily, self-negative feelings decrease after work because the two nurses always communicate and work together.\u003c/li\u003e\n \u003cli\u003eThe paired system remained not fully established because some mental fatigue items increased after work while others decreased, indicating that it is an innovative model of nursing care delivery by strengthening the relationship between the two nurses to respect each other.\u003c/li\u003e\n \u003cli\u003ePhysical and mental fatigue before and after work demonstrated no association in the paired-patient system and the conventional system in which a single nurse is in charge of multiple patients, but establishing a system and continuously verifying the effectiveness of the system remains necessary.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"1. Introduction","content":"\u003cp\u003eMany healthcare organizations globally are facing a nursing shortage that influences their ability to provide healthcare services. To address this issue, determining the appropriate nurse staffing and the appropriate nursing care delivery model (NCDM) required to provide quality patient care is essential (Fowler et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) (Prentice et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The general NCDM includes the following components. Common NCDMs involve function-specific nursing, team nursing, total patient care, and primary nursing. Hospital nursing managers identify the NCDM based on the characteristics of their hospital or combine multiple NCDMs into a system to provide quality and safe nursing care (Jennings, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2008\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEmpirical evidence related to the quality of nursing care for this NCDM is limited (Hall et al., 2004) (LeClerc et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). Additionally, studies of systems combine skill mix with NCDM by introducing assistant nurses and nursing assistants in response to nursing shortages (Lookinland et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2005\u003c/span\u003e) (Harris and Hall, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Thus, NCDM is currently sought and prepared following the characteristics of each hospital for nurses to divide labor and efficiently provide quality nursing services to patients and their families. Organizations are urged to organize their work and to consider innovative methods of NCDM due to the recent economic and human resource pressures.\u003c/p\u003e \u003cp\u003eRegarding NDCM, studies of the association between NDCM and patient or nurse outcomes have been conducted. A survey of Canadian surgical nurses in terms of patient outcomes revealed that nurses working in team nursing demonstrated more unfinished business and a higher frequency of patient adverse events than those working in total patient care (Havaei et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Additionally, an Italian hospital reported a decrease in the number of patients with urinary tract infections and venous catheter infections after introducing primary nursing, as well as a decrease in the number of patients with falls and pressure ulcers (Dal Molin et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConversely, concerning nurse outcomes, the transition of NDCM from individual patient-assigned nursing to team nursing in an Australian hospital has improved job satisfaction and substantially improved retention of key staff (Fairbrother et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Additionally, no significant change was found in nurses\u0026rsquo; job satisfaction when changing from team nursing to total patient care, although total patient care was more effective (Wells et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) (Tran et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Thus, no NCDM has been adequately investigated, as no NCDMs produce positive outcomes for patients and nurses.\u003c/p\u003e \u003cp\u003eIn Japan, fixed-team nursing and, more recently, a system in which two nurses pair up to provide nursing care (paired system) have become widespread. A 2017 survey revealed that 24% of national university hospitals had adopted fixed-team nursing and 52% had adopted the paired system (Higaonna and Morimoto, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). The paired system, where all nurses, including experienced nurses, work in pairs to provide daily nursing care for multiple patients, differs from the traditional Japanese system in which one nurse provides daily nursing care for multiple patients (single system). The number of nurses remained in the paired system, whereas the number of patients was greater than in the single system because the number of patients was the same as that handled by the two nurses in the single system. A study that compared the mortality rate and activities of daily living status of patients in this paired system with fixed-team nursing, which is a predominant practice in Japan, revealed no significant difference in mortality rate and an increase in the number of patients with decreased activities of daily living (Higaonna et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). However, studies on the effectiveness of the paired system are limited, partly because of the short period since its development.\u003c/p\u003e \u003cp\u003eThe paired system is characterized by nurses complementing each other and working together and is more efficient and less physically and mentally straining. The skill mix between assistant nurses and nursing assistants is frustrating because their roles are unclear (White et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). They emphasize that this role uncertainty results in competition among healthcare providers, workplace tensions, lack of trust among healthcare providers, and lack of effective teamwork (Baranek, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). However, the paired system may be an innovative NCDM in which nurses with the same qualifications work in pairs, thereby reducing the burden and decreasing fatigue without any role uncertainty. Furthermore, nurses are physically and mentally fatigued due to the nature of their work and the tasks required of them. Focusing on reducing fatigue among nurses is important, considering that fatigue demonstrates a strong negative impact on the patient.\u003c/p\u003e \u003cp\u003eA study of Spanish nurses revealed that the higher the level of such support from colleagues, the lower the mental fatigue score (Albar Mar\u0026iacute;n and Garc\u0026iacute;a-Ram\u0026iacute;rez, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). Paired systems always perform tasks with the support of their colleagues. Therefore, a paired system in which work is performed with constant support from colleagues is predicted to cause a sense of security among nurses and reduce mental fatigue from before to after work. Additionally, the high level of mental fatigue affects the quality of care (Poku et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) (Koy et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Reducing the mental fatigue of nurses is crucial for improving and maintaining the quality of nursing care. Furthermore, pairing not only reduces mental fatigue but also reduces the amount of care provided by one person and the stress of finding a nurse to help when another nurse\u0026rsquo;s help is required. Thus, increased physical work demands and stress cause physical fatigue (Farag et al. \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Few studies on NDCM have investigated physical and mental fatigue as an outcome for nurses. However, nurses\u0026rsquo; performance decreases when their physical and mental fatigue is high (Barker and Nussbaum, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Therefore, confirming the association between NDCM and nurses\u0026rsquo; mental and physical fatigue can provide recommendations for NDCM that will cause positive outcomes for patients and nurses.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cp\u003e\u003cstrong\u003e2.1. Aim\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study aimed to test the following hypotheses\u003c/p\u003e\n\u003cp\u003e1. A paired system had lower physical and mental fatigue levels before work compared to a single system.\u003c/p\u003e\n\u003cp\u003e2. Paired systems were less physically and mentally fatigued at the end of work compared to single systems.\u003c/p\u003e\n\u003cp\u003e3. Paired systems demonstrated a lesser increase in physical fatigue at the end of work compared to single systems.\u003c/p\u003e\n\u003cp\u003e4. Paired systems exhibited a lesser increase in mental fatigue at the end of work compared to single systems.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2. Research design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study utilized a comparative cross-sectional survey design with a single system so that the effectiveness of the paired system could be evaluated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3. Sample\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConvenience sampling was used. After confirming by telephone with the directors of nursing departments of general hospitals with \u0026gt;400 beds in five prefectures in the Chugoku region of Japan that used single and paired systems, a set of documents requesting research cooperation was mailed to them, and 675 nurses from two hospitals who agreed to cooperate in the study were selected as participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.4. Data collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe survey was administered to the participants for only one day from March to June 2018. The survey procedure was to distribute a portion of the pre and postservice survey forms together to the participants. The paired nurses were requested to distribute a portion of the survey form with the same number on it to each of them for the paired system. The nurses were asked to fill out the “Subject’s Attributes,” “\u003cem\u003eJikaku-sho shirabe,\u003c/em\u003e” and the POMS2 survey forms before starting work. The nurses were asked to complete the “work status,” “Jikaku\u003cem\u003e-sho shirabe,\u003c/em\u003e” and the POMS2 survey forms at the end of work. The completed forms were collected at the hospital and mailed to the principal investigator.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5. Measurements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5.1. Participant attributes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants’ age, sex, years of clinical experience, sleep time on the previous day, and attributes were investigated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5.2. Status of work on the day of the survey\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe status of work on the day of the survey was investigated in terms of “work during the day (day shift or long day shift),” “number of patients in charge (patients discharged or transferred in the morning were not included),” “rest time,” “overtime hours,” and “work status during the day.” In Japan, third-shift night shift workers work 8-h day shifts, and second-shift workers work 12-h long day shifts; thus, these were determined as the work during the day. Respondents were requested to select their work status during the day as “busy,” “same,” and “not busy” compared to the usual work status.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5.3. Physical fatigue: “\u003cem\u003eJikaku-sho shirabe”\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Japanese Society for Industrial and Labor Research developed \u003cem\u003eJikaku-sho shirabe\u003c/em\u003e as a measure of physical fatigue, which is mainly used to investigate fatigue in the sense of reduced physical capacity, as in this study (Sasaki and Matsumoto, 2005) (Kubo et al., 2011). This questionnaire consists of 25 subjective fatigue symptoms that are categorized into five factors of feeling: (ⅰ) drowsiness, (ii) instability, (iii) uneasiness, (iv) local pain or dullness, and (v) eyestrain. Participants were requested to rate their fatigue for each item on the following scale: “Strongly disagree,” “Mostly disagree,” “A little agree,” “Fairly agree,” and ”Strongly agree.” Each of these five intensities were assigned a score from 1 to 5. A higher score demonstrates a greater degree of fatigue.\u003cem\u003e Jikaku-sho shirabe \u003c/em\u003ehas been validated for factorial validity and internal consistency (Kubo et al., 2008)(Nagai et al., 2011)．\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.5.4. Mental fatigue: “POMS2 (short version)\u003c/strong\u003e \u003cstrong\u003e(POMS2)”\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePOMS2, as mental fatigue assessment, is sensitive to subjective stress and mood disorder levels and measures emotional state (Galantino et al., 2005) The POMS2 was used, which consists of the following five items: anger-hostility (AH), confusion-bewilderment (CB), depression-dejection (DD), fatigue-inertia (FI), tension-anxiety (TA), vigor-activity (VA), and friendliness (F). The scale consisted of five items in each of the lower five items of the scale and is rated on a five-point scale ranging from 0 (not at all) to 4 (very much). The POMS2 is characterized by its ability to measure transient emotions and moods based on the conditions in which they occur. The POMS2 calculates and evaluates the T score, which is a standardized version of the surveyed scores, and the “total mood disturbance (TMD)” score, which indicates overall mood status from items other than F. Higher T scores for TMD score and negative mood states (AH, CB, DD, FI, and TA) indicate more negative emotions and mood disorders. Higher T scores for positive affective states (VA and F) indicate a more positive affective state. The Japanese version of the POMS2 has been confirmed for standardization, reliability, and validity (Konuma et al., 2015).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.6 Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSingle and paired systems were compared for subject attributes, work status, physical and mental fatigue before work, and physical and mental fatigue after work using chi-square tests or paired \u003cem\u003et\u003c/em\u003e-tests. A repeated measure two-way analysis of variance (ANOVA) was utilized to compare single and paired systems for changes over time in physical and mental fatigue from before to after work. A \u003cem\u003et\u003c/em\u003e-test was conducted on the change in physical and mental fatigue before and after work in each of the single and paired systems.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.7. Ethical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten and oral explanations were provided to the facility administrators, and their consent was obtained. The participants were sent an explanatory letter and a survey form, and consent was assumed to have been obtained if they responded to the survey. The XXX University Epidemiological Research Ethics Review Committee approved the study (Approval No. XXX).\u003c/p\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003e3.1. Sample characteristics\u003c/h2\u003e\n \u003cp\u003eOf the 565 respondents (83.7% response rate), this study included 450 (79.6% valid response rate) with no missing values, including 40 and 410 in the single and paired systems, respectively.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003ch2\u003e3.2. Background of the participants and work status during the day\u003c/h2\u003e\n \u003cp\u003eThe backgrounds of the participants and their working conditions during the day were compared between the single and paired systems (Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The number of patients in charge was with 5.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11.0 and 7.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6 in the single-patient and paired groups, respectively, with the paired group demonstrating a significantly higher number of patients. Other items were not significantly different between the two systems.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eBackground of the participants and their work situation during the day\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003eSingle system (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\n \u003cp\u003eMean (SD) or n %\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003ePaired system (n\u0026thinsp;=\u0026thinsp;410)\u003c/p\u003e\n \u003cp\u003eMean (SD) or n (%)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e30.3 (7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e28.9 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eSex\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.045\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003cp\u003e80.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e20.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e370\u003c/p\u003e\n \u003cp\u003e90.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003cp\u003e9.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYears of clinical experience (years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e7.9 (7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e6.8 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHours of sleep on the previous day (hours)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e6.6(1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e6.6(1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.97\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eWork on the day\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eday shift\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003elong day shift\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eday shift\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003elong day shift\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003cp\u003e75.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e289\u003c/p\u003e\n \u003cp\u003e70.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e118\u003c/p\u003e\n \u003cp\u003e28.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e0.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber of patients in charge (persons)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e5.5(2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e7.3(3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBreak time (minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e53.0 (11.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e51.4 (12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOvertime (minutes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"4\"\u003e\n \u003cp\u003e35.4 (31.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"5\"\u003e\n \u003cp\u003e41.5 (45.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003eWorking conditions on the day of the event\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ebusy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSame as usual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI am not busy.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ebusy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSame as usual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eI am not busy.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" rowspan=\"2\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e25.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003cp\u003e50.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e25.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e110\u003c/p\u003e\n \u003cp\u003e26.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e185\u003c/p\u003e\n \u003cp\u003e45.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e115\u003c/p\u003e\n \u003cp\u003e28.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e[Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e about here]\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003e\u003cstrong\u003e3.3. Physical and mental fatigue before work\u003c/strong\u003e\u003c/h2\u003e\n \u003cp\u003eWe compared \u003cem\u003eJikaku-sho shirabe\u003c/em\u003e and POMS2 before working between the single and paired systems (Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e) and revealed no significant differences in all items. Among the \u003cem\u003eJikaku-sho shirabe\u003c/em\u003e items, (ⅰ) feeling of drowsiness was higher in both systems, whereas among the POMS2 items, \u0026ldquo;F\u0026rdquo; was higher in both systems.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of single and paired systems of physical and mental fatigue before work\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSingle system (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePaired system (n\u0026thinsp;=\u0026thinsp;410)\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eJikaku-sho shirabe\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFactors Ⅰ: feeling of drowsiness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.09 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.01 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFactors Ⅱ: feeling of instability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.60 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.64 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFactors III: feeling of uneasiness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.57 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.51 (0.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFactors Ⅳ: feeling of local pain or dullness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.83 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.75 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFactors Ⅴ: feeling of eyestrains\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.63 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.64 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003ePOMS2 (short version)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eanger-hostility (AH)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.0 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.5 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003econfusion-bewilderment (CB)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.1 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.3 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003edepression-dejection (DD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.5 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.1 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003efatigue-inertia (FI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.2 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.5 (10.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003etension-anxiety (TA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.8 (7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.1 (9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003evigor-activity (VA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.5 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.9 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003efriendliness (F)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.3 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.4 (8.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003etotal mood disturbance (TMD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.4 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.6 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e[Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e about here]\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n \u003ch2\u003e3.4. Physical and mental fatigue after work\u003c/h2\u003e\n \u003cp\u003eWe compared \u003cem\u003eJikaku-sho shirabe\u003c/em\u003e and POMS after working between the single and paired systems (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e) and revealed that mental fatigue \u0026ldquo;CB\u0026rdquo; was significantly higher in the single system (41.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.0) versus the paired system (44.6\u0026thinsp;\u0026plusmn;\u0026thinsp;9.0). The item of \u003cem\u003eJikaku-sho shirabe\u003c/em\u003e of (ⅰ) feeling of drowsiness\u0026rdquo; and the POMS2 item of \u0026ldquo;F\u0026rdquo; were high in both systems.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of single and paired systems of physical and mental fatigue after work\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eSingle system (n\u0026thinsp;=\u0026thinsp;40)\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePaired system (n\u0026thinsp;=\u0026thinsp;410)\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eJikaku-sho shirabe\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFactors Ⅰ: feeling of drowsiness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.28 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.28 (1.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFactors Ⅱ: feeling of instability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.48 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.66 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFactors III: feeling of uneasiness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.61 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.69 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFactors Ⅳ: feeling of local pain or dullness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.15 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.06 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFactors Ⅴ: feeling of eyestrains\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.93 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.88 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePOMS2 (short version)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eanger-hostility (AH)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.7 (10.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.5 (7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003econfusion-bewilderment (CB)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.5 (9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.6 (9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.040 *\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003edepression-dejection (DD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.0 (9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.4 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003efatigue-inertia (FI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.3 (10.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48.9 (11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003etension-anxiety (TA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.5 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.6 (9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003evigor-activity (VA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.2 (7.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44. 4 (9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003efriendliness (F)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.5 (9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50.1 (9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003etotal mood disturbance (TMD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.3 (10.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.0 (8.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e*\u003cem\u003et\u003c/em\u003e-test, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e[Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e about here]\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003ch2\u003e3.5. Changes in physical fatigue before and after work\u003c/h2\u003e\n \u003cp\u003eA two-way ANOVA of the Subjective Illness Questionnaire, before and after work between the single and paired systems, revealed no associations for all items ([ⅰ] feeling of drowsiness vs. F [1,448]\u0026thinsp;=\u0026thinsp;0.34; [ii] feeling of instability vs. F [1,448]\u0026thinsp;=\u0026thinsp;1.79; [iii] feeling of uneasiness vs. F [1,448]\u0026thinsp;=\u0026thinsp;2.08; [iv] feeling of local pain or dullness vs. F [1,448]\u0026thinsp;=\u0026thinsp;0.01; (v) feeling of eyestrain vs. F [1,448]\u0026thinsp;=\u0026thinsp;0.01) (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). A two-way ANOVA was then conducted for the bottom 25 items of \u003cem\u003eJikaku-sho shirabe\u003c/em\u003e, and an interaction was revealed for one item, (iii) discomfort: dizziness (F =[1,448]\u0026thinsp;=\u0026thinsp;7.996, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01). The single system decreased from 1.30 before work to 1.15 after work, whereas the paired system increased from 1.15 to 1.30. Additionally, \u003cem\u003et\u003c/em\u003e-tests were conducted before and after work in both the single and paired systems, revealing that the two items, (iv) feeling of local pain or dullness and (v) feeling of eyestrain, in \u003cem\u003eJikaku-sho shirabe\u003c/em\u003e significantly increased after work. The \u003cem\u003et\u003c/em\u003e-tests conducted before and after work in the single and paired systems, respectively, revealed that the two items, (iv) feeling of local pain or dullness and (v) feeling of eyestrain, in \u003cem\u003eJikaku-sho shirabe\u003c/em\u003e significantly increased after work in both systems. Items (ⅰ) feeling of drowsiness and (iii) feeling of uneasiness of \u003cem\u003eJikaku-sho shirabe\u003c/em\u003e significantly increased after work in the paired system alone (Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eChange in physical fatigue from before to after work\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSingle system\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePair system\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBefore\u003c/p\u003e\n \u003cp\u003ework\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAfter work\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003et\u003c/em\u003e-test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBefore work\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAfter work\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003et\u003c/em\u003e-test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eANOVA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFactors Ⅰ:\u003c/p\u003e\n \u003cp\u003efeeling of drowsiness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.09 (0.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.28 (0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.01 (0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.28 (1.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFactors Ⅱ:\u003c/p\u003e\n \u003cp\u003efeeling of instability\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.60 (0.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.48 (0.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.64 (0.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.66 (0.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.569\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFactors III:\u003c/p\u003e\n \u003cp\u003efeeling of uneasiness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.57 (0.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.61 (0.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.51 (0.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.69 (0.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFactors Ⅳ:\u003c/p\u003e\n \u003cp\u003efeeling of local pain or dullness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.83 (0.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.15 (0.73)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.75 (0.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.06 (0.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFactors Ⅴ:\u003c/p\u003e\n \u003cp\u003efeeling of eyestrains\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.63 (0.70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.93 (0.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.64 (0.79)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.88 (0.91)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\"\u003e*\u003cem\u003et\u003c/em\u003e-test, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e[Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e about here]\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n \u003ch2\u003e3.6. Change in mental fatigue before and after work\u003c/h2\u003e\n \u003cp\u003eA two-way ANOVA of the POMS 2 revealed no association between the single and paired systems before and after work in the change in \u003cem\u003et\u003c/em\u003e score for all items (AH vs. F [1,448]\u0026thinsp;=\u0026thinsp;0.58, CB vs. F [1,448]\u0026thinsp;=\u0026thinsp;3.00, DD vs. F [1,448]\u0026thinsp;=\u0026thinsp;0.07, FI vs. F [1,448]\u0026thinsp;=\u0026thinsp;0.04, TA vs. F [1,448]\u0026thinsp;=\u0026thinsp;0.40, VA vs. F [1,448]\u0026thinsp;=\u0026thinsp;0.02, F vs. F [1,448]\u0026thinsp;=\u0026thinsp;1.93, TMD vs. F [1,448]\u0026thinsp;=\u0026thinsp;0.28). Additionally, \u003cem\u003et\u003c/em\u003e-tests were conducted before and after work in each of the single and pair systems, revealing that TA and VA demonstrated significantly decreased T scores after work in both systems whereas FI exhibited a significantly increased T score. Items DD and F decreased significantly, whereas TMD increased significantly in the paired system (Table \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab5\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eChange in mental fatigue from before to after work\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePOM2\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eSingle system\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003ePaired system\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e-value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBefore work\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAfter work\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003et\u003c/em\u003e-test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBefore\u003c/p\u003e\n \u003cp\u003ework\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAfter work\u003c/p\u003e\n \u003cp\u003eMean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cem\u003et\u003c/em\u003e-test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eANOVA\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eanger-hostility\u003c/p\u003e\n \u003cp\u003e(AH)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.0 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.7 (10.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.5 (6.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.4 (7.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003econfusion-bewilderment\u003c/p\u003e\n \u003cp\u003e(CB)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.1 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.5 (9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.3 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.6 (9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003edepression-dejection\u003c/p\u003e\n \u003cp\u003e(DD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.5 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.0 (9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.1 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.4 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003efatigue-inertia\u003c/p\u003e\n \u003cp\u003e(FI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.2 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.3 (10.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.5 (10.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48.9 (11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003etension-anxiety\u003c/p\u003e\n \u003cp\u003e(TA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.8 (7.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.5 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.002*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.1 (9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.6 (9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003evigor-activity\u003c/p\u003e\n \u003cp\u003e(VA)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.5 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.2 (7.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.9 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44. 4 (9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003efriendliness\u003c/p\u003e\n \u003cp\u003e(F)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.3 (9.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.5 (9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e51.4 (8.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50.1 (9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003etotal mood disturbance\u003c/p\u003e\n \u003cp\u003e(TMD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.4 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.3 (10.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.6 (8.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.0 (8.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.000*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\"\u003e\u003cem\u003e*t\u003c/em\u003e-test, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003e[Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e about here]\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e4.1. Physical and mental fatigue before work\u003c/h2\u003e \u003cp\u003eNo difference was found in the physical and mental fatigue levels before work between the single and paired systems; thus, the paired or single system did not affect the fatigue level before work. Nurses experienced more fatigue than other healthcare professionals (Barker and Nussbaum, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) (Smith-Miller et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). In particular, nurses may experience fatigue that is exacerbated by shift work and may not recover before the next shift (Min et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Under such conditions, fatigue will be stronger in the single system than in the paired system due to the effects of pressure to assume sole responsibility, but this hypothesis was not tested. Sleep disturbance due to shift work decreases recovery from fatigue (Winwood and Lushington, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2006\u003c/span\u003e) (Min et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). The present results revealed that both groups demonstrated the highest (ⅰ) feeling of drowsiness of \u003cem\u003eJikaku-sho shirabe\u003c/em\u003e before work, indicating that they had not fully recovered from fatigue from shift work. Various factors, including sleep duration and leisure time, affect recovery from fatigue between shifts (Smith-Miller et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) (Mart\u0026iacute;nez-Zaragoza et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Thus, large individual differences were found in fatigue recovery, and this survey may not have reflected the differences between the two systems. However, we believe that continuing to investigate this issue as an evaluation of NDCM is necessary, since NDCM may have some effect at the beginning of work.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section2\"\u003e \u003ch2\u003e4.2. Physical and mental fatigue after work\u003c/h2\u003e \u003cp\u003eIn the paired system, CB after work was significantly higher and more mentally fatiguing than in the single system. Fatigue in nursing is a multifaceted problem because of its complex nature, blending factors, including personal and work system factors (Lee et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). In particular, work system factors can be both fatigue and preventative, depending on whether they are functioning or not (Steege and Dykstra, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Additionally, the components of the work system include people, organization, and environment (Steege and Dykstra, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Additionally, NDCM is part of the work system and is crucial to reducing nurses\u0026rsquo; fatigue levels. However, nurses were usually assigned to a single system in which one nurse was in charge of multiple patients and performed tasks in daily care in Japan for many years. Nurses accustomed to such a system may not be accustomed to the newly introduced pair system, and the pair system does not fully function as an effective system. Additionally, the paired system requires two nurses to work together, so teamwork is essential. Teamwork-related tasks exhibit a significant effect on the nurses\u0026rsquo; mental fatigue (Steege et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Therefore, teamwork is a potential reason why nurses experience mental fatigue in the paired system.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e4.3. Before and after work changes in physical fatigue\u003c/h2\u003e \u003cp\u003eWe predicted that the paired system would enable two persons to perform patient care and other tasks together and would cause less physical fatigue than the paired system. However, no association was observed between the single and paired systems in terms of physical fatigue before and after work, and the hypothesis could not be tested. In Japan, many hospitals have a fixed-team nursing system that combines team and primary nursing (Higaonna et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The results of the study revealed that the fixed-team nursing system is more effective than the primary nursing system. Fixed-team nursing involves one nurse who is basically in charge of multiple patients in her team and performs all daily care and procedures for the patients in her charge. Team members are asked to assist when care is required. The reported advantages of team nursing include the ability to share a heavy workload and to provide each other rest during breaks (O\u0026rsquo;Connell et al., 2006). In particular, even in a single system, team members can work together in a team environment. In particular, the environment is conducive to obtaining cooperation from team members, which may reduce the physical burden of the team members, even in the case of a single system. Therefore, the present study indicates that changes in the physical fatigue level before and after work were similar in both single and pair systems, with no interaction effect.\u003c/p\u003e \u003cp\u003eHowever, a significant increase in \u0026ldquo;Group I sleepiness\u0026rdquo; and \u0026ldquo;Group III discomfort\u0026rdquo; as the level of physical fatigue only in the paired group. Nausea is fatigue accompanied by general malaise, whereas instability is fatigue of the head and thinking. Time and multitasking demands have contributed to nurses\u0026rsquo; fatigue (Steege et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). The paired system may have affected physical fatigue levels due to the complex time and work management that occurs due to the large number of patients to be assigned and the need for coordination between the two.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003e4.4. Before and after work changes in mental fatigue\u003c/h2\u003e \u003cp\u003eWe predicted that the paired system would cause less mental fatigue because of the constant support of colleagues. However, no association was found between the single and paired systems in the change in mental fatigue before and after work, but the hypothesis was not tested. The single system is characterized by greater nurse self-sufficiency, more control over information and care decisions, and fewer role conflicts (Fawcett, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Thus, we believe that the single system did not impose a stronger psychological burden than the ability to control work at one\u0026rsquo;s own pace and that the pre- and post-work changes were similar to those in the paired system.\u003c/p\u003e \u003cp\u003eThe self-negative emotion DD significantly decreased after work in the paired system. Ongoing job stress causes mental fatigue and feelings of helplessness (Cordes and Dougherty, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e1993\u003c/span\u003e). This stress can be reduced through effective communication (Vertino, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). The pairing system is a form of communication in which two people are always communicating with each other. Two people always communicate and consult with each other while performing their duties in the pair system; thus, emotional stress is less likely to accumulate and DD is decreased.\u003c/p\u003e \u003cp\u003eHowever, F was significantly decreased and TMD was increased in the paired system, indicating that the constant action of two people decreased positive feelings toward the other after working due to their constant concern for the other. The association with coworkers is a factor that affects psychological fatigue (Farag et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Another factor that contributes to psychological fatigue is teaching new nurses and other professionals (Steege et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). In particular, the nurses who were paired with a partner for the first time or in a position to teach or be taught experienced transient stress during the workday, which manifested itself in overall mental fatigue. We believe that establishing a relationship of mutual respect and consideration between the two partners can reduce mental fatigue and provide an effective model for delivering nursing care.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003e4.5 Study limitations and implications for future research\u003c/h2\u003e \u003cp\u003eFirst, as this was a cross-sectional study, drawing causal conclusions is not possible. Second, as the results were from two hospitals and there were 41 participants in the single regime, the number of eligible institutions and sample size must be expanded to generalize. Third, as the participants included two- and three-shift workers, the possible influence of the working pattern on fatigue cannot be excluded and should be interpreted with caution. In addition, the effectiveness of the care system must be assessed comprehensively, including patient outcomes, impact on patient safety, nurse satisfaction, and impact on overtime.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eWe tested the effectiveness of a pair-based nursing delivery system developed in Japan based on four hypotheses. The results showed that there was no interaction between the paired system and the conventionally introduced single system in terms of physical and mental fatigue before and after work, and the hypotheses were not tested because of similar changes. In Japan, the single-pair system is combined with fixed-team nursing, so it is possible that the change in fatigue level was similar to that in the paired system because of the cooperative system in place. However, in the paired system, some items of mental fatigue increased after work and others decreased. In terms of mental fatigue, it became clear that two nurses working together could reduce the level of fatigue after work, and that the level of fatigue became stronger due to concern for the other nurse. Therefore, it was suggested that an innovative nursing care delivery system can be developed by examining ways to reduce mental stress, such as two nurses building a relationship of mutual respect and consideration.\u003c/p\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003e5.1. Relevance to clinical practice\u003c/h2\u003e \u003cp\u003eThis study indicated aspects in which fatigue can be reduced after work by two nurses working together in the paired system and aspects in which fatigue can be intensified based on teamwork with the partner. The reduction of nurses\u0026rsquo; fatigue is a crucial issue in the NCDM. Reducing nurse fatigue is crucial to providing safe patient care because it increases nurse job satisfaction, retention, and nurse performance.\u003c/p\u003e \u003c/div\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAlbar Mar\u0026iacute;n, M. J., \u0026amp; Garc\u0026iacute;a-Ram\u0026iacute;rez, M. (2005). Social support and emotional exhaustion among hospital nursing staff. \u003cem\u003eEuropean Journal of Psychiatry\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(2), 96\u0026ndash;106. https://doi.org/10.4321/S0213-61632005000200004\u003c/li\u003e\n \u003cli\u003eBaranek, P. M. 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Disentangling the effects of psychological and physical work demands on sleep, recovery and maladaptive chronic stress outcomes within a large sample of Australian nurses. \u003cem\u003eJournal of Advanced Nursing\u003c/em\u003e, \u003cem\u003e56\u003c/em\u003e(6), 679\u0026ndash;689. https://doi.org/10.1111/j.1365-2648.2006.04055.x\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Nursing Care Delivery Model, Nurse, Physical Fatigue, Mental Fatigue, A Cross-sectional Study","lastPublishedDoi":"10.21203/rs.3.rs-5107994/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5107994/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eA new nursing care delivery model has been developed in Japan in which all nurses, including experienced nurses, work in pairs to provide daily nursing care for multiple patients. This study aimed to confirm the effectiveness of the paired system by comparing physical changes and mental fatigue before and after work with the conventional system in which one nurse is responsible for several patients. Physical and mental fatigue levels were measured before and after for 675 nurses working at two hospitals with \u0026gt;400 beds. Repeated measures of two-way analysis of variance for changes over time before and after work revealed no interaction. In the paired system, self-negativity was significantly decreased after than before work. This is because, in the paired system, two workers always communicate and consult with each other while performing their work; thus, emotional stress may less accumulate. The system remains not fully established because it has only been implemented for a short time. Strengthening pair relationships was considered an innovative model.\u003c/p\u003e","manuscriptTitle":"Effects of nursing care delivery models on nurses’ fatigue: a cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-20 03:46:10","doi":"10.21203/rs.3.rs-5107994/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e625f9c0-873f-4fc8-a397-4a52cf4614ee","owner":[],"postedDate":"September 20th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":37801821,"name":"Nursing"}],"tags":[],"updatedAt":"2024-09-20T03:46:10+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-20 03:46:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5107994","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5107994","identity":"rs-5107994","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}