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ORIGINAL ARTICLES |
From the Department of Psychiatry and Biobehavioral Sciences (I.B.G., D.S., D.G.), University of California, Los Angeles, and the Department of Psychiatry and Human Behavior (A.C.-D.), University of California, Irvine, California.
Address reprint requests to: Iris B. Goldstein, PhD, Department of Psychiatry, UCLA, 760 Westwood Plaza, Los Angeles, CA 90024-1759. Email: irisg{at}ucla.edu
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSACKNOWLEDGMENTSREFERENCES |
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METHODS: Ambulatory blood pressure (BP) and heart rate (HR) were recorded over 24-hour periods on 2 work and 2 off days during the luteal and follicular phases of the menstrual cycle in 138 registered nurses, aged 25 to 50 years. Urinary catecholamines and cortisol were measured for day and night periods.
RESULTS: During waking hours systolic BP (SBP), HR, and epinephrine were higher on work than off days. Diastolic BP (DBP) and HR were highest at work. Nurses scoring high on job demands had elevations in daytime SBP, daytime HR only on work days, and nighttime epinephrine on work days. Compared with those with short work histories, nurses employed longer had consistently higher norepinephrine levels during days and nights, and higher nighttime DBP during off days. In unmarried nurses compared with married nurses, nighttime cortisol was lower during all 4 days and norepinephrine was lower during days off. All findings were independent of actigraph-recorded activity.
CONCLUSIONS: Although the work environment leads to increased activity of the cardiovascular and sympathoadrenal medullary system in healthy women, the effects are modified by the woman’s domestic role, by the length of her employment, and by the demands of her job.
Key Words: ambulatory blood pressure • catecholamines • cortisol • women • work
Abbreviations: BP = blood pressure; DBP = diastolic blood pressure; SBP = systolic blood pressure; HR = heart rate; ANOVA =analysis of variance; RN = registered nurse.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSACKNOWLEDGMENTSREFERENCES |
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We focused on the following factors that we felt could modify a woman’s physiological responses to work: menstrual cycle effects, marital status, presence or absence of children in the home, length of employment, and job strain. Prominent among these factors was the issue of whether BP and HR during work and off work days would vary as a function of menstrual cycle phase. Because increased cardiovascular activity is associated with greater sympathetic activation, any situation that further stimulates the sympathetic nervous system should lead to even greater BP and HR increases. Although findings vary considerably, increased sympathetic activity has been reported during the luteal phase of the menstrual cycle (6). One group of investigators (7–9) found higher BP and HR in the luteal phase than in the follicular phase, although others reported no changes in BP as a result of menstrual cycle phase (10, 11). Although there might be some increase in cardiovascular activity because of sympathetic activation during the luteal phase, prior findings would lead one to expect these effects to be small (12).
Concerning a woman’s role at home, the literature has shown that working full time may lead to some reduction in housework time, but the woman still retains primary responsibility for housework and child care (13–15). The added household responsibilities that accompany marriage and children could contribute to a working woman’s feelings of stress eliciting a sympathetic response and an increase in BP that could extend to the work situation. In support of this, some investigators found that compared with single women, those who were married had higher ambulatory BP at work (16) and during the work day (17). In addition, women who had children had higher BP at work and at home than those without children (17). We expected to find cardiovascular increases to be associated with having children and with being married. We expected that women with a long work history in nursing would exhibit lower cardiovascular levels because they would have learned skills enabling them to cope with problems at work.
Whether BP is elevated at work may be a function of the level of job strain, which is a ratio of job demands to job decision latitude (18). When compared with low-strain workers, high-strain university male and female normotensive employees had higher SBP at home in the evening and at work and higher DBP at work (19). For people with borderline hypertension, job strain was related only to DBP at night and during work, but not during leisure time (20). Schnall et al. (21) reported that high job strain in men with and without hypertension was associated with generalized elevations in BP extending not only to home but to sleep as well. Similarly, among normotensive and mild hypertensive male workers in Italy, high-strain subjects had elevations in BP throughout the work day, although there were smaller effects during leisure time and at night (22). Not only are most studies of BP and job strain confined to men, but most of the evidence gathered by Karasek and Theorell (18) on the concept of job strain has been derived from men. Some investigators have questioned whether job strain is associated with BP in women (23), with conflicting findings in this area (16, 24, 25). This may be because compared with men, women perceive working as being less stressful and actually associate work with enhanced well-being (26–28). The present study seeks to determine whether job strain in nurses is associated with increased activity of the cardiovascular and sympathoadrenal medullary systems.
To understand the meaning of cardiovascular responses during work days and off days, catecholamines and cortisol were also measured throughout the day and night. Fluctuations in these urinary stress hormones have been associated with increases in self-reported negative mood states (29, 30). According to Frankenhaeuser (31), elevations in catecholamines on a given day could be interpreted as being related to increased effort, whereas increases in cortisol reflect more negative affect or distress. By assessing urinary catecholamine and cortisol levels along with cardiovascular responses, we hoped to determine the impact of work and off work days on our sample of women nurses. To the extent that work has primarily positive benefits for women, we expected there to be very little difference in cortisol between work and off days.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONSACKNOWLEDGMENTSREFERENCES |
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Subjects were excluded if they reported any health problems, taking any medication, or using oral contraceptives. They were requested to refrain from the use of short-term acting drugs (eg, aspirin, antihistamines) at least 1 day before and during any of the study sessions. Subjects had an average body mass index (BMI) of 23.4 (3.4) kg/m2. We excluded those with severe obesity (BMI 
30 kg/m2), those who had been pregnant or lactating within the last 12 months, and postmenopausal women. Based on the average of three casual BP recordings taken according to standard assessment (32) over each of five sessions, only two subjects had BP levels that were over normal limits (141/89 and 138/93 mm Hg) (32). A minimum of 1 year of nursing experience was required for inclusion in the study. Only four of the subjects were smokers. Information on length of menstrual cycle was obtained from subjects. Those reporting irregular cycles or cycles of < 24 or > 34 days were excluded.
Design
Subjects were seen during two separate phases of their menstrual cycle. For the follicular phase, subjects were scheduled on days 4 to 8 after the beginning of menstruation. The luteal phase was scheduled 5 to 10 days after the surge in luteinizing hormone, as determined by the Clearplan home ovulation testing kit (Fisons Consumer Health, Sydney, Australia). This kit uses monoclonal antibody technology to detect the amount of luteinizing hormone normally occurring 24 to 36 hours before ovulation (approximately midcycle) (33, 34). Days were adjusted for women with cycles longer or shorter than 28 days. To confirm the occurrence of ovulation in the postovulatory phase, plasma progesterone levels were measured during the luteal phase in blood samples collected after removal of the ambulatory monitor in the morning. Analyses were done on the total group of 138 subjects, and then repeated with only those subjects who had progesterone levels of at least 3 ng/ml on both of their luteal phase sessions (N = 113). Because results with the two different groups of subjects were the same, all of our findings are based on all 138 subjects.
Each subject participated in a total of five separate sessions: one initial session where information was obtained on demographics and health history and four 24-hour ambulatory recording sessions. The ambulatory monitoring occurred on 2 work days and 2 off work days over a period of a few months. Half the subjects began the sequence of 4 study days in the follicular phase and half in the luteal phase, followed by the other study days in succession. Within phase, day (work day and off day) was counterbalanced.
Procedure
Ambulatory Monitor.
The Accutracker II (Suntech Medical Instruments, Raleigh, NC) was used for 24-hour ambulatory BP and HR monitoring (5). About one-half hour before the subject’s work shift in the morning, an assistant met the subject at work (between 6 AM and 7:30 AM) and applied the ambulatory monitor with the cuff on the nondominant arm. Subjects were instructed to keep their arms still and at their sides each time the instrument operated. On their off day, subjects were hooked up at a time as close as possible to the beginning of their work day. All subjects were monitored for four 24-hour days. On each measurement occasion, single readings of SBP, DBP, and HR were obtained. The ambulatory recorder was programmed to operate three times an hour on a random schedule during the day and once an hour at night during sleep. Actual time of awake and sleep periods was noted in subject’s diary. For each cuff inflation, subjects also indicated their location and posture.
Ambulatory data were first edited for artifacts based on Accutracker reading codes (insufficient electrocardiogram or Korotkoff sounds) and extreme values (> 200/120 or < 70/40 mm Hg). Editing was done entirely by set rules (5). Far outside values were excluded by the stem-and-leaf program of Systat (Evanston, IL). Of the total 36,877 readings, there were 4,190 exclusions (11.4%). For every subject, ambulatory measures for each of the four 24-hour sessions were divided into three time periods. The waking hours were divided into two periods: daytime and evening. The third period was at night during sleep. Work hours on days when subjects were at their job were used to determine the corresponding time periods on days when subjects were not working. Only sleep values were included in the night category. Awake values included both the daytime and evening categories. Classification of each reading as awake or asleep was based on diary entries and postsession reports.
Activity Monitor.
An actigraph (Mini-Motionlogger, Ambulatory Monitoring Inc., Ardsley, NY) was worn on the nondominant wrist and used to record frequency of movements in 1-minute intervals during each 24-hour period of ambulatory monitoring (35). We obtained average measures for daytime, evening, and night periods and for the 2- and 10-minute periods preceding each BP reading (35). The activity monitor was used to confirm the differentiation of sleep from awake readings. In addition, averaged data for daytime, evening, and night periods and for the 2- and 10-minute period preceding each BP reading were used separately as covariates in analyses of physiological measures. The same results were obtained whether longer or shorter time periods were used in analyses.
Job Strain.
The assessment of job strain was done with a 10-item questionnaire adapted by Steptoe et al. (36) from Karasek and Theorell (18). Items were rated on a 4-point scale from 1 = "strongly disagree" to 4 = "strongly agree" and included information on job demands (3 items), job control (3 items), and skill utilization (4 items). Job strain was defined as follows: [job demands/((job control + skill utilization)/2)] x 10, where the denominator is a measure of decision latitude. Subjects were divided by a median split into high (10) vs low (<10) job strain. We analyzed job strain [following Steptoe’s (36) definition] and also looked at its separate components, decision latitude and job demands.
Biochemical Assays
Plasma Progesterone.
Plasma progesterone levels were measured in duplicate (100 µl/assay tube) by solid-phase radioimmunoassay (RIA) using a commercially prepared kit (Coat-A-Count, Diagnostics Products Corp., Los Angeles, CA). The intraassay coefficient of variance (CV) is 2.6% and the interassay CV 5.1% at highest concentrations expected in this study with a minimum detectable dose = 0.03 ng/ml (95% confidence). Data reduction for progesterone RIA assay was done by a computer-assisted four-parameter logistics program (37).
Urinary Measures.
For each of the four sessions, urine was collected over a 24-hour period and stored in two separate bottles for the waking (daytime and evening) period and the period at night during sleep. Nighttime samples included all urine output collected during the night. Total sample volumes were recorded. The urine to be used for catecholamine analysis was acidified to pH 3.0 with 6N HCl, and three 10-ml aliquots were stored at -45°C until assayed. Creatinine samples were corrected for the subject’s weight to verify complete collection of urine.
Urine creatinine levels were determined spectrophotometrically using a commercially available colorimetric Jaffe-type assay (38) (Stanbio Laboratory, Inc., San Antonio, TX). Intraassay and interassay CVs were <9% at 5.6 mg/dl with reassay recoveries greater than 96%.
Urinary-free cortisol levels were determined in reconstituted methylene chloride extracts by an automated immunofluorescence procedure on an Abbott TDx Analyzer (Abbott Laboratories; Abbott Park, IL). The assay had less than 9% cross-reactivity with 11-deoxycortisol, corticosterone, cortisone, and less than 1% cross-reactivity with 10 other naturally occurring steroids. The interassay and intraassay CVs are <8% at 4 µg/dl and <4% at 40 µg/dl with a minimum detectable level (95% confidence) of 0.64 µg/dl. Urine extraction efficiencies were greater than 85%.
Urinary catecholamine levels (norepinephrine, epinephrine) were determined by a commercially available 125I-RIA (American Laboratory Products Company, Windham, NH). Urine samples (25 µl) were extracted using a macrotiter plate coated with a cis-diol-specific boronate affinity gel (60 minutes, room temperature, orbital shaker at 900 rpm) (39). The bound catecholamines were acylated (15 minutes, room temperature, orbital shaker 900 rpm), eluted with 0.025 M HCl (0.75 µl), and then enzymatically converted with catechol-PO-methyltransferase (water bath 37°C, 60 minutes) into N-acylnormetanephrine and N-acylmetanephrine. Acylated extracts were assayed in duplicate by two separate RIAs using norepinephrine and epinephrine antigens, respectively. Labeled and unlabeled complexes were separated by immunoprecipitation, and the aspirated pellets were quantified using a gamma counter (ICN Biomedical, formerly Micromedic, Isoflex Gamma Counter). Results were obtained by interpolation from the standard curve. The analytical sensitivities were 135 pg/ml and 22 pg/ml for norepinephrine and epinephrine, respectively, with an intraassay CV 
6% and interassay CV <7% for both catecholamines. A computer-assisted four-parameter logistics program (37) was used for the RIA assay. Although results are equivocal, there is some suggestion that catecholamine values may be influenced by the inclusion of bananas in the diet (40). We found the values for catecholamines were unaffected by the intake of bananas.
Data Analysis
To correct for differences in urinary volume, epinephrine, norepinephrine, and cortisol levels were divided by the concentration of creatinine, resulting in units of measurement in terms of nanograms per milligram of creatinine. In addition, these values were changed to logs in the statistical analyses. (Values reported in the text have been converted back to antilog values.) All 138 subjects were not included in every analysis because of missing data for some subjects during one of the four sessions. Three subjects lacked ambulatory night data; 3 subjects lacked ambulatory evening data; 3 subjects had incomplete urine collections.
To determine the influence of menstrual cycle Phase (Luteal/Follicular), Day (Work Day/Off day), and Time of Day (Daytime/Evening) on the cardiovascular responses during waking, we did 3-way within-subject ANOVAs using mean values separately for SBP, DBP, and HR. For catecholamines and cortisol and for nighttime, cardiovascular measures 2-way ANOVAs were calculated for Phase and Day. Prior analyses were repeated by including the following between-groups variables one at a time: high- (N = 74) and low- (N = 64) job strain, high- (N = 75) and low- (N = 63) job demands, high- (N = 72) and low- (N = 66) decision latitude, the presence (N = 77) or absence (N = 61) of children in the home, whether subjects were married (N = 79) or were not married (N = 59), and whether subjects were employed as nurses for a relatively long (14–30 years, N = 70) or short time (1–13 years, N = 68). Where groups were divided by median split, the sizes of the groups varied to avoid overlapping scores. For the between-group analyses, except for years working as a nurse, the groups did not differ on any of the following variables: age, BMI, education, alcohol intake, caffeine intake, length of shift (8 or 12 hours). Concerning years employed in nursing, age was used as a covariate. When any effects were significant (p < .05), analyses were repeated using the average activity value as a covariate. An index of posture (ratio of instances of standing to total number of readings) was also used as a covariate. The 3-way interactions were followed up by 2-way ANOVAs. To test for specific effects when there were significant interactions, t tests were calculated. In every case, comparisons were made between two cells where one factor was always held constant. Significance levels for t tests reflect Bonferroni adjusted p values.
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RESULTS |
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Job Strain
There were no differences between high- and low-job strain for any of the cardiovascular or neuroendocrine measures. Neither was decision latitude related to the physiological measures. However, some physiological measures (independent of activity) were significantly related to job demands. There was a Time of Day x Job Demands interaction for waking SBP [F(1/133) = 6.93, p = .009]. Because of higher levels in the daytime, high job demands subjects had a significant difference between daytime and evening SBP (Figure 2 ). There was a Day x Job Demands interaction for nighttime epinephrine [F(1/132) = 4.50, p = .036]. During the night, high job demands subjects had higher epinephrine levels during work than off days (Figure 3 ). Finally, there was a Day x Time of Day x Job Demands interaction for waking HR [F(1/133) = 5.38, p = .022]. The 3-way interaction for HR was examined by computing 2-way ANOVAs separately for high and low job demands subjects, resulting in a significant Day x Job Demands effect for high job demands subjects [F(1/72) = 25.94, p = .0001]. These effects were similar but not significant for low job demands subjects. Nurses with high job demands scores had elevated daytime HR values on the work compared with the off day (Figure 4 ).
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DISCUSSION |
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In her study of male and female middle managers and clerical workers, Frankenhaeuser et al. (43) reported that BP, HR, and epinephrine levels were significantly elevated while at work, with significant decreases at home at the end of the work day. However, whereas BP and norepinephrine of male managers dropped at the end of the work day, the levels of female managers not only failed to drop in the evening but sometimes increased in value. For men and women in varying occupations, BP was higher on the work than the off day, but the differences were not apparent during the night (3). The failure to "unwind" in the evening which Frankenhaeuser et al. (43) noted in female managers was not found for BP for the nurses in our study.
Menstrual Phase Effects
Our failure to find a significant relationship between ambulatory BP and menstrual cycle phase confirms the results of other investigators (10, 11), although it is at odds with the higher ambulatory SBP reported by Manhem et al. (7, 9) in 11 normotensive women during the luteal as compared with the follicular phase. In a discussion of nonambulatory studies, Stoney (12) concluded that when a between-subjects design was used, the results of investigations on cardiovascular variables and menstrual cycle phase were small and inconsistent. Moreover, within-subject studies have generally found no effect of menstrual cycle phase on cardiovascular responses to stress.
Concerning variables other than BP, our results of higher HR during the luteal phase are consistent with those of Manhem et al. (7, 9). However, unlike Manhem et al. (7), who did not find significant catecholamine differences as a function of menstrual cycle phase, we found that waking and nighttime norepinephrine levels in nurses were higher during the luteal than the follicular phase. Saab (44) concluded in her review that minimal evidence exists for increased stress-induced catecholamines in the luteal phase. In addition, all six of the women studied during a complete ovulatory cycle had higher plasma norepinephrine, but not epinephrine differences, during the luteal phase compared with the follicular phase (45). The results for urinary values were similar, but the difference between the two phases was smaller. Sato et al. (6) did not find menstrual phase related to HR or BP level, but instead showed that phase was related to power spectral analysis of HR variability. They felt that this measure of HR variability was more sensitive in assessing very small fluctuations in autonomic activity during the menstrual cycle. The present findings of increased HR and norepinephrine during the luteal phase is consistent with the conclusions of Sato et al. (6) suggesting a predominance of sympathetic activity during this phase.
Activity
The fact that activity, as measured by an actigraph, had a limited influence on our findings for BP and HR is consistent with a prior study of active, healthy men and women between the ages of 50 and 78 years (35). In an attempt to determine and to control for the influence of activity on ambulatory BP at work, some investigators have recorded measures felt to be related to activity, such as posture and diary ratings of type or level of activity (1, 42, 46). Differences in posture did not account for the findings.
Job Strain
Our failure to find a significant relationship between ambulatory BP and job strain supports the conclusions of some investigators (17, 24) that the concept of job strain may be more applicable to men than women. However, these findings contrast with the results reported in other studies (16, 25). Note that there are different methods of defining high-job strain, and that our results are based on the adaptation by Steptoe et al. (36) of the job strain concept. To be certain that our negative findings were not due to our use of this definition of job strain, we repeated our analyses using the four quadrants of job strain based on combinations of high- and low-job demands and high- and low-decision latitude (18). Again, the high-job strain group did not differ significantly from any of the other three job strain quadrants. Although in the current study job strain was not related to BP, SBP was elevated in high job demands nurses during daytime hours relative to evening hours (Figure 2). Also, high demands subjects had elevated daytime HR values on work days and a greater epinephrine difference between work and off days. (Figures 3 and 4).
Steptoe et al. (36) reported that high systolic stress reactivity in the laboratory combined with high-job strain ratings led to increased SBP on the afternoon of the work day. The job strain scores for the high [11.7 (1.7)] and for the low [8.37 (1.2)] groups of nurses in this study are comparable to the values reported by Steptoe et al. for male firefighters. However, the nurses differ from the firefighters on two of the components of the job strain score: higher job demands [10.2 (1.8)] coupled with greater job control [9.2 (1.6)]. This may help to explain why job demands, and not job strain, was a significant variable in this group.
Years Worked in Nursing
Rather than greater work experience being associated with a reduction in physiological levels, as we had hypothesized, nurses with longer work histories had higher norepinephrine levels during waking hours and during the nighttime on all four sessions. Also, compared with nurses with a short work history, those having a long work history had higher nighttime DBP during off days (Figure 5). This effect was independent of age. Because there were no differences in women with a long work history compared with those with a short work history concerning either marital status or children in the home, results were not due to either of these factors. In discussing this issue informally with our subjects, nurses working in the field longer were more aware of recent changes in the medical field and their negative impact on the nursing profession.
Marriage and Children
One problem with applying the job strain concept to women is that it fails to include a woman’s dual role at home and at work and the responsibilities that many women have with children at home. Where the issue of marital status has been explored among women with mild hypertension in a number of occupations, being married was associated with a higher ambulatory BP than being single (16). Also, among women in technical and clerical fields, those who were married had higher ambulatory DBP at work than single women (17). We did not find a relationship between marital status and BP. An association between marital satisfaction and health has been suggested by Gove et al. (47). In response to the following 5-point question: "How much enjoyment do you get from your home life?" 85% of married nurses in the present study responded with ratings of either 4 or 5 (1 = no enjoyment; 5 = a great deal of enjoyment). This level of home enjoyment could be related to high marital satisfaction, resulting in less stress and lower BPs than those found in other studies. However, lower sympathetic arousal was found in unmarried nurses, as evidenced by low levels of norepinephrine during the waking portion of their off days (Figure 6). Also, nighttime cortisol was lower in unmarried nurses during all four ambulatory recording days. In contrast, Luecken et al. (48) found no relationship between marital status and either catecholamines or cortisol during two 24-hour work days. Unlike the nurses in our study, these women were employed in clerical and customer service jobs and were 41% black. In addition, neither menopausal status nor menstrual cycle phase was considered.
Reviews of studies on women with children indicate that being a parent had little impact on a woman’s health (49). However, investigators found that when compared with working women with no children, those with children at home had higher 24-hour cortisol excretion levels, with no effect on catecholamines (48). Pickering (17) reported that having children was related to higher SBP and DBP at work and at home, with less of a likelihood for BP to decrease in the evening. In the present study, the only effect related to the presence of children in the home was a greater decrease in HR from daytime to evening hours in nurses with no children (Figure 7).
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CONCLUSIONS |
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Although many of the significant BP effects represented small differences, these differences were clinically meaningful. We need to be aware of factors that lead to increases in BP, even small ones, that are maintained over time and can have an eventual impact on cardiovascular risk. A DBP decrease as small as 2 mm Hg could have an immense impact on public health, leading to a 6% reduction in coronary risk and a 15% reduction in stroke and transient ischemic attacks (50). Because nurses are frequently faced with daily exposures to illness and disease, as well as "life and death" conditions, we had expected greater elevations in cardiovascular and neuroendocrine responses to the work environment. However, a recent study of air traffic controllers showed that the ambulatory BP of men engaged in this so-called "stressful" occupation did not differ from men employed in various other jobs (51). The investigators concluded that the stressful nature of their jobs did not influence their daily BP, because these men were able to cope effectively with the requirements of their job. The nurses in our study also may have learned to cope with their daily activities at work. The feeling of having relatively high control over their work may have aided them in this respect.
There is evidence showing that women are not affected by job strain in the same manner as men (17, 24). The findings of Blumenthal et al. (16) of elevated SBP in high job strain women in a variety of occupations may have been partially accounted for by the fact that their subjects had mild hypertension and were somewhat older (29–59 years) than the nurses in our study.
Our nurses showed no spill-over effects of daytime BP to the rest of the day. On both work and off days, BP decreased in the evening, with a much larger drop during the night. Studies show that work does not pose a health risk for women. On the contrary, women working outside of the home were often healthier than those who worked only at home (see review in 27). Also, women in female-dominated professions, such as nursing, had higher work self-esteem and less role conflicts than those in fields dominated by men or in nonprofessional jobs (52).
Finally, it is important to note that these results may not generalize to other samples of women. The subjects were in a female-dominated profession of college-educated, highly skilled workers. In addition, by restricting our study to women who were healthy and nonhypertensive, we may have excluded subjects who chronically respond to work stress with large increases in BP.
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ACKNOWLEDGMENTS |
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Received for publication August 25, 1998.
Revision received January 13, 1999.
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