臺灣博碩士論文加值系統

下視丘主管人體24小時日夜節律，而輪班工作會干擾此節律之運作，因此輪班工作對工作人員會造成不良的健康影響。本研究利用縱貫性設計來探討輪班護理人員的壓力、疲勞、睡眠與唾液中相關生理指標。
本研究以南部某教學醫院之輪班護理人員為研究對象，採立意取樣的方式，徵求需輪班、年齡在20-45歲、目前在醫院病房工作、且工作年資大於一年以上的女性臨床護理人員參與。資料收集分三天完成，這三天分別為在休假滿2日以上第一天返回日班工作時，及上完2日日班與上完2日大夜班後的第三天，在收集當天，參與者利用上班中間休息時間填寫有關睡眠、工作壓力及疲勞之問卷，並在當日上午八點及下午四點採集唾液檢體，唾液檢體採用酵素連結免疫分析法（Enzyme-linked immunosorbent assay，簡稱ELISA）進行測定，而資料分析則以SPSS統計軟體進行。
研究結果顯示，三班護理人員中，大夜班護理人員的「工作負荷」顯著高於日班及休假後；大夜班的疲勞指數較高且前晚的睡眠問題比例較高，但三班間並無顯著差別；在比較各班睡眠問題、壓力及疲勞之相關，發現三班之疲勞與長期睡眠問題均呈正相關，而疲勞與工作負荷之正相關則僅在日班呈現。
在日班及休假後，護理人員唾液中cortisol早上及下午的平均濃度呈現早高午低的情形，而在夜班護理人員則呈現早低午高的相反狀況。睡眠品質不佳及休假時的疲勞與cortisol濃度降低有關，且大夜班工作負荷的增加則與下午的cortisol濃度增加有關。
休假後唾液TNF-α濃度呈現早低午高的情形，而大夜班則在TNF-α濃度呈現早高午低之情形，此外疲勞指數也與大夜班下午IL-6的濃度成正相關。TNF-α及IL-6濃度分別在休假早上、夜班早上及下午呈現正相關，cortisol濃度與休假後早上IL-6濃度呈負相關和大夜班早上TNF-α濃度則呈正相關。
輪值夜班之護理人員，一方面受到生理節律改變的影響，一方面又因工作負荷較大，具潛在睡眠及疲勞的問題，較容易影響身體健康，因此針對長期夜班輪值人員應給予密切健康追蹤及職場健康促進活動。

In the human body, hypothalamus controls our 24 hours circadian rhythm, but shiftwork tends to interfere with this regular rhythm and causes adverse health effects among shiftworkers. This study, designed longitudinally, was conducted to investigate the relationship between sleep quality, work stress, fatigue and relevant saliva biological markers among shift workers.
Study subjects were purposively recruited from shiftwork nurses in a teaching hospital from southern Taiwan. Shiftwork nurses, aged 20-45, currenly working in a hospital ward and with at least one-year shiftwork experience, were invited to participate. Data collection was completed on three different days, as the following: the first day of a day shift after returning from at least two days of off day; the third day of a day shift; and the third day of a night shift. On each day of data collection, a questionnaire was completed during mid-day break and saliva specimens were collected at 8am and 4pm, respectively. Saliva specimen was analyzed using Enzyme-linked immunosorbent assay and numerical data was analyzed by SPSS statistical software.
The results showed that night shift workers were significantly higher on the average score of “work demand” scale than off and day shift workers; while compared to off and day shift workers, night shift workers had higher fatigue scores and greater proportion of sleep problems on the previous night, the discrepancies were not statistically significant. Nevertheless, fatigue was closely related to long-term sleep problems on all shifts but was merely related to work demand on day shift.
On off and day shift, average saliva cortisol concentrations were both higher in the morning and lower in the afternoon; as a contrary, concentration on night shift was lower in the morning and higher in the afternoon. Poor sleep quality and fatigue during off day were related to decreased concentration of cortisol; while elevated work demand increased afternoon cortisol concentration on night shift.
Concentration of Saliva TNF-α was lower in the morning and higher in the afternoon on off shift; while on night shift TNF-α concentration was higher in the morning and lower in the afternoon. Concentration of TNF-α and IL-6 were correlated to each other on off day morning, night shift morning and evening. Concentration of cortisol was negatively correlated with IL-6 on off day morning and positively correlated with TNF-α on night shift morning.
Nurses who work on night shift are affected by the circadian rhythm and work demand, therefore they might have greater potentials for sleep problems, fatigue and even adverse health effects. Hence, for long-term night shift nurses, management should follow their health conditions closely and provide workplace health promotion.

致謝 I
中文摘要 IV
英文摘要 VI
目錄 VIII
表目次 XI
圖目次 XIII
附錄目次 XIV

第一章 緒論 1
1.1 研究背景與動機 1
1.2 研究目的 3
1.3 研究問題 3
1.4 名詞定義 4
第二章 文獻探討 6
2.1 輪班形式 6
2.2 輪班工作的健康效應探討 7
2.2.1 輪班與生物學問題：日夜節律（circadian rhythm）對生理節律的影響 9
2.2.2 輪班對身體和心理健康的影響 10
2.2.3 輪班對社會的影響 18
2.2.4 輪班工作的適應性 19
2.3 疲勞概念 20
2.3.1 疲勞的定義 23
2.3.2 造成疲勞的因素 24
2.3.3 疲勞的診斷 28
2.3.4 疲勞所呈現的身心反應 30
2.3.5 疲勞的測量 31
2.4 壓力概念 35
2.4.1 壓力的定義 35
2.4.2 影響壓力的因素 36
2.4.3 壓力的身心反應 37
2.4.4 工作壓力的定義 38
2.4.5 工作壓力的來源 39
2.4.6 工作壓力的致病模型理論 41
2.5 壓力、疲勞與生理指標 47
2.5.1 疲勞的生理機制 47
2.5.2 壓力的生理機制 48
2.5.3 免疫功能 50
2.5.4 疲勞、壓力與相關細胞激素之探討 50
第三章 研究方法與材料 54
3.1 研究架構 54
3.2 研究對象 55
3.3 研究工具 55
3.3.1 結構式問卷： 55
3.3.2 唾液檢體採樣：Salivette®（Saratedt，Germany） 58
3.3.3 酵素連結免疫分析法ELISA-細胞激素分析 58
3.4 研究資料收集流程 64
3.5 資料處理、統計分析 68
3.5.1 描述性統計 68
3.5.2 推論式統計 69
3.6 研究對象權益的保護 70
第四章 研究結果 71
4.1 描述性統計分析 71
4.2 輪班與疲勞、工作壓力、睡眠品質及唾液生理指標之相關 72
4.2.1 輪班與疲勞狀況 72
4.2.2 輪班與工作壓力 72
4.2.3 輪班與睡眠品質 73
4.2.4 輪班與生理指標 75
4.3 疲勞、工作壓力、睡眠品質及唾液生理指標之相關 77
第五章 討論 79
5.1 輪班護理人員疲勞、睡眠情況與工作負荷之現況 79
5.2 輪班、疲勞、工作壓力及睡眠型態之探討 80
5.3 生理指標之探討 82
5.4 研究限制 88
第六章 結論與建議 90
6.1 結論 90
6.2 建議 91
參考文獻 92
表 115
圖 134
附錄 143

表目次
表5.3.1、 收案期間的四個月內未上過日班的護理人員唾液TNF-α及IL-6濃度分布 86
表5.3.2、 「表示很難適應大夜班」的護理人員唾液TNF-α及IL-6濃度分布 86
表4.1.1、 研究護理人員年齡及年資之平均數及標準差 115
表4.1.2、 研究護理人員基本資料、健康狀況及生活習慣分佈 115
表4.2.1、 輪班護理人員在疲勞問卷各分項的平均分數與信度分析 116
表4.2.2、 輪班護理人員在疲勞量表得分加總計分標準化†後之變異數分析 117
表4.2.3、 輪班護理人員在工作特質問卷各分項的平均分數與信度分析 118
表4.2.3、 輪班護理人員在工作特質問卷各分項的平均分數與信度分析（續） 119
表4.2.4、輪班護理人員在工作特質量表得分加總計分標準化†後之變異數分析 120
表4.2.5、 輪班護理人員過去一個月睡眠品質 121
表4.2.6、 過去一個月「回答有睡眠問題」的輪班護理人員平均影響睡眠日數 122
表4.2.7、 輪班護理人員過去一個月平均影響睡眠日數之變異數分析 123
表4.2.8、輪班護理人員過去一個月平均睡眠品質之變異數分析 124
表4.2.9、 輪班護理人員換班二天後，睡眠問題對睡眠的影響之變異數分析 125
表4.2.10、輪班護理人員換班二天後，前晚睡眠情形 126
表4.2.11、輪班護理人員換班二天後，前晚睡眠品質之變異數分析 127
表4.2.12、輪班護理人員唾液中cortisol、TNF-α及IL-6之平均濃度、標準差及中位數 128
表4.2.13、輪班護理人員早上與下午唾液cortisol、TNF-α及IL-6濃度，以成對樣本檢定 129
表4.2.14、不同輪班班別間護理人員唾液cortisol、TNF-α及IL-6濃度之統計分析 130
表4.3.1、 輪班護理人員早上唾液中生理指標值與各連續變項間的相關係數矩陣表 131
表4.3.2、輪班護理人員下午唾液中生理指標值與各連續變項間的相關係數矩陣表 132
表4.3.3、輪班護理人員唾液早上及下午生理指標差異值與各連續變項間的相關係數矩陣表 133

圖目次
圖2.4.6.1、「負荷-控制模式」 43
圖2.4.6.2、工作壓力與健康模式 44
圖2.4.6.3、Job demand-Control-Social support Model 45
圖2.4.6.4、付出-報酬失衡模式 46
圖2.4.6.5、NIOSH工作壓力模型 47
圖2.5.2.1、ㄧ般適應症候群 48
圖2.5.2.2、急性壓力的生理反應 49
圖2.5.4.1、疲勞、壓力與相關細胞激素 52
圖3.1.1、 研究架構 54
圖3.3.2.1、Salivette 58
圖3.4.1、資料收集過程 65


附錄目次
附錄一、臨床研究受試者同意書 143
附錄二、研究問卷 146
附錄三、人體試驗委員會核准證書 151
附錄四、研究工具同意使用函（鄭雅文老師） 152
附錄五、疲勞問卷計分方式 153
附錄六、工作特質量表問卷計分方式 154
附錄七、研究工具同意使用函（郭浩然老師） 156
附錄八、睡眠品質問卷計分方式（過去一個月睡眠情形；長期睡眠情形） 157
附錄九、睡眠品質問卷計分方式（轉換班別後，短期睡眠情形） 158

Adamu, B., Sani, M. U., & Abdu, A. (2006). Physical exercise and health: a review. Niger J Med, 15(3), 190-196.
Ahlberg, K., Ekman, T., Gaston-Johansson, F., & Mock, V. (2003). Assessment and management of cancer-related fatigue in adults. Lancet, 362(9384), 640-650.
Ahlgren, J. (1967). Kinesiology of the mandible. An EMG study. Acta Odontol Scand, 25(6), 593-611.
Akerstedt, T. (1995). [Increased risk of accidents during night shift. An underestimated problem are fatigue-induced accidents]. Lakartidningen, 92(20), 2103-2104.
Akerstedt, T. (2003). Shift work and disturbed sleep/wakefulness. Occup Med (Lond), 53(2), 89-94.
Akerstedt, T., & Froberg, J. E. (1976). Interindividual differences in circadian patterns of catecholamine excretion, body temperature, performance, and subjective arousal. Biol Psychol, 4(4), 277-292.
Akerstedt, T., Knutsson, A., Westerholm, P., Theorell, T., Alfredsson, L., & Kecklund, G. (2004). Mental fatigue, work and sleep. J Psychosom Res, 57(5), 427-433.
Arilla, M. C., Gonzalez-Rioja, R., Ibarrola, I., Mir, A., Monteseirin, J., Conde, J., et al. (2006). A sensitive monoclonal antibody-based enzyme-linked immunosorbent assay to quantify Parietaria judaica major allergens, Par j 1 and Par j 2. Clin Exp Allergy, 36(1), 87-93.
Axelsson, J., Akerstedt, T., Kecklund, G., Lindqvist, A., & Attefors, R. (2003). Hormonal changes in satisfied and dissatisfied shift workers across a shift cycle. J Appl Physiol, 95(5), 2099-2105.
Barton, J. (1994). Choosing to work at night: a moderating influence on individual tolerance to shift work. J Appl Psychol, 79(3), 449-454.
Beard, D. D. (2002). Chronic fatigue syndrome clinical practice guidelines: psychological factors. Med J Aust, 177(9), 526; author reply 526-527.
Beehr, T. A., Farmer, S. J., Glazer, S., Gudanowski, D. M., & Nair, V. N. (2003). The enigma of social support and occupational stress: source congruence and gender role effects. J Occup Health Psychol, 8(3), 220-231.
Beehr, T. A., Walsh, J. T., & Taber, T. D. (1976). Relationship of stress to individually and organizationally valued states: higher order needs as a moderator. J Appl Psychol, 61(7), 41-47.
Benjamin, G. A. (1984). Shift workers. Pers J, 63(6), 72-76.
Berger, A. M., & Hobbs, B. B. (2006). Impact of shift work on the health and safety of nurses and patients. Clin J Oncol Nurs, 10(4), 465-471.
Blachowicz, E., & Letizia, M. (2006). The challenges of shift work. Medsurg Nurs, 15(5), 274-280.
Boivin, D. B., Tremblay, G. M., & James, F. O. (2007). Working on atypical schedules. Sleep Med, 8(6), 578-589.
Bolondi, L., Gramantieri, L., Chieco, P., Melchiorri, C., Trere, D., Stecca, B., et al. (1996). Enzymatic cytochemistry, DNA ploidy and AgNOR quantitation in hepatocellular nodules of uncertain malignant potential in liver cirrhosis. Dig Dis Sci, 41(4), 800-808.
Bower, J. E., Ganz, P. A., & Aziz, N. (2005). Altered cortisol response to psychologic stress in breast cancer survivors with persistent fatigue. Psychosom Med, 67(2), 277-280.
Calcagni, E., & Elenkov, I. (2006). Stress system activity, innate and T helper cytokines, and susceptibility to immune-related diseases. Ann N Y Acad Sci, 1069, 62-76.
Calnan, M., Wadsworth, E., May, M., Smith, A., & Wainwright, D. (2004). Job strain, effort--reward imbalance, and stress at work: competing or complementary models? Scand J Public Health, 32(2), 84-93.
Cameron, C. (1973). A theory of fatigue. Ergonomics, 16(5), 633-648.
Cheng, Y., Luh, W. M., & Guo, Y. L. (2003). Reliability and validity of the Chinese version of the Job Content Questionnaire in Taiwanese workers. Int J Behav Med, 10(1), 15-30.
Cohen, D., Eisdorfer, C., Prinz, P., Breen, A., Davis, M., & Gadsby, A. (1983). Sleep disturbances in the institutionalized aged. J Am Geriatr Soc, 31(2), 79-82.
Cooper, C. L., & Baglioni, A. J., Jr. (1988). A structural model approach toward the development of a theory of the link between stress and mental health. Br J Med Psychol, 61 ( Pt 1), 87-102.
Cooper, C. L., Manning, C. A., & Poteet, G. (1988). Stress, mental health & job satisfaction among nurse managers. Health Serv Manage Res, 1(1), 51-58.
Costa, G., & Di Milia, L. (2008). Aging and shift work: a complex problem to face. Chronobiol Int, 25(2), 165-181.
Dawson, D., & Reid, K. (1997). Fatigue, alcohol and performance impairment. Nature, 388(6639), 235.
De Moor, M. H., Beem, A. L., Stubbe, J. H., Boomsma, D. I., & De Geus, E. J. (2006). Regular exercise, anxiety, depression and personality: a population-based study. Prev Med, 42(4), 273-279.
Dinarello, C. A. (2000). Proinflammatory cytokines. Chest, 118(2), 503-508.
Dinges, D. F. (1995). An overview of sleepiness and accidents. J Sleep Res, 4(S2), 4-14.
Drake, C. L., Roehrs, T., Richardson, G., Walsh, J. K., & Roth, T. (2004). Shift work sleep disorder: prevalence and consequences beyond that of symptomatic day workers. Sleep, 27(8), 1453-1462.
Elfering, A., Semmer, N. K., & Grebner, S. (2006). Work stress and patient safety: observer-rated work stressors as predictors of characteristics of safety-related events reported by young nurses. Ergonomics, 49(5-6), 457-469.
Ericson-Lidman, E., Norberg, A., & Strandberg, G. (2007). Meanings of being a female co-worker to a person developing burnout. Scand J Caring Sci, 21(2), 155-162.
Ericson-Lidman, E., & Strandberg, G. (2007). Burnout: co-workers'' perceptions of signs preceding workmates'' burnout. J Adv Nurs, 60(2), 199-208.
Eriksen, C. A., & Kecklund, G. (2007). Sleep, sleepiness and health complaints in police officers: the effects of a flexible shift system. Ind Health, 45(2), 279-288.
Foundation, N. S. (2005). Sleep in America poll.
Friswell, R., & Williamson, A. (2008). Exploratory study of fatigue in light and short haul transport drivers in NSW, Australia. Accid Anal Prev, 40(1), 410-417.
Fukuda, K., Straus, S. E., Hickie, I., Sharpe, M. C., Dobbins, J. G., & Komaroff, A. (1994). The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group. Ann Intern Med, 121(12), 953-959.
Gold, D. R., Rogacz, S., Bock, N., Tosteson, T. D., Baum, T. M., Speizer, F. E., et al. (1992). Rotating shift work, sleep, and accidents related to sleepiness in hospital nurses. Am J Public Health, 82(7), 1011-1014.
Grandjean, E. (1968). Fatigue: its physiological and psychological significance. Ergonomics, 11(5), 427-436.
Gustafsson, K., Lindfors, P., Aronsson, G., & Lundberg, U. (2008). Relationships between self-rating of recovery from work and morning salivary cortisol. J Occup Health, 50(1), 24-30.
Hamaideh, S. H., Mrayyan, M. T., Mudallal, R., Faouri, I. G., & Khasawneh, N. A. (2008). Jordanian nurses'' job stressors and social support. Int Nurs Rev, 55(1), 40-47.
Hann, D. M., Jacobsen, P. B., Azzarello, L. M., Martin, S. C., Curran, S. L., Fields, K. K., et al. (1998). Measurement of fatigue in cancer patients: development and validation of the Fatigue Symptom Inventory. Qual Life Res, 7(4), 301-310.
Hart, C. L., Ward, A. S., Haney, M., & Foltin, R. W. (2003). Zolpidem-related effects on performance and mood during simulated night-shift work. Exp Clin Psychopharmacol, 11(4), 259-268.
Hennig, J., Friebe, J., Ryl, I., Kramer, B., Bottcher, J., & Netter, P. (2000). Upright posture influences salivary cortisol. Psychoneuroendocrinology, 25(1), 69-83.
Hiestand, D. M., Britz, P., Goldman, M., & Phillips, B. (2006). Prevalence of symptoms and risk of sleep apnea in the US population: Results from the national sleep foundation sleep in America 2005 poll. Chest, 130(3), 780-786.
Humm, C. (2008). Night-shift napping. Nurs Stand, 22(17), 20-21.
Hurrell, J. J., Jr., Nelson, D. L., & Simmons, B. L. (1998). Measuring job stressors and strains: where we have been, where we are, and where we need to go. J Occup Health Psychol, 3(4), 368-389.
Ilhan, M. N., Durukan, E., Taner, E., Maral, I., & Bumin, M. A. (2008). Burnout and its correlates among nursing staff: questionnaire survey. J Adv Nurs, 61(1), 100-106.
Jockovich, M., Cosentino, D., Cosentino, L., Wears, R. L., & Seaberg, D. C. (2000). Effect of exogenous melatonin on mood and sleep efficiency in emergency medicine residents working night shifts. Acad Emerg Med, 7(8), 955-958.
Johnson, J. V., Hall, E. M., & Theorell, T. (1989). Combined effects of job strain and social isolation on cardiovascular disease morbidity and mortality in a random sample of the Swedish male working population. Scand J Work Environ Health, 15(4), 271-279.
Karasek, R. (1996). Job strain and the prevalence and outcome of coronary artery disease. Circulation, 94(5), 1140-1141.
Karasek, R., Brisson, C., Kawakami, N., Houtman, I., Bongers, P., & Amick, B. (1998). The Job Content Questionnaire (JCQ): an instrument for internationally comparative assessments of psychosocial job characteristics. J Occup Health Psychol, 3(4), 322-355.
Karlsson, B., Knutsson, A., & Lindahl, B. (2001). Is there an association between shift work and having a metabolic syndrome? Results from a population based study of 27,485 people. Occup Environ Med, 58(11), 747-752.
Kawano, Y. (2008). Association of job-related stress factors with psychological and somatic symptoms among Japanese hospital nurses: effect of departmental environment in acute care hospitals. J Occup Health, 50(1), 79-85.
Kokkinos, C. M. (2007). Job stressors, personality and burnout in primary school teachers. Br J Educ Psychol, 77(Pt 1), 229-243.
Kristensen, T. S., Hannerz, H., Hogh, A., & Borg, V. (2005). The Copenhagen Psychosocial Questionnaire--a tool for the assessment and improvement of the psychosocial work environment. Scand J Work Environ Health, 31(6), 438-449.
Krupp, L. B., LaRocca, N. G., Muir-Nash, J., & Steinberg, A. D. (1989). The fatigue severity scale. Application to patients with multiple sclerosis and systemic lupus erythematosus. Arch Neurol, 46(10), 1121-1123.
Kurumatani, N., Koda, S., Nakagiri, S., Hisashige, A., Sakai, K., Saito, Y., et al. (1994). The effects of frequently rotating shiftwork on sleep and the family life of hospital nurses. Ergonomics, 37(6), 995-1007.
La Pine, M. P., Malcomson, F. N., Torrance, J. M., & Marsh, N. V. (2006). Night shift: can a homeopathic remedy alleviate shift lag? Dimens Crit Care Nurs, 25(3), 130-136.
Marino, J. L., Holt, V. L., Chen, C., & Davis, S. (2008). Shift work, hCLOCK T3111C polymorphism, and endometriosis risk. Epidemiology, 19(3), 477-484.
Maslach, C. (1979). Burned-out. Can J Psychiatr Nurs, 20(6), 5-9.
Maslach, C., & Leiter, M. P. (2008). Early predictors of job burnout and engagement. J Appl Psychol, 93(3), 498-512.
Maslach, C., Schaufeli, W. B., & Leiter, M. P. (2001). Job burnout. Annu Rev Psychol, 52, 397-422.
McGillis Hall, L., & Doran, D. (2007). Nurses'' perceptions of hospital work environments. J Nurs Manag, 15(3), 264-273.
McNair, D. M., Lorr, M., & Droppleman, L. F. (1971). Manual for the Profile of Mood States.
Meyers, C. A., Albitar, M., & Estey, E. (2005). Cognitive impairment, fatigue, and cytokine levels in patients with acute myelogenous leukemia or myelodysplastic syndrome. Cancer, 104(4), 788-793.
Muecke, S. (2005). Effects of rotating night shifts: literature review. J Adv Nurs, 50(4), 433-439.
Murata, K., Yano, E., & Shinozaki, T. (1999). Cardiovascular dysfunction due to shift work. J Occup Environ Med, 41(9), 748-753.
Niedhammer, I., Lert, F., & Marne, M. J. (1994). Effects of shift work on sleep among French nurses. A longitudinal study. J Occup Med, 36(6), 667-674.
NISOH, U. (1999). Stress at work (NISOH 99-101). (National Institute of Occupational Safety and Health).
O''Leary, E. S., Schoenfeld, E. R., Stevens, R. G., Kabat, G. C., Henderson, K., Grimson, R., et al. (2006). Shift work, light at night, and breast cancer on Long Island, New York. Am J Epidemiol, 164(4), 358-366.
Olson, K., Turner, A. R., Courneya, K. S., Field, C., Man, G., Cree, M., et al. (2008). Possible links between behavioral and physiological indices of tiredness, fatigue, and exhaustion in advanced cancer. Support Care Cancer, 16(3), 241-249.
Opal, S. M., & DePalo, V. A. (2000). Anti-inflammatory cytokines. Chest, 117(4), 1162-1172.
Pezelj-Ribaric, S., Prso, I. B., Abram, M., Glazar, I., Brumini, G., & Simunovic-Soskic, M. (2004). Salivary levels of tumor necrosis factor-alpha in oral lichen planus. Mediators Inflamm, 13(2), 131-133.
Pines, A., & Kafry, D. (1978). Occupational tedium in the social services. Soc Work, 23(6), 499-507.
Piper, B. F., Dibble, S. L., Dodd, M. J., Weiss, M. C., Slaughter, R. E., & Paul, S. M. (1998). The revised Piper Fatigue Scale: psychometric evaluation in women with breast cancer. Oncol Nurs Forum, 25(4), 677-684.
Piper, B. F., Longman, A., Protho, P., Sheridan, C., & Scofield, R. (1986). Certification renewal--task force report and recommendations. Oncol Nurs Forum, 13(3), 97-105.
Pisarski, A., Brook, C., Bohle, P., Gallois, C., Watson, B., & Winch, S. (2006). Extending a model of shift-work tolerance. Chronobiol Int, 23(6), 1363-1377.
Porock, D., & Juenger, J. A. (2004). Just go with the flow: a qualitative study of fatigue in biotherapy. Eur J Cancer Care (Engl), 13(4), 356-361.
Pryce, J., Albertsen, K., & Nielsen, K. (2006). Evaluation of an open-rota system in a Danish psychiatric hospital: a mechanism for improving job satisfaction and work-life balance. J Nurs Manag, 14(4), 282-288.
Redeker, N. S., Ruggiero, J. S., & Hedges, C. (2004). Sleep is related to physical function and emotional well-being after cardiac surgery. Nurs Res, 53(3), 154-162.
Reinberg, A., Motohashi, Y., Bourdeleau, P., Touitou, Y., Nouguier, J., Levi, F., et al. (1989). Internal desynchronization of circadian rhythms and tolerance of shift work. Chronobiologia, 16(1), 21-34.
Rhodus, N. L., Cheng, B., Myers, S., Bowles, W., Ho, V., & Ondrey, F. (2005). A comparison of the pro-inflammatory, NF-kappaB-dependent cytokines: TNF-alpha, IL-1-alpha, IL-6, and IL-8 in different oral fluids from oral lichen planus patients. Clin Immunol, 114(3), 278-283.
Roberts, A. D., Wessely, S., Chalder, T., Papadopoulos, A., & Cleare, A. J. (2004). Salivary cortisol response to awakening in chronic fatigue syndrome. Br J Psychiatry, 184, 136-141.
SahebJamee, M., Eslami, M., AtarbashiMoghadam, F., & Sarafnejad, A. (2008). Salivary concentration of TNFalpha, IL1 alpha, IL6, and IL8 in oral squamous cell carcinoma. Med Oral Patol Oral Cir Bucal, 13(5), E292-295.
Sahraian, A., Fazelzadeh, A., Mehdizadeh, A. R., & Toobaee, S. H. (2008). Burnout in hospital nurses: a comparison of internal, surgery, psychiatry and burns wards. Int Nurs Rev, 55(1), 62-67.
Samaha, E., Lal, S., Samaha, N., & Wyndham, J. (2007). Psychological, lifestyle and coping contributors to chronic fatigue in shift-worker nurses. J Adv Nurs, 59(3), 221-232.
Santavirta, N., Solovieva, S., & Theorell, T. (2007). The association between job strain and emotional exhaustion in a cohort of 1,028 Finnish teachers. Br J Educ Psychol, 77(Pt 1), 213-228.
Schneider, R. A. (1998). Reliability and validity of the Multidimensional Fatigue Inventory (MFI-20) and the Rhoten Fatigue Scale among rural cancer outpatients. Cancer Nurs, 21(5), 370-373.
Scott, P. J., & Huskisson, E. C. (1977). Measurement of functional capacity with visual analogue scales. Rheumatol Rehabil, 16(4), 257-259.
Sedgwick, P. M. (1998). Disorders of the sleep-wake cycle in adults. Postgrad Med J, 74(869), 134-138.
Seki, Y., & Yamazaki, Y. (2006). Effects of working conditions on intravenous medication errors in a Japanese hospital. J Nurs Manag, 14(2), 128-139.
Selye, H. (1956). The stress of life. New York:McGraw-Hill.
Sharp, K. (2007). Atypical fatigue. Clin J Oncol Nurs, 11(5), 628-630.
Shen, J., Botly, L. C., Chung, S. A., Gibbs, A. L., Sabanadzovic, S., & Shapiro, C. M. (2006). Fatigue and shift work. J Sleep Res, 15(1), 1-5.
Siegrist, J. (1996). Adverse health effects of high-effort/low-reward conditions. J Occup Health Psychol, 1(1), 27-41.
Siegrist, J., & Junge, A. (1990). Measuring the social dimension of subjective health in chronic illness. Psychother Psychosom, 54(2-3), 90-98.
Siegrist, J., Peter, R., Junge, A., Cremer, P., & Seidel, D. (1990). Low status control, high effort at work and ischemic heart disease: prospective evidence from blue-collar men. Soc Sci Med, 31(10), 1127-1134.
Simunkova, K., Hampl, R., Hill, M., Doucha, J., Starka, L., & Vondra, K. (2007). Salivary cortisol in low dose (1 microg) ACTH test in healthy women: comparison with serum cortisol. Physiol Res, 56(4), 449-453.
Skipper, J. K., Jr., Jung, F. D., & Coffey, L. C. (1990). Nurses and shiftwork: effects on physical health and mental depression. J Adv Nurs, 15(7), 835-842.
Smets, E. M., Garssen, B., Bonke, B., & De Haes, J. C. (1995). The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue. J Psychosom Res, 39(3), 315-325.
Smith, L., Tanigawa, T., Takahashi, M., Mutou, K., Tachibana, N., Kage, Y., et al. (2005). Shiftwork locus of control, situational and behavioural effects on sleepiness and fatigue in shiftworkers. Ind Health, 43(1), 151-170.
Stein, K. D., Martin, S. C., Hann, D. M., & Jacobsen, P. B. (1998). A multidimensional measure of fatigue for use with cancer patients. Cancer Pract, 6(3), 143-152.
Suzuki, K., Ohida, T., Kaneita, Y., Yokoyama, E., & Uchiyama, M. (2005). Daytime sleepiness, sleep habits and occupational accidents among hospital nurses. J Adv Nurs, 52(4), 445-453.
Swaen, G. M., Van Amelsvoort, L. G., Bultmann, U., & Kant, I. J. (2003). Fatigue as a risk factor for being injured in an occupational accident: results from the Maastricht Cohort Study. Occup Environ Med, 60 Suppl 1, i88-92.
Tahara, Y., Sakurai, K., & Ando, T. (2007). Influence of chewing and clenching on salivary cortisol levels as an indicator of stress. J Prosthodont, 16(2), 129-135.
Tenkanen, L., Sjoblom, T., Kalimo, R., Alikoski, T., & Harma, M. (1997). Shift work, occupation and coronary heart disease over 6 years of follow-up in the Helsinki Heart Study. Scand J Work Environ Health, 23(4), 257-265.
Theorell, T., Karasek, R. A., & Eneroth, P. (1990). Job strain variations in relation to plasma testosterone fluctuations in working men--a longitudinal study. J Intern Med, 227(1), 31-36.
Trendall, J., & Esmond, G. (2007). Fatigue in people with chronic obstructive pulmonary disease: development of an assessment tool. J Clin Nurs, 16(7B), 116-122.
Trinkoff, A. M., & Storr, C. L. (1998). Work schedule characteristics and substance use in nurses. Am J Ind Med, 34(3), 266-271.
van Amelsvoort, L. G., Schouten, E. G., Maan, A. C., Swenne, C. A., & Kok, F. J. (2001). Changes in frequency of premature complexes and heart rate variability related to shift work. Occup Environ Med, 58(10), 678-681.
Walsh, J. K., & Schweitzer, P. K. (1999). Ten-year trends in the pharmacological treatment of insomnia. Sleep, 22(3), 371-375.
Wang, H. X., Leineweber, C., Kirkeeide, R., Svane, B., Schenck-Gustafsson, K., Theorell, T., et al. (2007). Psychosocial stress and atherosclerosis: family and work stress accelerate progression of coronary disease in women. The Stockholm Female Coronary Angiography Study. J Intern Med, 261(3), 245-254.
Wilkinson, C. (2008). Junior doctors'' working hours: perspectives on the reforms. Int J Nurs Pract, 14(3), 200-214.
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. J Adv Nurs, 56(6), 679-689.
Winwood, P. C., Winefield, A. H., & Lushington, K. (2006). Work-related fatigue and recovery: the contribution of age, domestic responsibilities and shiftwork. J Adv Nurs, 56(4), 438-449.
Wyller, V. B. (2007). The chronic fatigue syndrome--an update. Acta Neurol Scand Suppl, 187, 7-14.
Yeh, W. Y., Cheng, Y., Chen, C. J., Hu, P. Y., & Kristensen, T. S. (2007). Psychometric properties of the Chinese version of Copenhagen burnout inventory among employees in two companies in Taiwan. Int J Behav Med, 14(3), 126-133.
方楸淑, & 王瑞霞. (2007). 外科加護病房病患睡眠品質及其相關因素探討. 實證護理, 3(1), 54-63.
王佳慧, 李碧霞, 鄭綺, 高靖秋, 楊勤熒, & 蔡仁貞. (2006). 護理人員疲倦卅活力度、健康促進生活型態與健康相關生活品質之研究. 新臺北護理期刊, 8(1), 7-16.
王肇齡, 黃志中, 楊俊毓, & 莊弘毅. (2000). 個人疲勞強度問卷中文版之效度及信度的評估. 臺灣家庭醫學雜誌, 10(4), 192-201.
史麗珠, 張薰榕, 劉孟茹, & 鄭秀貴. (2007). 醫療工作的壓力源感受量表之設計及信效度檢定. 臺灣公共衛生雜誌, 26(6), 10.
行政院勞工委員會勞工安全衛生研究所. (2004). 93年度受僱者工作環境安全衛生調查. 台北：行政院勞工委員會勞工安全衛生研究所.
行政院主計處. (2004). 各業受雇員工每人每月平均工作時數. 中華民國統計年鑑.
吳才元, & 劉衡生. (2007). Acute and Chronic Inflammation: Effect of the Risk Factor (s) on the Progression of the Early Inflammatory Response to the Oxidative and Nitrosative Stress. Journal of Biomedical & Laboratory Sciences, 19(3), 5.
吳明隆. (2006a). SPSS與統計應用分析二版. (五南圖書出版股份有限公司).
吳明隆. (2006b). SPSS與統計應用分析二版. 五南圖書出版股份有限公司.
李再立, & Michael, G. (2004). 唾液採樣法對唾液免疫球蛋白A、總蛋白質、澱粉酶和皮質固醇濃度的影響. 體育學報, 36, 13.
李逸. (2004). 公共衛生護理人員工作壓力感受、因應策略與壓力結果之探討—以互動型工作壓力模式為架構. 臺灣公共衛生雜誌, 23(5), 398-405.
林天送. (2001a). 你的睡眠時間足夠嗎? 健康世界(183), 2.
林天送. (2001b). 你是怎麼睡著的?-談睡眠機制. 健康世界(184), 3.
林作慶. (2006). 輪班工作人員身體活動與睡眠品質之相關研究－以航空國際線空服人員越洋航班為例. 體育學報, 39(1), 39-53.
林隆益, & 張均昌. (1989). 人類唾液中蛋白質含量測定之研究. The Kaohsiung Journal of Medical Sciences, 5(7), 9.
林嘉玲, 潘美玉, & 張媚. (2006). 社區老人睡眠品質之探討. 臺灣醫學, 10(4), 9.
施嫈瑜, 李世代, & 郭聖達. (2003). 慢性疲勞病患之身體、精神症狀與人格特質調查. 臺灣公共衛生雜誌, 22(5), 6.
施嫈瑜, 李世代, 郭聖達, 陳鏡任, & 楊土恆. (2003). 慢性疲勞病患之身體心理症狀及相關檢查的描述性研究. 臺灣家庭醫學雜誌, 13(2), 61-70.
施嫈瑜, 李明濱, 李世代, & 郭聖達. (2004). 壓力與健康：生理病理反應. 北市醫學雜誌, 1(1), 17-24.
施嫈瑜, 林易賢, 蘇昭儒, 鄭振鴻, 李世代, & 郭聖達. (2005). 慢性疲勞及其症候群. 北市醫學雜誌, 2(12), 7.
洪瑜嬬, 林佩蓁, 潘純媚, 陳秋蓉, 何啟功, & 吳明蒼. (2007). 護理人員的輪班工作與睡眠品質、身心健康及家庭功能之間的相關性. 勞工安全衛生研究季刊, 15(1), 17-30.
唐佩玲, 陳玟伶, 鄭琇分, 張敬俐, & 林惠賢. (2005). 護理人員憂鬱程度及其相關因素之探討. 中華心理衛生學刊, 18(2), 55-74.
徐嘉駿. (2006). 睡眠重要嗎？讓科學證據告訴你. 健康世界(250), 3.
徐儆暉、李諭昇. (2008). 工作環境安全衛生狀況認知調查-2007年. from http://www.iosh.gov.tw/Book/Report_Publish.aspx?P=1171
婁培人, 陳文彬, 李憲彥, & 徐茂銘. (1997). 唾液腺的神經支配. 中華民國耳鼻喉科醫學會雜誌, 32(3), 7.
張晏蓉, 葉婉榆, 陳春萬, 陳秋蓉, 石東生, & 鄭雅文. (2007). 台灣受僱者疲勞的分布狀況與相關因素. 臺灣公共衛生雜誌, 26(1), 13.
張榮珍, 李朝雄, & 李引玉. (1998). 精神科病房實施護理人員月輪班制對護理品質影響之先驅性研究. 護理雜誌, 45(5), 41-49.
許森彥, 郭浩然, & 蘇世斌. (2006). TFT-LCD光電產業輪班作業員工睡眠品質研究. 中華職業醫學雜誌, 13(3), 157-167.
許森彥, & 蘇世斌. (2003). 夜班及輪班工作者的健康問題. 中華職業醫學雜誌, 10(2), 71-80.
陳亮恭, 黃信彰, 周世斌, & 董祐芳. (2004). Self-reported Well-being and Circadian Hormone Changes in Nightshift Nurses. 北市醫學雜誌, 1(3), 289-296.
陳端容. (2006). 工作組織社會心理特質與自評健康：比較DC與ERI工作壓力模式對醫師族群之適用性. 臺灣公共衛生雜誌, 25(2), 93-106.
陸洛. (1994). Stressors, Personality and Mental Health: A Follow - Up Study. The Kaohsiung Journal of Medical Sciences, 10(9), 5.
陸洛. (1997). Hassles ,Appaisals, Coping and Distress: a Closer Look at the Stress Process. The Kaohsiung Journal of Medical Sciences, 13(8), 8.
勞工衛生安全研究所. (2001). 輪班作業危害預防手冊.
彭美姿, 劉盈君, & 張艾如. (2003). 癌症病房護理人員之工作壓力－文獻探討. 護理雜誌, 50(2), 71-76.
曾雯琦, 楊政議, & 林彥如. (2005). 女性護理人員的睡眠衛生. 護理雜誌, 3(52), 71-75.
曾慧萍, & 鄭雅文. (2002). 「負荷－控制－支持」與「付出－回饋失衡」工作壓力模型中文版量表之信效度檢驗：以電子產業員工為研究對象. 臺灣公共衛生雜誌, 21(6), 13.
湯柏齡, 陳永煌, & 諶立中. (2002). 工作壓力. 中華職業醫學雜誌, 9(2), 3.
馮兆康, & 李中一. (1998). 護理人員自覺疲勞盛行率及其相關因子. 中華職業醫學雜誌, 5(3), 129-138.
黃守正, 郭育良, 柯德鑫, & 鄭雅文. (2003). 職場社會心理特質與自覺健康狀態之相關. 中華職業醫學雜誌, 10(4), 235-244.
黃峰蕙, & 巫美鳳. (1999). 夜班對護理人員之影響及改善措施的探討. 護理雜誌, 46(3), 73-78.
黃寶園, & 林世華. (2007). 人格特質與社會支持對壓力反應歷程影響之研究：結合統合分析與結構方程模式二計量方法. 教育心理學報, 39(2), 32.
感染控制雜誌編輯部. (2007). 國內外新知　護理人員的工作負荷對重症患感染風險的影響. 感染控制雜誌, 17(3), 3.
楊素珍, & 張瑩如. (2006). 睡眠節律的發展與照護行為的關係. 護理雜誌, 53(4), 5-10.
董貞吟, 李佶明, 王珊文, 劉珮吟, & 張家儒. (2004). 運用綱際綱路進行醫院職業安全衛生教育之初探性研究. 工業安全衛生, 8, 8-29.
董貞吟, 張德明, 陳正誠, 李佶明, 李嘉容, & 楊佳璇. (2005). 護理人員對職業健康危害的認知及現況探討. 中華職業醫學雜誌, 12(4), 241-254.
廖士程, 李明濱, & 李宇宙. (2000). 睡眠的生物學基礎及臨床的意義. 臺灣醫學, 4(6), 652-664.
廖永樑, 葉慧儀, 陳惠玲, 廖東南, & 楊義爵. (2004). 冠心症患者其IL-1ra與IL-6之相關性. Journal of Biomedical & Laboratory Sciences, 16(3), 6.
劉玲伶, 蔡明翰, & 吳彥林. (2006). 醫師的睡眠剝奪與疲累之探討. 北市醫學雜誌, 3(3), 194-200.
鄭雅文. (2003). 談政府基層公衛人力問題. 臺灣公共衛生雜誌, 22(5), 3.
鄭雅文, 葉婉榆, & 林宜平. (2007). 台灣職場疲勞問題的社會性. 臺灣公共衛生雜誌, 26(4), 251-253.
蕭永薰, 黃元中, & 何廷俊. (1999). 日夜節律與輪班制工作. 中華職業醫學雜誌, 6(2), 63-72.
蕭伃伶, 謝佳容, & 劉淑娟. (2006). 護理人員幽默與健康狀況之研究. 新臺北護理期刊, 8(2), 53-62.
謝文順. (2001). 身體活動與睡眠品質的關係. 中華體育季刊, 14(4), 97-106.
謝漢雄. (1982). 人員排班技術之研究. 管理評論, 1(1), 67-78.
羅士翔, 陳文慶, 柯景塘, & 王榮德. (2007). 工作過勞致死之定義及診斷基準. 北市醫學雜誌, 4(2), 8.
羅元婷, 羅慶徽, 林金定, 呂學琳, 朱明若林雅雯, 賴朝英, et al. (2006). 某醫學中心推動“健康促進醫院”計劃：職場工作環境與醫院員工健康狀況之研究. 中華職業醫學雜誌, 13(3), 143-156.
竇秀花, 許佩蓉, & 李世代. (2005). 從護理之家談護理人員角色與工作壓力. 長期照護雜誌, 9(2), 8.
顧淑芳, 林永崇, & 曾修儀. (2005). 護理人員於負壓病房照顧肺結核病患之風險評估初探. 中華職業醫學雜誌, 12(3), 161-167.