Annals of Indian Psychiatry

ORIGINAL ARTICLE
Year
: 2022  |  Volume : 6  |  Issue : 3  |  Page : 224--228

Sleep quality, sleep hygiene awareness, and chronotype in nursing shift workers


Nirav Bhupendrabhai Chanpa1, Deepak Sachidanand Tiwari1, Vishal Kanhiyalal Patel2, Dhruv Shaileshbhai Patel3,  
1 Department of Psychiatry, M.P. Shah Medical College, Jamnagar, Gujarat, India
2 Department of Psychiatry, Dr. M.K. Shah Medical College and Research Center, Ahmedabad, Gujarat, India
3 Department of Psychiatry, Civil Hospital, Ahmedabad, Gujarat, India

Correspondence Address:
Dr. Nirav Bhupendrabhai Chanpa
B- 74, Durvesh Nagar, Opposite Kailash Nagar, Lodhiawadi Road, Junagadh - 362 001, Gujarat
India

Abstract

Background: Shift workers have various physical and psychological adverse effects due to their work schedule. Some of them are reporting poor sleep quality. Our study aimed to measure sleep quality and its relation with sleep hygiene awareness and chronotype in nursing shift duty workers. Materials and Methods: A cross-sectional survey had been carried out in nursing shift duty workers working at a tertiary care center. A total of 300 participants were recruited through convenient sampling. After taking ethical approval, consented participants were made to fill the pro forma which contained basic demographic details and scales such as Pittsburgh Sleep Quality Index, Sleep Belief Scale, and Composite Scale of Morningness. Data were entered and analyzed using trial version of SPSS. Results: Around 40% of the participants had poor sleep quality. Sleep quality had been statistically significantly associated with sleep hygiene awareness and chronotype of shift workers. Sleep quality had also been associated with needle stick injury and usage of sleeping pills. Conclusion: shift workers with poor sleep quality were more likely to have lower sleep hygiene awareness and evening type of chronotype. Elder shift workers had good sleep quality, better sleep hygiene awareness, and better morning-type chronotype as compared with younger shift workers.



How to cite this article:
Chanpa NB, Tiwari DS, Patel VK, Patel DS. Sleep quality, sleep hygiene awareness, and chronotype in nursing shift workers.Ann Indian Psychiatry 2022;6:224-228


How to cite this URL:
Chanpa NB, Tiwari DS, Patel VK, Patel DS. Sleep quality, sleep hygiene awareness, and chronotype in nursing shift workers. Ann Indian Psychiatry [serial online] 2022 [cited 2022 Dec 10 ];6:224-228
Available from: https://www.anip.co.in/text.asp?2022/6/3/224/360068


Full Text



 Introduction



Sleep is a physiological state occurring in alternation with wakefulness, and for the quality of life of an individual, sleep duration and quality are equally important.[1] Sleep is a state which is crucial for physical, mental, and emotional well-being, and around one-third of the lifespan is spent asleep according.[2] Shift work is a way of arranging daily working hours so that different persons or teams work in succession to cover more than the usual 8 h day.[3] Nurses are required to provide continuous healthcare, so they typically involve in shift work around the clock. Nurses are one of the largest groups of shift workers. Much research has been conducted on nurses' sleep problems and related factors including health effects, accidents, and their life-long outcomes. One study has reported that shift work has been related to poor quality of care and moderate cardiac stress level throughout the shift work.[4] An estimated one in five workers worldwide is engaged in night shift work according to the US Bureau of Labor Statistics.[5] Serious psychological and physiological effects on the workers are associated with shift work, especially more common with night shiftwork. It is associated with negative effects such as family, social, and emotional problems, fatigue, fluctuations in mood, reproductive issues, sleep disturbances, reduced alertness, cognitive decline, and increase in accidents.[6] Sleep disturbances such as increase sleep latency, intermittent awakening from sleep, and early morning awakening can be seen in shift duty workers. Treatment of patients can be adversely affected by poor sleep quality and mental health of nurses. Diurnal preference is also linked with sleep quality and sleep hygiene awareness. It also depends on age of the participants as majority of old-aged participants had morning-type chronotype. Sleep hygiene is a set of behavioral and environmental recommendations which are intended to promote healthy sleep. It was originally developed for use in the treatment of mild-to-moderate insomnia.[7] Patients are made aware about healthy sleep habits, and to improve their sleep, they are encouraged to follow various practices such as avoid caffeine, exercise regularly, eliminate noise from the sleeping environment, and maintain a regular sleep schedule.[8] However, its efficacy in the management of insomnia is questionable.[9] Hence, we planned to conduct study to find association between sleep quality and sleep hygiene awareness and chronotype in nursing shift duty workers of tertiary care center of Gujarat as there are many inconsistencies in the literature regarding the link between quality of sleep and sleep hygiene awareness and chronotype.

 Materials and Methods



A cross-sectional, observational study was carried out to find association of sleep quality with sleep hygiene awareness and chronotype among nursing shift duty workers in tertiary care center of Gujarat. Consented participants with at least one night duty per week were included in our study. Participants who were permanent night shift workers, having history of chronic medical conditions, and having chronic pain disorders were excluded from this study. The study was started after taking approval from the institutional ethical committee. Nursing shift duty workers who were working in different wards were explained about the aims of the research and due nature of the study. A total of 300 participants were selected by simple convenient sampling. Each participant was given individual semi-structured pro forma which contained basic demographic details and scales. Scales were translated into Gujarati and then back translated into English by language expert.

Materials

Pittsburgh Sleep Quality Index

Pittsburgh Sleep Quality Index (PSQI) was used for the assessment of sleep quality. It differentiates poor sleep from good sleep by measuring even items: sleep latency, use of sleeping medication, sleep duration, subjective sleep quality habitual sleep efficiency, sleep disturbances, and daytime dysfunction during the last month. Scoring of answers is based on a Likert scale scoring 0–3, whereby 3 reflects the negative extreme on the scale. A total score of “5” or more indicates a poor sleeper. The seven component scores of PSQI had an overall reliability coefficient (Cronbach's alpha) of 0.83. It has 89.6% sensitivity and 86.5% specificity. It could be used to screen patients for the presence of significant sleep disturbance. It may identify patients who are likely to have a sleep disturbances concomitant with psychiatric disturbances. It could also be used to monitor the progression of sleep disturbances and their interaction with other symptoms during the course of psychiatric illnesses such as depression.[10]

Sleep Belief Scales

Sleep Belief Scale (SBS) has 20 items. The scale has been divided into three factors such as sleep incompatible behavior (items 1, 2, 7, 8, 11, 12, 14, 17), sleep wake cycle behaviors (items 3–5, 10, 16, 19, 20), and thoughts and attitude to sleep (items 6, 9, 13, 15, 18). It specially asks the participants not to think of how their sleep is influenced, in particular, but of how they believe these behaviors affect people, in general. We scored correct answers as +1, neutral ones (neither effect) as 0, and incorrect ones as −1. Hence, the possible score range is between −20 and +20 and the participants who got the score in the range of 0–5 were classified as having a poor awareness, 6–13 as having an intermediate awareness, and 14–20 as having an excellent awareness The higher the score, the better the awareness. The internal consistency (Cronbach's alpha) of the SBS was satisfactory for the total sample (α = 0.714) and similar for gender groups. Reliability was 0.690–0.0718 if one item was deleted.[11]

Composite Scale of Morningness

The Composite Scale of Morningness (CSM) measures chronotype (morningness/eveningness). It contains 13 questions, most of them having four choices, with a Likert-type response format, and the total scores range from 13 (extreme eveningness) to 55 (extreme morningness). Score 44 and above indicates morning-type chronotype, of 22 and less indicates evening type, and of 23–43 indicates intermediate type.[12]

Statistical analysis

All data thus collected were tabulated and analyzed by using Microsoft Excel and trial version of SPSS stands for Statistical Product And Service Solution which is a software run by IBM. IBM headquarter has been situated in New York, USA. Sociodemographic profiles of the participants have been expressed in terms of frequency and percentage. ANOVA t-test and independent t-test were used for quantitative data and Chi-square test was used for qualitative data. P < 0.05 was considered statistically significant.

 Results



Three hundred female nursing shift duty workers were included in our study. Participants' age ranged from 23 to 58 years with a mean age of the participants being 39.23 years. The prevalence of poor sleep quality in shift duty workers was 39.34%.

[Table 1] shows that sleep quality was statistically significantly associated with needle stick injury (P = 0.009) and history of using sleeping pills (P = 0.002) as denoted by Chi-square test.{Table 1}

Sleep quality

The average mean score of sleep quality in our sample was 4.97 and significant differences were found between sleep quality and all three age groups [Table 2]. Association between sleep quality and chronotype showed significant association (P < 0.001) as denoted by ANOVA test, evening types showed poorer sleep quality as compared with morning types, post hoc Bonferroni comparisons showed that the differences were significant among evening–morning types (P < 0.001) and evening–intermediate types (P < 0.001) but nonsignificant among morning–intermediate types (P = 0.111). We also found significant association (P < 0.001) between sleep quality and sleep hygiene awareness of participants; post hoc Bonferroni comparisons showed that the differences were significant among all groups of sleep hygiene awareness [Table 3].{Table 2}{Table 3}

Chronotype

The average mean score of CSM score was 41.49 and significant differences were found between chronotype and all age groups (P < 0.001); post hoc Bonferroni comparisons showed that the differences were significant among all groups of chronotype. Scores of morningness were rising as advancement of participants' age. Older age of participants had higher morningness score, while youngers had lower morningness score.

Sleep hygiene awareness

The average mean score of SBS score was 11.61 and significant differences were found between sleep hygiene awareness and all age groups (P = 0.005); post hoc Bonferroni comparisons showed that the differences were significant among young and adult group (P = 0.012) but not significant between young and middle-aged group and adult and middle-aged group.

[Figure 1] shows that negative correlation was observed between PSQI score and CSM score (r = 0.204) and statistically significant (0.001) association was found between both score as denoted by Pearson's correlation test. Correlation between PSQI score and SBS score was also found to be negative (r = 0.091) but statistically significant (0.001) which was also denoted by Pearson's correlation test.{Figure 1}

 Discussion



In our study, more than 50% of the participants had a history of needle stick injury, and it was significantly associated with sleep quality. Long work hours and chronic insomnia are associated with an increased risk for needle stick as well as sharp injuries among nurses, which was shown in the study conducted in Taiwan.[13] A study conducted by Shao et al. in 2016 showed that sleep quality was poor among those nursing workers who were taking medications, which was similar with our study in which significant association had been found between sleep quality and history of using of sleeping pills.[14] Around 40% of the participants had poor sleep quality in our study which was consistent findings with the studies done by Lajoie et al. in 2015 (42%) and Yazdi et al. in 2012 (52%).[15],[16] Study conducted by Shao et al. in 2016 at Taiwan showed that 57% of participants had poor sleep quality.[14]

Our study showed that sleep quality was significantly associated with age group of participants, sleep quality of the participants got improved as advancement of their age, and young age group had poor sleep quality as compared with adult and middle-aged group. Study conducted by Chung et al. also found that older age and longer years of duty decreased the risk for worse sleep.[17] This might be because more experienced shift workers might have developed tolerance to shift work, so they could sleep well. In our study, sleep hygiene awareness was significantly associated with age group of the participants and mean score for sleep hygiene awareness increases with age, which was similar finding with the study conducted on 652 participants at Romania.[18] Mean score for sleep hygiene awareness falls under intermediate category in our study which was similar with the findings from other countries such as Romania (9.2) and Saudi Arabia (10.49).[18],[19] In the present study, higher mean scores of morningness were observed in middle-aged participants which was similar finding with the study conducted at Japan.[20] This result reinforces the evidence that individuals tend to become morning people as the years go by, willing to advance the phase of their biological rhythm. Mean average CSM score was 41.49 and majority of the participants had been included in intermediate category which was consistent finding with Brazil and Iran.[16],[21]

In our study, SBS score and PSQI score were negatively correlated and statistically associated. It suggested that participants with lower sleep hygiene awareness had poorer sleep quality. A study conducted in medical students from the USA showed that these findings suggest that knowing about proper habits does not necessarily influence sleep quality, whereas practicing proper habits is strongly related to good overall sleep quality.[22] In our study, CSM score and PSQI scores were also significantly associated but negatively correlated which meant that morning-type people had good sleep quality as compared with evening types. It may be due to unhealthy sleep habits or disturbance in sleep–wake cycle. A study conducted in China also had similar findings.[17]

 Conclusion



In our study, sleep quality and sleep hygiene awareness were associated statistically, so sleep quality was poor in those shift workers with lower sleep hygiene awareness. Sleep quality had also been associated with chronotype of shift duty workers as morning types had good sleep quality as compared with evening types. Elder shift workers had good sleep quality, better sleep hygiene awareness, and better morningness chronotype as compared with younger shift workers.

Limitations

As this is a cross-sectional study, it limits the assessment of causality. This study had been conducted in particular locality and included only female shift workers, so we cannot generalize findings of our study.

Declaration of patient consent

Patient consent statement was taken from each patient as per the institutional ethics committee approval along with consent taken for participation in the study and publication of the scientific results/clinical information/image without revealing their identity, name, or initials. The patient is aware that though confidentiality would be maintained anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Schwartz JR, Roth T. Neurophysiology of sleep and wakefulness: Basic science and clinical implications. Curr Neuropharmacol 2008;6:367-78.
2Colten HR, Altevogt BM. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington (DC):National Academies Press (US); 2006.
3Costa G. Shift work and occupational medicine: An overview. Occup Med (Lond) 2003;53:83-8.
4Chen J, Davis LS, Davis KG, Pan W, Daraiseh NM. Physiological and behavioral response patterns at work among hospital nurses. J Nurs Manag 2011;19:57-68.
5US Bureau of Labor Statistics. Employment Situation Summary. Washington, DC: US Government Printing Office; 2014.
6Akerstedt T. Psychological and psychophysiological effects of shift work. Scand J Work Environ Health 1990;16 Suppl 1:67-73.
7Hauri P. Current Concepts: The Sleep Disorders. Washington (DC):The Upjohn Company; 1982;2:85.
8Zarcone VP, Kryger MH, Roth T, Dement WC. Principles and Practice of Sleep Medicine. Elsevier, 2016.
9Stepanski EJ, Wyatt JK. Use of sleep hygiene in the treatment of insomnia. Sleep Med Rev 2003;7:215-25.
10Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh sleep quality index: A new instrument for psychiatric practice and research. Psychiatry Res 1989;28:193-213.
11Adan A, Fabbri M, Natale V, Prat G. Sleep beliefs scale (SBS) and circadian typology. J Sleep Res 2006;15:125-32.
12Smith CS, Reilly C, Midkiff K. Evaluation of three circadian rhythm questionnaires with suggestions for an improved measure of morningness. J Appl Psychol 1989;74:728-38.
13Lo WY, Chiou ST, Huang N, Chien LY. Long work hours and chronic insomnia are associated with needlestick and sharps injuries among hospital nurses in Taiwan: A national survey. Int J Nurs Stud 2016;64:130-6.
14Shao MF, Chou YC, Yeh MY, Tzeng WC. Sleep quality and quality of life in female shift-working nurses. J Adv Nurs 2010;66:1565-72.
15Lajoie P, Aronson KJ, Day A. A cross-sectional study of shift work, sleep quality and cardio metabolic risk in female hospital employees. BMJ Open 2015;5:1-8.
16Yazdi Z, Sadeghniiat-Haghighi K, Javadi AR, Rikhtegar G. Sleep quality and insomnia in nurses with different circadian chronotypes: Morningness and eveningness orientation. Work 2014;47:561-7.
17Chung MH, Chang FM, Yang CC, Kuo TB, Hsu N. Sleep quality and morningness-eveningness of shift nurses. J Clin Nurs 2009;18:279-84.
18Voinescu BI, Szentagotai-Tatar A. Sleep hygiene awareness: Its relation to sleep quality and diurnal preference. J Mol Psychiatry 2015;3:1.
19Alshahrani M, Al Turki Y. Sleep hygiene awareness: Its relation to sleep quality among medical students in King Saud University, Riyadh, Saudi Arabia. J Family Med Prim Care 2019;8:2628-32.
20Seo YJ, Matsumoto K, Par YM, Shinkoda H, Noh TJ. The relationship between sleep and shift system, age and chronotype in shift workers. Biolo Rhythm Res 2001;31:559-79.
21Silva RM, Zeitoune RC, Beck CL, Martino MM, Prestes FC, Loro MM. Chronotype and work shift in nursing workers of university hospitals. Rev Bras Enferm 2017;70:958-64.
22Brown FC, Buboltz WC Jr., Soper B. Relationship of sleep hygiene awareness, sleep hygiene practices, and sleep quality in university students. Behav Med 2002;28:33-8.