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สนับสนุนการจัดทำโดย
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วารสารสมาคมจิตแพทย์แห่งประเทศไทย Sleep disturbances among nurses of Songklanagarind Hospital* Tawanchai Jirapramukpitak,
M.D.** * Presented at the 6th Congress of ASEAN Federation of Psychiatry Mental Health and the 10th ASEAN Forum on Child and Adolescent Psychiatry, Bangkok, Thailand, 4-7 November, 1996. ** Department of Psychiatry, Faculty of Medicine, Thammasat University, Pathumtanee, Thailand. *** Department of Psychiatry, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkla 90112, Thailand. Abstract Objective : To evaluate the prevalence of sleep disturbances andfactors associated with poor sleep quality in nurses at Songklanagarind Hospital. Methods : A cross-sectional epidemiological study was carried outin all female nurses (n=461) in Songklanagarind Hospital. Three hundred twenty-six nurses completed a Thai version of the Pittsburgh Sleep Quality Index (T-PSQI) and a sleep survey including questions about factors associated with sleep disturbances. Factors associated with poor sleep quality were compared between those nurses with poor and good sleep quality by using Logistic regression. Results : There was a high prevalence (73%) of poor sleep quality(T-PSQI score >5) in all study subjects. The prevalance of sleep disturbances was more widespread among nurses working rotating shifts (76.7%) than ones working permanent day (51.1%), and it decreased with age : at age 40-60 years 43.75% of the nurses (versus 22.8% at age 21-30). Sleep disturbances were also related to category of workplaces, to napping and to recent stressful life events. A logistic regression analysis showed that rotating shift work and stressful life events were the major associated factors of poor sleep quality. Conclusions : This study revealed that about three quarters of the nurses in Songklanagarind Hospital had poor sleep quality. Rotating shift work and stressful life events primarily contributed to poor sleep quality among these nurses. Key words : Sleep disturbances, shift work, nurses ปัญหาคุณภาพการนอนหลับของพยาบาลประจำการโรงพยาบาลสงขลานครินทร์ * ตะวันชัย
จิรประมุขพิทักษ์, พ.บ. ** บทคัดย่อ คณะผู้วิจัยได้ศึกษาหาความชุกของปัญหาคุณภาพการนอนไม่ดีและวิเคราะห์หาปัจจัยต่างที่มีความสัมพันธ์กับคุณภาพการนอนหลับของพยาบาลในโรงพยาบาลสงขลานครินทร์ จากข้อมูลการสำรวจคุณภาพการนอนหลับของพยาบาลประจำการโรงพยาบาลสงขลาครินทร์ อำเภอหาดใหญ่ จังหวัดสงขลา จำนวน 461 คน ด้วยแบบสอบถาม Pittsburgh Sleep Quallty Index (PSQI) ฉบับภาษาไทย ได้รับการตอบรับกลับมา 326 คน คิดเป็นร้อยละ 70.71 พบว่าพยาบาลประจำการที่มีคุณภาพการนอนไม่ดี (T-PSQI Score > 5) มีจำนวน 238 คน คิดเป็นร้อยละ 73 โดยพยาบาลที่ทำงานเปลี่ยนผลัดไปเรื่อยๆ มีแนวโน้มที่จะมีคุณภาพการนอนไม่ดีสูงกว่าพยาบาลที่ทำงานผลัดเช้าอย่างเดียว (ร้อยละ 76.7 เปรียบเทียบกับร้อยละ 51.1) ความชุกของปัญหาคุณภาพการนอนหลับลดลงตามอายุที่มากขึ้นคือพบปัญหาเพียงร้อยละ 43.75 ในกลุ่มอายุ 40-60 ปี เปรียบเทียบกับร้อยละ 77.2 ในกลุ่มอายุ 21-30 ปี นอกจากนี้ปัญหาการนอนหลับยังสัมพันธ์กับสถานที่ทำงาน, การงีบหลับ และความเครียดในชีวิต โดยการศึกษาปัจจัยที่สัมพันธ์กับคุณภาพการนอนไม่ดีโดยใช้ logistic regression พบว่าปัจจัยที่มีความสัมพันธ์กับการมีคุณภาพการนอนที่ไม่ดีในช่วง 1 เดือนสูงที่สุดคือ การทำงานเป็นผลัด และการมีเหตุการณ์ที่เป็นความเครียด การศึกษานี้พบว่าประมาณสามในสี่ของพยาบาลประจำการโรงพยาบาลสงขลานครินทร์มีคุณภาพการนอนหลับที่ไม่ดี โดยมีปัจจัยสำคัญจากการทำงานเป็นผลัดและความเครียดในชีวิต วารสารสมาคมจิตแพทย์แห่งประเทศไทย 2540 ; 42(3) : 123-32. คำสำคัญ การนอนหลับ, การทำงานเป็นผลัด, พยาบาล * นำเสนอในการประชุม the 6th Congress of ASEAN Federation of Psychiatry Mental Health and the 10th ASEAN Forum on Child and Adolescent Psychiatry, กรุงเทพ, 4-7 พฤศจิกายน 2539. **
ภาควิชาจิตเวชศาสตร์ คณะแพทยศาสตร์ มหาวิทยาลัยธรรมศาสตร์ ปทุมธานี Introduction Although nurses should know how to take care of themselves and are expected to be healthy people, a study in Thailand by Luecha et al .1 showed that a large proportion of nurses complained about health problems. One of the problems found in a large percentage (42%) of these nurses was insomnia. Insomnia in this study was only one subjective aspect of "sleep quality". Other aspects may include sleep duration, sleep latency or number of arousal, as well as other subjective aspects, such as "depth" or restfulness" of sleep.2 In addition, poor sleep quality may indicate underlying sleep or medical disorders.2 Thus, sleep quality is a better clinical construct to describe sleep disturbances than is using one subjective complaint. Sleep disturbances among some nurses may be affected by several factors. One factor that has been widely studied is shift work. It was agreed that nurses working night or rotating shifts had poorer sleep quality than nurses working permanent day or evening shifts.3-6 The consequences of sleep disturbances due to shift work are numerous. A study showed that female shift workers reported higher rates of sleeping pill, tranquilizer, and alcohol use, as well as more job stress and more emotional problems.7 Nurses working on a rotating basis nodded off more at work and had twice the odds of a reported accident or errors related to sleepiness.8 Shiftworkers had more complaints in symptoms of gastrointestinal disorders and cardiovascular disorders.9 Thus, rotating shift work brings about many sleep problems and consequences. Another factor that contributes to poor sleep quality is stress. The occurrence of stressful life events play a major role in the development of chronic insomnia.10 The stress from situations such as work or personal life change may also result in poor sleep quality. The prevalence of poor sleep quality among Thai nurses and factors related to it remain unknown. The purpose of this study was to examine the prevalence of sleep disturbances and factors associated with poor sleep quality in a sample of Songklanagarind Hospital nurses in southern Thailand. Materials and Methods Procedure and Subjects A cross-sectional study was carried out in 1995 in Songklanagarind hospital, a university hospital in Had Yai, Southern Thailand. The population was all female registered nurses (n = 461) from all wards, outpatient departments and the nursing service office. The rate of participating nurses was 70% (n=321). Mean age of the sample was 29.8 years (sd = + 5.85) with a distribution into three age groups : 21-30 years (58.0%), 31-40 years (37.1%) and 40-60 years (4.9%). Workplaces were divided into 4 categories according to some common characteristics that they share. A medical category (34.2%) consisted of medical, pediatric, newborn, and psychiatric wards. A surgical category (41.4%) consisted of surgical, ophthalmic, obstetrical, gynecologic, orthopaedic, E.N.T, and trauma wards. An intensive category (16.9%) consisted of ICU, pediatric ICU, and the burn unit. And an ambulatory category (17.6%) consisted of outpatient departments and the nursing service office. Anonymous questionnaire packages were distributed to all female registered nurses working at least 4 days/week or 32 hours/week and who have worked longer than 6 months in Songklanagarind Hospital. Participants completed the questionnaire on their own time and returned them to the authors. Instruments Data was gathered with the Pittsburgh Sleep Quality Index (PSQI) developed by Buysse et al.2 We used a Thai version that was modified from the PSQI and translated it from and back into the original English version. The PSQI is a self-rated questionnaire which assesses sleep quality and disturbances over a 1 month time interval. Nineteen individual items generate seven component scores: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and daytime dysfunction. Each component score has a range of 0-3 points. In all cases, a score of "0" indicates no difficulty, while a score of "3" indicates severe difficulty. The seven component scores are then added to yield one "global" score, with a range of 0-21 points, "0" indicating no difficulty and "21" indicating severe difficulties in all areas. A global PSQI score greater than 5 yielded a diagnostic sensitivity of 89.6% and a specificity of 86.5% (kappa = 0.75, p < 0.001) in distinguishing good and poor sleepers.2 Included in the questionnaire package was a general sleep survey containing questions about demographic characteristics, ward, shift work schedule, physical illness, pregnancy, children, frequency of drinking coffee/tea, job satisfaction, napping, and stressful life events during the past month. Analysis To investigate factors related to poor sleep quality, the subjects were divided into two groups : Good/Poor sleepers. Both groups were defined as follows : Good sleepers were persons who have a global PSQI score equal to or less than 5. Poor sleeper were persons who have a global PSQI score greater than 5. Statistical methods included comparisons of frequency (Chi-square tests), with adjustment (Mantel-Haenszel's test) and logistic analysis. Data analysis was performed using Epi Info statistical package (version 5) and the logistic regression program in STATA. Results Prevalence of sleep disturbances Table 1 shows that about three quarters (73%) of the nurses had poor sleep quality during the past month. Poor sleep quality was related to age: 77.2% of the 21-30 year olds, 70.2% of the 31-40 year olds, and 43.75% of the 40-60 year olds had poor sleep quality during the past month (X2 = 9.14, df = 2, p<0.01) Sleep disturbances were more widespread among nurses working rotating shifts (76.7%) than among nurses working permanent day (51.1%)(X2 = 13.38, df = 1, p<0.0002) Poor sleep quality was also related to the category of the workplaces: 80.9% of the nurses in the intensive category, 76.7% of the nurses in the surgical category, 72.6% of the nurse in the medical category, and 47.6% of the nurses in the ambulatory category had poor sleep quality during the past month (X2 = 9.15, df = 3, p<0.027) Poor sleeping was not found to be related to the other demographic, occupational and health variables such as marital status, pregnancy, physical illness or drinking coffee/tea. Other factors associated with sleep disturbances As seen in Table 2, there are 2 factors that related to poor sleep quality, napping and recent stressful life events. Poor sleepers reported napping more than 1 time/week (89.7%), while good sleepers napped equal to or less than 1 time/week (71.0%) (X2 = 4.61, df = 1, p<0.03) Poor sleep quality was also more widespread among those nurses reporting recent stressful life events (80.1%) than the nurses who did not report these(65.2%) (X2 = 9.20, df = 1, p<0.002). Sleep disturbances were not found to be related to job satisfaction. Multivariate analysis A logistic regression analysis was performed on the 322 subjects with sleep quality based on PSQI score. The variables : age (21-30, 31-40, 40-60), shift work (permanent day, rotating shifts). category of wards (medical, surgical, intensive, ambulatory), napping (0-1, > 1) and stressful life events during the past month (no, yes) were entered into a logistic regression as independent variables. The dependent variable was the quality of sleep (good, poor) during the past month. In this final model, we selected only the main variables. The results in Table 3 show that, when other variables were taken into account in the logistic model, shift work and recent stressful life events were the major factors associated with sleep quality. The risk for poor sleep quality was 3 times greater in those nurses who were working on alternating schedules compared to those working permanent day, and 2 times greater in those who reported stressful life events during the past month. After adjustment, the other factors entered into the logistic regression did not affect the quality of sleep. Discussion This study is the first attempt to evaluate sleep quality among Thai nurses by using a standardized questionnaire. Previous studies gathered data by using a symptom checklist that did not assess various aspects of sleep disturbances.1,11 The assessment of sleep quality has major clinical relevance, it can help identify underlying sleep disorders and medical disorders that could help design appropriate treatment strategies to solve these problems About three quarters (73%) of our subjects had poor sleep quality during the month before completing the questionnaire. Compared with the study by Luecha et al.1 reporting that 42% of nurses in Ramathibodi Hospital, Thailand, suffered from insomnia. An explanation is that a high proportion of the nurses in our study not only had insomnia, but may also had other sleep problems. Some nurses reported excessive daytime sleepiness. Some reported their sleep was fragmented and not deep. Because there have not been any studies on the prevalence of sleep problems in general Thai population, the results of our study may imply a high rate of sleep disturbances among Thai people. Our results that rotating shift work affects sleep quality of the nurses support the longitudinal study of Neidhammer et al.3 who found that nurses on alternating schedule had more sleep disorders. Findings of effects of shift work have also been reported by Escriba et al.4 who found that shiftwork led to a reduction in the length of sleep and an alteration in the quality of sleep. Shah et al.5 reported that non- rotational workers enjoyed more frequent and longer naps and had less disturbances in their sleep patterns than rotational workers. And Lee et al.6 found that there were higher incidences of sleep disturbances and excessive sleepiness for women working night and rotating shifts. Our study confirmed that recent stressful life events are related to poor sleep quality. The finding is consistent with the notion that transient or short-term sleep disturbances and even chronic insomnia may occur inresponse to various stresses such as work-related difficulties, interpersonal conflicts, financial problems, or major life changes such as marriage, birth of a child, or death of a loved one.10,12 The results of the logistic regression analysis revealed that, when all factors were entered into a logistic model, age, category of workplaces, and napping at work did not affect sleep quality. It may be that these factors were confounded by other factors. First, with respect to age, most of the young nurses work on alternating schedule, while the older tends to work permanent day. Thus the age of these nurses is influenced by shift work. Likewise, for category of wards, most of the intensive, surgical, and medical nurses work rotating shift, while the ambulatory nurses work permanent day. Interestingly, the characteristics and work load of each workplace might result in poor sleep quality to some extent, as seen that the highest percentage of poor sleepers were found among subjects in the intensive category, fewer percentage was from the surgical category, and the fewest came from the medical category. However, the difference among these groups was not statistical significant. For napping at work, there was no significant association between napping at work and sleep quality. This suggests that the result presented regarding napping at work is not a direct effect of poor sleep quality, but influenced by sleep deprivation due to shift work. This finding is supported by the work of Chan,13 who reported that the proportion of nappers was higher in night workers than in day, morning, and afternoon shift workers. Akerstedt14 also found that 51 percent of rotating shift worker were habitual nappers and concluded that for most shift workers napping compensates for sleep loss caused by the temporal displacement of sleep. There are some limitations in our study. First, a Thai version of the PSQI has not been validated for Thai people yet. It is necessary to do this work. Second, although the results of our study help illustrate factors relevant to sleep quality, some factors were not described in details such as stressful life events and job satisfaction as well as other factors that influence sleep quality. More work is needed to clarify the impact of these factors. Severity of the nurses' sleep problems may be alleviated by intervention on these major associated factors. First, sleep disturbances due to shift work is caused by the circadian regulation of sleep/wakefulness.15 Thus, we can touch upon some scheduling aspects of work. A schedule with minimum sleepiness should have a short night shift, rotate clockwise, have the night shift at the end of series of shifts, and have a slow rotation. Other strategies are striving for as stimulating and nonsedentary tasks as possible. Napping, particularly before the night shift, would reduce subsequent night shift sleepiness somewhat.15 Recently, an interesting new approach is the attempt to change the circadian phase rapidly by exposing subjects to bright light (>2,000 lux) in the evening and shielding them from sunlight in the morning by use of dark goggles.16 This appears to rapidly delay the phase of circadian rhythm. The method is promising, but much work remains to be done before it may have any practical applications. However, the main task with regard to management of sleep problem due to shift work is that of: first, convincing administrators that there is a problem and that shift work concerns cannot simply be dismissed as a "personal problem" that the individual shift nurses simply has to learn to cope with.17 Second, with respect to stress events, one should be educated about stress-coping strategies and good sleep hygiene practice.18 Although nurses have good knowledge about being healthy, they may not be able to cope with sleep problems well enough. Future follow-up assessments of this sample will determine whether sleep disturbances among these nurses are persistent after sleep intervention. References 1. Luecha Y, Lauhachinda Y, Thanooruk R, et al. Health Status of Nurses in Ramathibodi Hospital. Rama Med J 1990;13(3):170-6. 2. Buysse DJ, Reynolds CF, Monk TH, et al. The Pittsburgh Sleep Quality Index : A new instrument for psychiatric practice and research. Psychiatry Res 1989;28(2):193-213. 3. Neidhammer I, Lert F., Marne MJ. Effects of shiftwork an sleep among French nurses. A longitudinal study. J occup med 1994;36:667-74. 4. Escriba V., Perez HS., Bolumar F. Shiftwork : Its impact on the length and quality of sleep among nurses of the Valencian region in Spain. Int Arch Occup Environ Health 1992;64:125-9. 5. Shan MZ. Sleep and wakefulness pattern of nurses engaged in rotational shift work. JPMA J Pak Med Assoc 1990;40:245-6. 6. Lee KA. Self-reported sleep disturbances in employed women. Sleep 1992; 15:493-8. 7. Gordon NP, Cleary PP, Parker CE., et al. The prevalence and health impact of shift work. Am J Public Health 1986; 76(10): 1225-8. 8. Gold DR, Rogacz S., Bock N., et al. Rotating shift work, sleep and accidents related to sleepiness in hospital nurses. Am J Public Health 1992;82(7):1011-4. 9. Glazner LK. Shift work : its effect on workers. AAOHN J 1991;39:416-21. 10. Kales A, Soldatos CR, Kales JD. Sleep disorders : insomnia, sleep walking night terrors, nightmares, and enuresis. Ann Intern Med 1987;106(4):582-82. 11. Taboonpong N. Impact of shiftwork on nurses. Program and Abstracts of the Founding Congress of the Asian Sleep Research Society 1994: 105 (Abstr P-43). 12. Kales JD, Soldatos CR, Kales A. Diagnosis and treatment of sleep disorders. In : Greist JH, Jefferson JW, Spitzer RC, eds. Treatment of Mental Disorders. New York : Oxford University Press;1982:473-500. 13. Chan OY, Phoon WH, Gan SL, et al. Sleep-Wake Patterns and Subjective Sleep Quality of Day and Night Workers : Interaction Between Napping and Main Sleep Episodes. Sleep 1989; 12(5): 439-48. 14. Akerstedt T, Torsvall L. Napping in shift work. Sleep 1985;8(2):105-9. 15. Akerstedt T. Review Article : sleepiness as a consequence of shift work. Sleep 1988;11(1):17-34. 16. Eastman CI. Improving adaptation to non-24-hr sleep schedules with bright light. Sleep Res 1987;16:14. 17. Monk TH. Shift work. In:Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. Philadelphia : W.B. Saunders company;1994:542-6. 18. Zarcone VP. Sleep Hygiene. In : Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. Philadelphia: W.B. Saunders Company; 1994:542-6. Table 1 Prevalence of sleep disturbances and associated demographic factors among the nurses. Factors (number) % Good sleepers Poor sleepers P values (PSQI < 5) (PSQI > 5) Age (n=326) 0.010 21-30 (n=189) 58.0 % 22.8 % (43) 77.2 % (146) 31-40 (n=121) 37.1 % 29.8 % (36) 70.2 % (85) > 40 (n=16) 4.9 % 56.25 % (9) 43.75 % (7) 27.0 % (88) 73.0 % (238) Marital status (n=326) ns single, divorced, 64.7 % 25.1 % (53) 74.9 % (158) widow (n=211) married (n=115) 35.3 % 30.4 % (35) 69.6 % (80) Shift work (n=326) 0.0002 permanent day (n=47) 14.4 % 48.9 % (23) 51.1 % (24) rotating shifts(n=279)85.6 % 23.3 % (65) 76.7 % (214) Category of workplaces (wards) (n=278) 0.027 medical (n=95) 34.2 % 27.4 % (26) 72.6 % (69) surgical (n=115) 41.4 % 23.5 % (27) 76.7 % (88) intensive (n=47) 16.9 % 19.1 % (9) 80.9 % (38) ambulatory(n=21) 7.6 % 52.4 % (11) 47.6 % (10) Pregnancy (n=326) ns no (n=313) 96.0 26.2 % (82) 73.8 % (231) yes (n=13) 4.0 46.2 % (6) 53.8 % (7) Physical illness (n=323) ns no (n=231) 71.5 % 26.8 % (62) 73.2 % (169) yes (n=92) 28.5 % 27.2 % (25) 72.8 % (67) Coffee/Tea (n=326) ns not/not often (n=303) 92.7 % 27.4 % (83) 72.6 % (220) everyday/quite often 7.1 % 21.7 % (5) 78.3 % (18) (n=23) Table 2 Other factors associated with poor sleep quality Factors (number) % Good sleepers Poor sleepers P values (PSQI < 5) (PSQI > 5) Job satisfaction (n=325) ns satisfied (n=295) 90.8 % 27.1 % (80) 72.9 % (215) unsatisfied (n=30) 9.2 % 23.3 % (9) 76.7 % (23) Napping (n=322) 0.03 <1 time/week (n=293) 91.0 % 29.0 % (85) 71.0 % (208) >1 time/week (n=29) 9.0 % 10.3 % (3) 89.7 % (26) Stressful life events (n=326) 0.002 no (n=155) 47.5 % 34.8 % (54) 65.2 % (101) yes (n=171) 52.4 % 19.9 % (34) 80.1 % (137) Table 3 Logistic regression analysis : shift work and stressful life events odds ratio S.E. Z Sig IC 95% shift work - rotating shift 3.05 1.01 3.39 0.000 1.6-5.8 - permanent day 1.00 stressful events - yes 2.09 0.54 2.84 0.004 1.26-3.49 - no 1.00
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