The prevalence of sleep disorders and deprivation symptoms has dramatically increased in nurses and allied health professionals. The aim of the study was to evaluate the prevalence of sleep disorders and sleep deprivation symptoms in nurses and allied health professionals occupying at 5 training hospitals affiliated with Lorestan University of Medical Sciences, Iran, 2017. The current cross-sectional analytic-descriptive study was performed on a total of 936 nurses and allied health professionals. The data collection was performed by self-report questionnaire verified by Lorestan University of Medical Sciences. The findings obtained were analysed by descriptive and deductive statistics using SPSS software version 16. Findings demonstrated that subjects had sleep disorders in 98.8% of cases, while remains had 1 to 29 items of sleep ones. Disorders of initiating sleep and fatigue, and weakness after waking up were observed in 67.5% and 64.9% of them, respectively. Subjects in 72.8% of cases preferred to stay at bed in the morning and 28.9% had night terrors and Rapid Eye Movement behaviour disorder. In terms of physical symptoms, fatigue and weakness had the maximum frequency (29.9%). Physical, mental, and emotional symptoms were observed in 96.7%, 94.8%, and 95.5%, respectively. The maximum frequency (38.4%) was correlated to inhibition of study. Results indicated that subjects have sleep disorders and sleep deprivation symptoms in different severities. As for nurses and allied health professionals are key individuals in healthcare system and on the other hand they are potential patients in future, paying especial attention to them is necessary.

Keywords: Nurses, allied health professionals, shifts, sleep deprivation symptoms, sleep disorders

In the United States of America, at least 40 million people annually suffer from chronic, long-term sleep disorders, and an additional 20 million experience occasional sleeping problems. These disorders and the resulting sleep deprivation symptoms interfere with daily and social activities. Also, they account for an estimated $16 billion in medical costs annually, while the indirect costs due to lost productivity and other factors are probably much greater.¹

A sleep-restricted state called sleep deprivation can cause fatigue, daytime sleepiness, clumsiness and weight loss or weight gain;² it adversely affects the brain and cognitive function.^3,4 However, in a subset of cases sleep deprivation can paradoxically lead to increased energy and alertness and enhanced mood; it has even been used to synchronise and consolidate circadian rhythms and as a treatment of depression.^5–7 Sleep deprivation noticeably affects human function, also the mood is more influenced by sleep deprivation than either cognitive or motor performance and that partial sleep deprivation has a more profound effect on functioning than either long-term or short-term sleep deprivation.⁸ The negative effects of sleep deprivation on alertness and cognitive performance demonstrate declinations in activity and function of brain.⁹ Also, sleep and circadian problems represent common non-motor features of Parkinson and Huntington diseases, and attention-deficit hyperactivity disorder.^10,11

Undesirable and night shift schedule results in sleep-wake disturbances, alterations of sleep duration, chronic sleep restriction and excessive sleepiness, alterations in sleep architecture, sleep fragmentation, circadian rhythm disorders and disruption and obstructive sleep apnoea causing sleepiness during night shifts and reducing sleep length and quality in daytime sleep after the night shift. In its serious form it is also called shift work sleep disorder.^12,13

Sleep disorders, physical and mental problems, job dissatisfaction, diminished performance at work and social isolation have been reported in some 88% of the American and Canadian shift-workers.¹⁴ More recent studies; nevertheless, have demonstrated that the 12-hour shifts favoured by many nurses and frequent overtime are associated with difficulties staying awake on duty, reduced sleep times, and nearly triple the risk of making an error.^15–17

Based on the 2006 Survey of Labour and Income Dynamics conducted by Statistics Canada, about 11% of employed Canadians work rotating shifts, while 6% work regular evenings and 2% work regular night shifts. The prevalence of both rotating and evening work is much higher among people under 30 than at elder ages. The number of women working evening, night, and especially, rotating shifts has dramatically increased over the last 10 years.¹⁸ Poor sleep quality; misalignment of circadian rhythms, and subsequent sleepiness and sleep-related performance deficits among nurses and especially night-shift workers is a critical issue for healthcare system. It not only leads to health problems of the nurses, but also associates with a lower work performance and a higher risk of medical errors, which may jeopardise patient’s safety.^19,20 Hence, present research was designed to evaluate the prevalence of sleep disorders and sleep deprivation symptoms in nurses and allied health professionals occupying at 5 training hospitals affiliated with Lorestan University of Medical Sciences, Iran in 2017.

A cross-sectional analytic-descriptive study was conducted from March 1^st, 2017 to September 1^st, 2017. The research population was all of the nurses and allied health professionals (n=1586) occupied in 5 training hospitals of Lorestan University of Medical Sciences, Iran in 2017, but a total of 936 ones in a survey on shift work, sleep and health responded to questionnaires met inclusion criteria and were enrolled in current study by means of simple sampling method and on the basis of purpose as all of them were determined in different shifts and then necessary information were collected. After obtaining nurses’ and allied health professionals’ agreement to participate, the researchers introduced themselves to them, explained the trial’s objectives and assured the participants that their information would confidentially be kept, without mentioning their names. Then, necessary explanations were provided concerning the questionnaires. Afterwards, consent forms were signed by the subjects. Demographics (gender, age, marital status, degree, experience, and hours of time, occupational status, and wards) were collected and questionnaires were distributed among them. Sleep disorders and sleep deprivation symptoms were measured by a self-report questionnaire verified by Lorestan University of Medical Sciences, Iran. Inclusion criteria were not-taking anxiolytic and narcotic medications, not-taking alcohol and caffeine, having no apparent physical and mental disorder(s), occupying in current shift for at least 1 month, and absence of critical condition in recent 1 month. The aforementioned questionnaires were distributed among selected samples and filled out with the help of researchers. Of 936 subjects, 850 ones returned filled questionnaires. Then, documented data were extracted. The findings obtained were finally analysed by descriptive and deductive statistics using SPSS software version 16.

Ethical considerations

The protocol was designed in accordance with the ethical principles of the Helsinki Declaration.²¹ Lorestan University of Medical Sciences’ Ethics Committee considered the project to fall outside its mandate. The nurses and allied health professionals were given a verbal lecture and written information about the goals and approach of the project, and then they declared to help the researchers to perform the study.

Demographics

According to Table 1, the ratio of subjects’ gender was 1: 2.43 (female/male). The range of age was 21 to 57. The mode was observed in 35 year-olds age-group with relative frequency of 9.9%. The minimum and maximum frequency was demonstrated in healthcare providers with the experience of 29 to 30 years, and 1 to 2 years, respectively. Some 62.6% of subjects were nurses, 12.9% nurses’ aides, 7.8% midwives, 6.8% surgical technologists, 4.7% anaesthesiology technologists, 1% radiology technologists, and remainders laboratory technologists. About 69.2% were married and remainders single. Also, 66.4% of them had rotating shifts, 12.2% night shifts, 10.8% permanent-morning shifts, and remainders morning and evening shifts. Moreover, 42.4% of nurses and allied health professionals had a degree of BSc. Some 57.2% were employed and remainders as contractual, and subjects with overtime shifting and staffing plan. The subjects occupied in different wards of the hospitals. The maximum frequency was observed in who occupied in medicine ward (25.3%). Also, 33.2% of nurses and allied health professionals did not have additional shifts, but others had hours of overtime from 10 to 180 hours in a month.

Sleep disorders

Based on current findings, only 20.9% of subjects did not have disorder in initiating sleep. The maximum disorder in initiating sleep after half an hour was observed in 67.5% of the subjects Table 2. The frequency of subjects with 1, 2, and 3 disorder(s) was 28.9%, 42.4%, and 7.8%, respectively. The maximum frequency (87.1%) of sleep maintenance disorder was concerned fatigue during the day. Totally, only 2.4% of the subjects did not have any problem in terms of sleep maintenance. The maximum frequency (64.9%) was for weakness and fatigue after waking up. The frequency of subjects with 1, 2, and 3 disorder(s) in waking up stage was 25.2%, 36%, and 20.7%, respectively. The excessive sleepiness was observed in 72.8% of nurses and allied health professionals with 5 disorders. Moreover, the most para-somnia (28.9%) was indicated as night terrors and Rapid Eye Movement behaviour disorder. In 98.8% of the subjects, 1 to 29 items of sleep disorders were observed. In this between, the maximum frequency was concerning who recorded 9 scores (of 21) of sleep disorders (Table 3).

Sleep deprivation symptoms

Sleep deprivation symptoms are presented in Table 4. In terms of physical symptoms, the maximum frequency belonged to weakness and fatigue, and headache with the values of 29.9% and 24.5%, respectively. The maximum mental symptoms were related to indisposition feeling, and aggression and irritability with the frequency of 24.7% and 23.8%, respectively. Totally, 24 scores were allocated to mental symptoms; it showed that 94.8% of subjects recorded scores in the range of 1 to 24. Moreover, 95.5% of them with emotional symptoms recorded scores in the range of 1 to 36. The maximum frequency was related to inhibition of study and fun with the amounts of 38.4% and 36.2%, respectively. There were sleep deprivation symptoms in 97.9% with the scores from 2 to 99.

Findings analysed based on pearson correlation

Correlations based on Pearson ratio (η²) among demographics and sleep deprivation symptoms are demonstrated in Table 5. Correlation between initiating sleep with sleep deprivation symptoms were ranged from 0.06 to 0.37 for total sleep disorders and sleep maintenance disorder, respectively. Furthermore, correlations among other findings were positive.

Findings analysed based on spearman correlation

Correlations based on Spearman ratio (r) among demographics and sleep deprivation symptoms are presented in Table 6. Correlations between experience with sleep maintenance disorder and physical symptoms were positive and significant (0. 20 and 0.12, respectively). Positive and significant correlation was obtained between hours of overtime with excessive sleepiness and total sleep disorders (0.11 and 0.10, respectively).

Findings analysed based on Kruskal-Wallis test

Correlations based on Kruskal-Wallis test (λ²) among demographics and sleep deprivation symptoms are shown in Table 7. Correlation between degree of study and sleep deprivation symptoms were ranged from 7 to 26.1 for total sleep disorders and emotional symptoms, respectively. Significant correlation was obtained between occupational status with initiating sleep, excessive sleepiness, and mental, emotional, physical, and total symptoms of sleep deprivation being 19.4, 13, 16.2, 26.6, 16.4, and 21.8, respectively. Concerning wards wherein subjects occupied, correlations were ranged from 23.3 to 62.3 for initiating sleep and emotional symptoms of sleep deprivation.

Findings analysed based on Wilcoxon test

As illustrated in Table 8, negative and significant correlations were obtained between gender with disorder in initiating sleep and excessive sleepiness (-2.7 and -1.9, respectively). Females had a higher state of disorder in initiating sleep as compared with higher excessive sleepiness in males. Moreover, negative and significant correlations were achieved between marital status with physical and mental symptoms (-2.1 and -2.7, respectively). Both symptoms were lower in singles than marrieds (Table 9).

Study limitations

The limitations of the study were sampling of training hospitals and that of 936 nurses and allied health professionals, 850 ones quite collaborated with us.

Based on current findings, misalignment between shift schedule and hours of sleep caused disorders in sleep initiation and maintenance of 67.5% and 87.1% of the shift-workers. Present findings were consistent with the study of Gamaldo et al.,²² They reported that being of misalignment between the sleep pattern and the desired sleep schedule causing difficulty in initiating sleep, maintaining sleep, and/or experiencing poor quality sleep predisposing people to insomnia or excessive sleepiness. Unfortunately, current statistics of the subjects with disorder in sleep maintenance was noticeably significant.²² Vallières et al.,²³ reported that difficulties in falling and maintaining sleep experienced by shift workers exacerbates certain physical and mental problems and impairs their life quality. The report of Vallières et al.,²³ was compatible with current findings.

Present findings showed that some two-third of the subjects with circadian sleep disorders suffered from fatigue. Saleh et al.,²⁴ reported similar findings.²⁴ Moreover, Ferreira and de Martino indicated that sleep disorders and sleep deprivation in night-shift workers might cause high levels of fatigue.²⁵ Subjects with excessive sleepiness in 72.8% of cases showed disorders such as sleep irresistible attacks, naps during the day, episodes of disorientation or confusion and movement disorder, staying at bed more than normal time, and drowsiness. In consistence, Boivin & Boudreau²⁶ reported that vigilance, performance, health and safety of shift-workers are significantly influenced by excessive sleepiness.²⁶ Findings obtained showed that undesirable shift schedule of N&Ps contribute to sleep disorders and following work impairment. Congruently, Swanson et al. reported that sleep disorders considerably increases the possibility of negative outcomes of shift-workers.²⁷ In current study, the frequency of physical, mental, and emotional symptoms of sleep deprivation were remarkably significant being 96.7%, 94.8%, and 95.5%, respectively. In consistent with the several reports, obtained findings demonstrated that undesirable shift schedule affect circadian rhythms²⁸ causing mentioned symptoms, which may lead to occupational error,²⁹ leave them at higher risk of daily and social aspects,³⁰ and have a negative effect on attention,³¹ daily performance,³² and working memory.³³

Furthermore, several reports demonstrated that sleep deprivation, alteration and disruption of the circadian rhythms influence physical, mental and emotional aspects and have a deleterious effect on fine motor coordination in healthcare providers and may differentially impair processing of more-detailed visual information.^34–38 Conversely, Scherer et al. indicated that sleep deprivation does not affect dynamic visual acuity.³⁹ Also, no significant decrease was shown in performance of sleep deprived healthcare providers in the study of O’Brien et al.,⁴⁰

Current findings showed a direct association between hours of overtime with excessive sleepiness. In agreement, van Leeuwen et al.,⁴¹ and Pikovsky et al.,⁴² reported that hours of overtime among healthcare providers are associated with increased sleepiness significantly leads to excessive sleepiness.^41,42 Scott et al. reported a direct correlation between hours of overtime with decreased vigilance and increased risk of errors in nurses.¹⁷ Moreover, overtime shifting adversely influences health and safety of shift-workers.⁴³

In current study, the correlation between excessive sleepiness and gender was significant. Similarly, Doi and Minowa reported significant correlation between excessive sleepiness and gender in shift-workers with undesirable sleep-wake schedule.⁴⁴ In contrast to the present study, they reported that being married in sleep deprived shift-workers is a protective factor against excessive sleepiness. In current findings, the correlation was significant between occupational status with sleep disorders and symptoms of sleep deprivation. There were no reports, to our knowledge, to compare with current findings in terms of degree of study and occupational status with sleep deprivation symptoms. Only verified report was available from Centres for Disease Control and Prevention in terms of sleep duration among shift-workers indicated a high prevalence of short sleep duration in healthcare providers with night shifts.⁴⁵ In conclusion, decreased performance and vigilance in nurses and allied health professionals with sleep deprivation symptoms may result in decreased safety and health of the patients.

Current findings indicated that nurses and allied health professionals have disorders in initiating and maintaining sleep and physical, mental, and emotional symptoms of sleep deprivation in differently impressive severities. Also, there were significant correlations between gender, marital status, experience, and hours of overtime with sleep disorders and symptoms of sleep deprivation. As for nurses and allied health professionals are key individuals in healthcare system, and unfortunately as potential patients in future mainly owing to undesirable and heavy shifts, paying special attention to them is necessary. Also, as for heavy shifts of nurses and allied health professionals, we suggest favourable and desirable shift schedule for them also investigating their sleep quality in regular intervals, arranging favourable shift schedule as they can do their daily activities and do meditation and exercises to get more comfort ability and more energy.

The researchers would earnestly like to appreciate all of the personnel who participated in the current research.

The author declares that there is no conflict of interest.

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