Sleep hygiene among nurses employed in hospital wards

INTRODUCTION

Sleep is a time of organism regeneration, and so, for planning sleep, it is important to keep elementary rules of sleep hygiene, among others the time of going to bed, avoiding devices generating blue light before sleep, and avoiding meals, beverages, and stimulants before sleep, as well as restraining from physical effort before going to bed [1]. One should not sleep during the day and, if necessary, limit the time of sleep to a maximum of one hour [2]. In the canon of rules of sleep hygiene, it is important to go to bed in a relaxed state. Undertaking relaxing activities and avoiding stressful situations are recommended several hours before going to bed [3]. The work practised has a significant influence on sleep.
In Poland about 8% of people have shift work, connected with night work. Article 151 of the Labour Code states that a person working at night means a person whose labour schedule comprises at least 3 hours of work at nighttime or a quarter of whose work time in a settlement period is during the night (between 21:00 and 7:00) [4]. Such a labour schedule results in many negative consequences because it creates conflict between daily circadian physiology and the requirement of work and sleep at biologically unsuitable times [5]. Most nursing staff have 12-hour shift work, which makes night work necessary to guarantee permanent care and necessity of life rescue [6]. In shift working persons, one may observe the so-called shift lag syndrome. Its cause is in desynchronisation of the day/night cycle and sleep/wakefulness cycle and of the rhythmical functioning of the organism [7]. This state is a great challenge for maintaining good sleep quality and proper functioning of a daily circadian rhythm and other processes characterised by rhythmicity. It has been proven that sleeping during the day is not as regenerative for organism as night relaxation [4]. The quality of compensative sleep during the day is bad even if it is long enough. Relaxation after a night shift is burdened with numerous inconveniences connected with delayed falling asleep, frequent waking for the need of urination, high levels of ambient noise, etc. These factors result in lack of satisfaction with the quality of sleep [8].
The aim of this work was the assessment of observing sleep hygiene rules by nurses employed in treatment and conservative wards.

MATERIAL AND METHODS

The research was carried out in 2022 on a group of 129 professionally active nurses employed in hospital wards (treatment [81 persons] and conservative [48 persons]) in healthcare establishments in the territory of Poland. The research results were collected via the Internet. The research inclusion criteria were as follows: being a nurse currently working in a hospital ward, treatment or conservative, informed and voluntary consent for participation in the research, free access to the Internet, and being a member of a social group associating nurses.
Research tools in their electronic version were made available via the Facebook platform, namely the author’s questionnaire form and a standardised tool: the inventory of sleep hygiene and parasomnia (IHSP). The questionnaire form comprised 33 questions: 6 questions concerning respondent’s particulars, 10 questions concerning their professional situation, 7 questions about sleep hygiene, and 10 questions about their health. The inventory of sleep hygiene and parasomnia comprised 35 closed questions covering the following spheres: sleep hygiene, course of falling asleep, symptoms appearing during sleep, course of awaking, and mood on the next day. The questioned persons had the possibility of withdrawal from the research at any stage.
The research materials obtained via the author’s questionnaire were sorted according to the frequency of answers given to each question, then the numerical values were transferred into percentage values. In the statistical elaboration the following tests were applied: independency χ², t-test for independent samples, and univariate analysis of variance. The materiality level of p < 0.05 was assumed. Calculations were made using SPSS 22 software. According to the information of the Bioethical Commission of the Collegium Medicum of the Jagielloński University, survey and questionnaire research is not subject to bioethical commission assessment [9]. The research author’s questionnaire did not include sensitive data.

RESULTS

The group of questioned persons consisted of 129 nurses between the ages of 23 and 59 years. The most numerous group comprised those over 40 years old, at 51.9%. The average age was 40.8 years. Married women prevailed – 63.6%, 59.7% lived in towns, and 62% declared high (master degree) education. 62.8% (n = 81) of nurses were employed in treatment wards, the remaining 37.2% (n = 48) worked in conservative wards. The overwhelming majority (107 persons [82.9%]) worked in a 12-hour system, and 22 nurses (17.1%) worked in a 7.35-hour system. 54.3% of nurses had worked in their profession for more than 15 years. 85.0% of the enquired nurses had 5 to 8 night duties in a month, and 55.8% of nurses declared uninterrupted work for over 12 hours. Nurses in the treatment and conservative wards believed their shift work negatively affects their sleep (38.0%, n = 49) or that it considerably worsens their sleep (33.3%, n = 43), and 14 persons (10.8%) did not notice any influence of shift work on worsening of their sleep. 14.0% of the women (n = 18) gave ambiguous answers, and 3.9% the nurses (n = 5) indicated that this question is not applicable to them. A negative effect of shift work was indicated more frequently by the nurses working in a 12-hour system (73.3%, n = 85) (p = 0.0118), they declared frequent awaking at night (44.0%, n = 51) (p = 0.047), they stated that in the morning when getting out of bed they felt relaxed for the first half an hour only (31.90%, n = 37) (p = 0.0077) (Table 1). During the day (24 hours) nurses slept for 6 hours 40 minutes on average, but they stated that 8 hours of sleep would be satisfactory for them. The analysis of the research results showed that nurses in treatment and conservative wards (24.4%) needed on average 4 hours and 42 minutes of sleep after their night duty. The time span of sleep was very wide – from 1 to 12 hours. The enquired nurses stated that in the majority their sleep after night duty is of 3 to 5 hours’ duration (63.8%) (Fig. 1). While analysing the work time of nurses working in one- or two-shift systems, no differences in the need for sleeping time of nursing staff working in a two-shift system (p = 0.7313) as compared to a one-shift system were found (Table 2). Analysing behaviour connected with sleep hygiene, it was proven that the questioned nurses usually slept at home, in a comfortable bed (93.0%), and in adequate conditions (84.5%), and they avoided excessive physical and psychical efforts before sleeping (70.5%), results presented in Table 3. Elementary sleep hygiene rules include the limitation of blue light before sleeping and staying outdoors for a minimum of 15 minutes every day. Most nurses working on treatment and conservative wards stated that they did not limit blue light (67.4%, n = 87). Few nurses limited blue light by applying protective eye filters on their mobile phone/computer (19.4%, n = 25) or wore glasses blocking blue light (16.3%, n = 21). Few nurses stated that they limited blue light by not using phone, computer, or TV after 9 p.m. (4.7%, n = 6) or by applying red bulbs in the bedroom (0.8%, n = 1) (Fig. 2). Observation of this rule was not statistically significant according to ward, position, or job seniority. 58.1% (n = 75) of the questioned nurses confirmed staying outdoors for a minimum of 15 minutes every day, exposing themselves to daylight/sunlight. Physical activity is also an important factor for regenerating sleep but not later than 3 hours before going to bed, as well as avoiding stimulants. The research results show that 78.3% (n = 101) of the questioned nurses did not practise physical activity during the day and 6.2% (n = 8) confirmed their everyday physical activities. 15.5% (n = 20) of questioned nurses gave a “neither yes nor no” answer (Fig. 3). While analysing the influence of stimulants (Table 3), smoking cigarettes before sleep was declared by 16.3% of nurses, drinking alcohol before sleep by 9.3%, and caffein by 7.3%. Nurses in towns smoked cigarettes before sleep more frequently, which was statistically significant (p = 0.0299). Analysis of sleep among questioned nurses against obeying hygiene rules showed that 54.2% (n = 13) of nurses who went to bed and arose at the same time every day declared full satisfaction from sleep, which showed a significant statistical relationship (p = 0.0003). 83.3% (n = 20) of the nurses who went to bed when they felt sleepy were also satisfied with their sleep, and this relationship was also statistically significant (p = 0.0013). Other results concerning nurses obeying sleep hygiene rules as regards sleep assessment proved not to be statistically significant (Table 4).

DISCUSSION

To maintain bio-psycho-social balance one should sleep about 7-8 hours per day. The most important role of sleep is to ensure regeneration of the organism, which makes efficiency possible during wakefulness. Obeying sleep hygiene rules increases sleep quality and positive functioning of the organism [1]. Research shows that the number of hours of sleeping among the nursing staff, especially among shift-work employees, is significantly lower than in professional groups working in the day only, on weekdays [10]. Babiarczyk and Bujok, examining the length of sleeping time among one- and two-shift employees, showed that sleep length at two-shift persons is by 5-7 hours per week shorter as compared to one-shift employees [4]. However, the author’s research does not confirm this fact. Both nurses working in a shift system and those working in a one-shift system, devoted over 6 hours to sleep. In her research, Andrzejewska proved that persons working in a night system cannot ensure that they have rest in the time naturally indicated by their biological clock, which results in worse sleep quality [8]. The same opinion was expressed by 66.3% of nurses questioned by Szymańska-Czechór and Kędra [11]. Nurses questioned in the author’s material achieved similar results: 71.3%, were of the opinion that shift work affects them negatively, worsening their sleep quality. There is an important aspect affecting sleep quality – sleeping off the backlog of night duty. From my own analyses, it results that 63.8% of the enquired nurses needed 4 hours, on average, after a night duty and 12.6% needed 6 hours. Similar results as regards average length of sleep after a night duty were achieved by Szymańska-Czechór and Kędra, but the difference was only in the sleep lasting over 6 hours – such a need for sleep was declared by 6.2% of nurses only [11]. Research made by Tomaszek et al. showed that 49% of nurses working in a shift system slept after a night duty, but 51% of them did not go to bed after a night duty [12]. Insufficient sleeping time after a night duty was declared by 41% of nurses enquired by Basińska and Wilczek-Rużyczka [13]. Analysis of my own research proved that 54.2% of nurses went to bed and arose at the same time every day, but the result of research made by Tomaszek et al. was different – only 19% of them went to bed at the same time [12]. Different results were also achieved by the authors of foreign research made on a group of 202 nurses in 16 wards of a hospital in Melbourne. They proved that 79% of questioned nurses working in a shift system went to bed at different times and 83% woke up also at different times, which confirmed that the enquired group of nurses did not obey sleep hygiene rules [14]. Limitation of use of electronic devices generating blue light before sleep is an important sleep hygiene rule. There is a disconcerting result achieved in the enquired group: only 4.7% of the enquired persons obeyed this rule. Nearly identical results were achieved by Czuper et al., who reealed that only 5% of the enquired nurses abstained from use of electronic equipment before going to bed [15]. The authors of investigations in a Korean hospital on a group of 199 nurses achieved the result of 91% of enquired persons applying the rule of limitation of blue light from a smartphone or TV screen because it is considered a factor disturbing sleep and increasing wakefulness. Korean research from 2018 showed that 63.5% of nurses obeyed sleep hygiene rules [16].
An important sleep hygiene rule is to spend time outdoors, exposing ourselves to sunlight, for a minimum of 15 minutes every day. My own research showed that this rule was applied by 58.1% of nurses.
In the elaboration of Tomaszek et al., we can read that staying outdoors from 1 to 2 hours daily was declared by 43% of enquired persons, and less than 1 hour – by 25% [12]. The results of my own and other authors’ research show that Polish nurses obey sleep hygiene rules only partly. To prevent the consequences of not obeying sleep hygiene rules, it would be reasonable to avoid shift work, mostly work in night system. However, for employees working in the healthcare service it is not possible due to the necessity of providing permanent care for patients [7]. Thus, it is reasonable to disseminate knowledge on sleep hygiene among nurses, stressing its importance for human health and life.

CONCLUSIONS

Selective obeying of sleep hygiene among nurses working in a 12-hour shift system in hospital treatment and conservative wards results in sleep deficit after night duties. 71.3% of nurses working in a shift system indicated a negative influence of such work on sleep.
Elimination of blue light before sleep was practised by 4.7% of enquired nurses, and application of blocking filters was confirmed by 35.7% of them.
Satisfaction from sleep was declared by 54.2% of nurses who went to bed and arose at the same time and who went to bed when feeling sleepy.
It is necessary to educate nurses working in a shift system about the advantages resulting from obeying sleep hygiene rules. It will positively affect their quality of life and the efficiency of their professional work.

Disclosures

This research received no external funding.
Institutional review board statement: Not applicable.
The authors declare no conflict of interest.

References