The Prevalence of Sleep Quality and Quantity among Emergency

Department Nurses in Indonesia

Lilis Setyowati and Erma Wahyu Mashfufa

Department of Nursing, Faculty of Health Science, University of Muhammadiyah Malang, Indonesia

Jalan Bendungan Sutami 188A Malang 65145

Keyword: Sleep quality, sleep quantity, nurse, emergency department.

Abstract: Sleep disturbance is a frequent complaint in nurses, particular in nurses of emergency department (ED).

Increase the occurrences of medical errors and impact patients’ safety. Rapid rotating shift work is a

common type of shift work in nurses in Indonesia. The question is whether the quality and quantity of

nurses’ sleep is disturbed and what factors influence nurses' sleep in East Java, Malang- Indonesia. The

study was conducted in four hospitals. A total of 115 ED nurses with mean age of 32.3 years. The

parameters (i.e., total sleep time, sleep onset latency, wake after sleep onset, and sleep efficiency were

retrieved based on 7-day sleep diaries. PSQI was used to measure sleep quality. One-sample T-test and

correlation Spearman were used for data analyses. Finding, approximately 82% ED nurses had poor sleep

quality (PSQI > 5). With exception of WASO, ED nurses reported shorter TST, longer SOL, and poorer SE

than normal. The factors correlated with sleep only Body Mass index and exercise. This study suggests that

fast rotating-shift ED nurses experienced poor sleep quality and quantity.

1 INTRODUCTION

Sleep and rest are very important for human life.

One-third of human life is spent sleeping. Kazemi et

al., (2005) in Akbarzadeh et al., (2014) a person's

sleep needs differ depending on the level of

development. the benefits of sleep for cellular

improvement, comfort, calm, and mental-physical

relaxation are created during sleep. The mechanism

can restore, help human physical and mental

regeneration question is whether the quality and

quantity of nurses sleep is disturbed and what factors

influence nurses' sleep (Park, Lee, & Park, 2018).

Park et al., (2018) The prevalence of poor sleep

quality in nurses causes a lower in performance to

caring patients, these factors are caused by work

shifts and age. Shift working is a common

characteristic health professional. The impact of

shift work to strongly interfere with sleep, especially

for nurses’ work in ED (Weaver, Stutzman, Supnet,

& Olson, 2016).

Two dangerous elements and affect the nurse's

health status, as well as patient safety and quality of

care, are the effects of poor sleep Dorrian et al.,

(2008) in (Ruggiero & Avi-Itzhak, 2016). The eight-

hour shift patent with faster rotation is common in

the medical field in Indonesia. It consists of three

shifts, such as morning shift seven hours, from 7:00

to 14:00), evening shift (seven hours, from 14:00 to

21:00 hours), and night shift (10 hours, from 21.00

to 7.00). On average, each ED nurse may experience

three different types of shifts in a week in Indonesia

(Saftarina & Hasanah L, 2014).

The purpose of this study examined the sleep

pattern of nurses’ ED such as; sleep efficiency, wake

time after sleep onset, sleep latency, total sleep time,

and sleep quality in ED nurses, and examine which

correlation sleep and demographic characteristic.

2 METHODS

2.1 Participants

Data collected from 115 ED nurses from four

hospitals in Malang City, Indonesia. The participants

who met the following inclusion criteria that 1)

Setyowati, L. and Mashfufa, E.

The Prevalence of Sleep Quality and Quantity among Emergency Department Nurses in Indonesia.

DOI: 10.5220/0009122700830087

In Proceedings of the 2nd Health Science International Conference (HSIC 2019), pages 83-87

ISBN: 978-989-758-462-6

 2020 by SCITEPRESS – Science and Technology Publications, Lda. All rights reser ved

nurses had worked more than three months in the

ED, 2) worked for consecutive seven-day duty and

one day off during study period, 3) were required to

have the ability to sleep diary and PSQI. A multi-

stage sampling technique was used to recruit the

participants and used design the cross-sectional.

2.2. Research Procedures

Data were collected from nurses working in four

hospital on ED. This study used information sheet to

collect participants’ demographic characteristics

(e.g., personal income, education level, work

experiences, gender, age, material status, body mass

index [BMI], comorbidity, hypnotic use, back

depression inventory, and habit drink alcohol,

coffee, and tea).

In the coment study, it was used to assess six-

duty day and one on day off . TST is a total sleep

time during the night or after the participant duty.

SE is a proportion of the total sleep time and total

time in bed multipled by 100%. SOL is the length of

time that is calculated from lying down to sleep

onset after light off. WASO refers to the time of

wakefulness after sleep initiation. Those parameters

represent sleep quantity in our participants.

2.3. Data Analysis

All data analyses ware performed by using the

statistical Package for the Social Sciences 23 (IBM

Corp., Armonk, NY, USA). Descriptive analyses

was used to estimated the social-demographic data,

sleep parameters and Trail Making Test score using

the mean ± standard deviation for continuous

variables, and case number and percentage for

categorical variables. one-sample T-Test was used

to test the differences between sleep parameters data

compared with norm data (M. Ohayon et al., 2017).

3 RESULTS AND DISCUSSION

Regarding the consequence of score BDI and

hypnotic use, no one in the study has symptoms of

depression and does not use any medication for

sleep disorders. The mean age of the respondents

was 32.24 years (SD = 8.77). Approximately half of

the participants were female (54.8%). In terms of

BMI, the mean BMI was 23.59 (SD =

3.02). Furthermore, the majority participants have

working experience > 5 years (60.9%). Half

participants’ monthly personal income was < $ 250.

Besides, the education level of participants more

than a half percent was Licensed practical nurse

(LPN) the rest had Associated Diploma-3 nurse

(79%). There were 52.2% and 65.2% of participants

having habits of consuming coffee and tea, and more

than half of participants (n = 58) regularly exercise

every week (Table 1).

Table 1: Number and percentage of demographic

characteristics of participants (n=115).

Characteristics of

the respondent

Total

(%)

Age (mean, SD)

32.2

(8.8)

20 – 29

(52.2)

30 – 39

(27.8)

≥ 40

(20.0)

Gender

Male

(45.2)

Female

(54.8)

BMI (mean, SD)

23.6

(3.0)

Marital Status

Single and divorced

(38.3)

Married

(60.9)

Education level

Diploma-3

(79.1)

Registered nurse (RN)

(20.9)

Working experience

(year)

(mean, SD)

(8.5)

< 4 years

(39.1)

≥ 5 years

(60.9)

Personal income a month

< $ 250

(51.3)

≥ $ 250

(48.7)

Coffee intake every day

(47.8)

Yes

(52.2)

Tea intake every day

(34.8)

Yes

(65.2)

HSIC 2019 - The Health Science International Conference

Characteristics of

the respondent

Total

(%)

Exercise habit every week

(49.6)

Hypnotic use

(0)

The distribution in sleep parameters in ED

nurses.

Results of sleep parameters, including WASO, TST,

SOL, SE, and the global score of PSQI presented in

Table 3. The mean (SD) of ED nurses more likely to

have prolonged SOL, shorter TST, poorer SE, lower

WASO and a higher global score of PSQI compared

to norm published 29.89 (20.49), 327.7 (66.59), 88

(6), 8.7 (5.5) and 7.68 (2.73), respectively (all the p

< 0.001) (M. M. Ohayon, Carskadon, Guilleminault,

& Vitiello, 2004) .

Table 2: Distributions of self-reported sleep parameters

and TMT scores of the study (n=115).

Note:

WASO = Wake After Sleep Onset, TST = Total Sleep Time, SOL

= Sleep onset Latency, SE = Sleep Efficiency, PSQI = Pittsburgh

Sleep Quality Index (Ohayon, Carskadon, Guilleminault,

&Vitiello, 2004; Sánchez-Cubillo et al., 2009)

The analysis shows that BMI and exercise have a

positive correlation with nurses' sleep patterns.

Spearman correlations were used to connect sleep

with characteristic demographics, show in table 3.

Table 3: Correlation between sleep quality and

independent variables (n=115).

Independent variables

Age

0,01

0,894

Gender

0,02

0,80

BMI

0,45**

< 0,001

Marital status

0,04

0,65

Education

0,06

0,95

Working experience

0,11

0,22

Drink coffee

0,09

0,32

Drink Tea

0,06

0,47

Exercise

0,25**

0,008

Note: **: Correlation is significant at the .01 level (2-tailed);

* : Correlation is significant at the .05 level (2-tailed)

Correlation Spearman

The interpretation of this study is limited by the

cross-sectional design. The results cannot be

generalized to all nurses who work shifts, selection

bias is introduced by recruiting nurses from four

high-quality hospitals in Indonesia and one

education hospital. We also understand the

emotional health of participants. In addition, we did

not evaluate family commitment factors, such as

caring for the child and family because the majority

of participants were married and had children.

The possible explanation is that our participants

had only five hours sleep averagely and thus WASO

decreased when comparing with norm population

who had seven to eight hours sleep. Consistent with

previous studies that supported nurses have a

reduced cognitive function associated sleep

deprivation (Wolf et al., 2017; Kaliyaperumal et al.,

2017). Our finding suggested that ED nurses who

involved in rapidly rotating shifting work had a poor

executive function. Both sleep disturbance and

rapidly rotating shifting work may contribute to the

consequence; however, our study could not confirm

the possible effects or mechanism of sleep and/or

shifting works on executive functions. Further

investigation should examine the matter (Niu et al.,

2013; Magee et al., 2016). Another finding in our

study was that our participants might have difficulty

starting a deep sleep, we found that they had WASO

longer than the norm.

The findings in our study that nurses slept worse

because of the demands of work. In related studies,

poor sleep quality in French adults was found to be a

strong contributor to poor concentration, difficulty

performing tasks and more work-related accidents

and injuries (Lockley et al., 2007). Similarly, other

findings from Japanese workers having poor sleep

quality were found to have a much higher

prevalence of work injuries (Grandner, Williams,

Knutson, Roberts, & Jean-Louis, 2016). However,

the findings of the opposite relationship, nurses who

work in shifts have experienced work-related

injuries are more susceptible to poor sleep quality.

Occupational accidents caused by poor sleep cause

nurses to take sick leave, and this has a serious

Norm

Participants

Variable

Mean

WASO

(minutes)

8.7

5.5

<0.001

TST

(minutes)

420

327.7

66.6

<0.001

SOL

(minutes)

29.89

20.5

<0.001

SE (%)

<0.001

PSQI

7.68

2.73

<0.001

< 5 (n, %)

18.3

>5 (n, %)

81.7

The Prevalence of Sleep Quality and Quantity among Emergency Department Nurses in Indonesia

impact on their income. As such, their sleep quality

may be affected not only by their injuries but also by

stress or workload in the ED.

Our study found that WASO, TST, and SE in our

participants were lower than the norm. Supported by

a study of Roach et al. (2006) in S.-F. Niu et al.,

(2013) that sleep nurses will experience interference

due to work shifts. Someone who sleeps between 20:

00-24: 00 has the longest TST and the highest level

of melatonin release, while those who sleep at 12:

00-14: 00 experience the shortest TST because

melatonin is at the lowest level. In addition to

changes in circular rhythms, it is found that the sleep

patterns and activities of night shift workers who

sleep during the day are different from the others

and make them more sensitive to environmental

disturbances such as light, noise, improper

temperatures, and telephone ringing, and so on. ,

which causes them to have more WASO than day

shift workers who sleep at night. In this study, the

biological hours of night shift workers are

interrupted by their work at night and sleep during

the day. By sleeping during the day, cortisol levels

still rise and melatonin levels can decrease, which

damages the sleep schedule and can explain why the

night shift group has lower SE than the day shift

group.

Accumulation of sleep deprivation and sleep

deficits can cause chronic fatigue and an increase in

the amount of sleep needed for recovery. Thus,

nurses in the shift group who work the night shift

may have accumulated sleep debt and, consequently,

experience fatigue, which leads to a reduction in the

interval between sleep time and sleep onset on the

second day of the night shift (Shu-Fen Niu et al.,

2017).

Therefore, the findings cannot be generalized to

quickly rotate the shift schedule. Next, participants

were female nurses from the general surgical and

medical ward. The level of activity of nursing staff

and work stress is related to the severity of their

patient's condition. Our results cannot be generalized

to all nurses in different wards. Future studies should

explore the sleep quality of nursing staff in hospitals

in various regions and work with different shift

patterns.

In our study found that influences sleep in the

participant if it was related to the demographics only

BMI and exercise habits. Several potential

pathways, both biological and behavioral, where the

duration of sleep problems is related to being

overweight/obese. Laboratory results have shown

how sleep restriction is related to changes in the

production of hormones that control appetite, such

as leptin and ghrelin, which can cause weight gain

Omizade (2010) in (Bogossian et al., 2012; Lim,

Huang, Chua, Kramer, & Yong, 2016). The

relationship between short sleep and obesity is a

stronger distribution of BMI Mitchell (2010) in (Lim

et al., 2016). Other studies found short sleep

duration can also affect eating patterns, with a

stronger preference for fatty foods when tired.

Furthermore, waking up gives more opportunities

for snacking and dinner which will add to your total

calorie intake. Although there are changes in diet

and hormones may be small, it has been shown that

even small changes in diet can cumulatively change

the energy balance.

4 CONCLUSIONS

Shift rotation is a complex problem that is

simultaneously influenced by several factors,

including disruption in the sleep-wake cycle,

circadian misalignment, individual inclinations, and

family factors, especially in parenting. In this study

that influenced nurses' sleep was BMI factors and

exercise habits. ED nurses with rapidly rotating

shifts have poor sleep quality, longer sleeping

latency, worse sleep efficiency, shorter sleep

duration, lower WASO compared with a healthy

population. Only BMI and exercise have influenced

the sleep pattern of nurses.

ACKNOWLEDGMENTS

The authors thanks to the nurses ED in Malang City,

East Java, Indonesia for their participation and it is

funded by Ministry of Higher Education, Research

and Technology (Kemenristekdikti) Indonesia

through Penelitian Terapan Unggulan Perguruan

Tinggi (PTUPT) Grant.

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The Prevalence of Sleep Quality and Quantity among Emergency Department Nurses in Indonesia