ORIGINAL ARTICLES

Philippine Journal Of Otolaryngology-Head And Neck Surgery Vol. 37 No. 2 July – December 2022

Kathrynne Endenna S. Andaya, MD Quality of Sleep Among Shift Work Nurses

Department of Otorhinolaryngology
Head and Neck Surgery
at the Baguio General Hospital:
Baguio General Hospital and Medical Center
A Pilot Cross - Sectional Study

ABSTRACT
Objective: The primary objective of this study was to determine the quality of sleep among 12-
hour shift-work nurses at the Baguio General Hospital using the Pittsburg Sleep Quality Index
(PSQI).

Methods: This was a preliminary cross-sectional study with a primary endpoint of assessing the
sleep quality of the participants using the PSQI. The association of sleep quality with individual
and work factors was also determined.

Design: Cross - Sectional Study

Setting: Tertiary Government Training Hospital
Patient: 154 12-hour shiftwork nurses

Results: The majority (88.96%) of the participants self-reported having poor sleep quality.
Among the components of the PSQI, current shift was significantly associated with habitual
sleep efficiency (Fisher exact test p < .049). No significant associations were found between
demographic characteristics and PSQI Global score, with most respondents having poor sleep
quality regardless of participant characteristics.

Conclusion: Majority of nurses working in 12-hour shifts had poor sleep quality. Night shift
Correspondence: Dr. Kathrynne Endenna S. Andaya
Department of Otorhinolaryngology nurses had higher habitual sleep efficiency scores compared to day shift nurses indicating that
Head and Neck Surgery those working in the night shift had poorer habitual sleep efficiency.
Baguio General Hospital and Medical Center
Governor Pack Road, Baguio City 2600
Philippines  Keywords: sleep quality; shift worker; PSQI; nurse; night shift; day shift; workplace health; 12-hour
Phone: (+63) 916 269 1945
Email: kathrynne_solang@yahoo.com shift
The author declares that this is an original material and
is not being considered for publication or has not been Shiftwork means employment outside the established workday, which is typically 8 am -
published elsewhere; that the final manuscript has been read
and approved by the author, and that the requirements for
4 pm.1 Essential for the successful functioning of institutions requiring 24-hour operation (such
authorship have been met by the author. as hospitals), it requires employees to work outside of physiologic sleep hours. A shift worker is
Disclosures: The author discloses that there are no financial defined as a person who does not work a standard daytime schedule.2 Shift work affects sleep
or personal relationships, intellectual passion, political or quality: current or past performance of shift work was significantly associated with poor sleep
religious beliefs, and institutional affiliations that might lead to
a conflict of interest. quality among shift-working nurses in Shanghai, China;3 18% of shiftwork nurses at the Lung
Center of the Philippines had Shift Work Disorder (SWD);4 and SWD had a prevalence of 32.1%
Presented at the 2021 Annual Research Presentation at the
BGHMC Secretary’s Cottage, Governor Pack Road Baguio City. among night workers and 10.1% in day workers in a random population study.5 Poor quality of
March 11, 2021. sleep also negatively impacts ability to work which is crucial in healthcare settings.3
The Baguio General Hospital and Medical Center (BGHMC) currently employs 380 nurses.
Among these, 308 are shift workers who work twelve-hour shifts daily. At the moment, there is
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Philipp J Otolaryngol Head Neck Surg 2022; 37 (2): 26-29 c Philippine Society of Otolaryngology – Head and Neck Surgery, Inc.
Attribution - NonCommercial - NoDerivatives 4.0 International

26 Philippine Journal Of Otolaryngology-Head And Neck Surgery

 ORIGINAL ARTICLES
Philippine Journal Of Otolaryngology-Head And Neck Surgery Vol. 37 No. 2 July – December 2022

no fixed policy dictating shift changes every seven days. These changes random number generator, participants were chosen at random with a
are dependent only on the preferences of the nurses in each unit, 20% adjustment for attrition.
without regard to how it may affect quality of sleep. Test questionnaires included the PSQI and demographic (age, sex,
The aim of this study was to determine the quality of sleep among marital status, comorbidities) and work factor (length of employment,
12-hour shift-work nurses in this institution using the Pittsburgh Sleep shift schedule) data. Selected participants were contacted through
Quality Index (PSQI). the Nursing Division Office and informed consent was obtained
individually by a research assistant before participants responded to
METHODS the questionnaire. Potential participants were briefed on the nature and
This cross sectional study sought to determine the quality of sleep objectives of the study, possible risks and benefits, and were informed
among consenting 12-hour shiftwork nurses using the Pittsburgh that participation was fully voluntary, with withdrawal being possible
Sleep Quality Index (PSQI) from November 1 to 30, 2020.    The PSQI is at any point. The participants were also given the choice to skip any
a widely used self-rated questionnaire to assess sleep quality. Having questions they preferred to. Test questionnaires were distributed to
a diagnostic sensitivity of 89.6% and a specificity of 86.5%,6 it showed consenting participants, and answered at their leisure one day after
strong reliability and validity with moderate structural validity in a completion of their shift, then retrieved seven days after distribution.
variety of samples, suggesting that it fulfills its intended use to screen
for sleep dysfunction.7 Data Analysis
The protocol for this study was approved by Baguio General Hospital Data was encoded and tabulated using the 2019 version of Microsoft
and Medical Center Research Ethics Committee (BGHMC-ERC-2020-36). Excel version (Microsoft Corp., Redmond, WA, USA) following a coding
Considered for inclusion were staff nurses employed at the BGHMC who manual that was prepared prior to statistical analysis. The data was
were directly involved in patient care and who followed shift schedules: then statistically analyzed using IBM Statistical Package for the Social
seven days of 7am-7pm followed by 7 days of 7pm-7am after a seven- Sciences (IBMÒ SPSSÒ Statistics) V.17 (IBM Corp., Armonk, NY, USA) and
day-off; seven days of 7pm-7am followed by 7 days of 7am-7pm after R Project for Statistical Computing version 4.0.3 (https://www.r-project.
a seven-day-off. Nurses who were not directly involved in patient org/).
care, who were in the ancillary services, on duty during office hours A Fisher exact test statistic was computed to explore the association
only or head nurses assigned to administrative roles, were excluded. of the demographic profile of the shift nurses to the participants’ quality
Additionally, staff nurses directly involved in patient care who were of sleep.  Descriptive and inferential statistics were used in describing,
promoted to administrative roles, or transferred to ancillary services comparing and analyzing data.  Significance was determined as
during the study period, or those who converted from shift schedules a p-value of ≤ .05. The effects of possible confounders were also
to office-hour schedules during the study period were excluded. determined and controlled.
Similarly, nurses undergoing psychiatric or psychological care or who
were diagnosed with or treated for serious medical conditions (such as RESULTS
severe COVID-19) during the study period were excluded. Out of 308 participants who consented to participate and were
We used the OpenEpi version 3.01 formula of sample size given test questionnaires, only 154 nurses returned the questionnaires,
n = [DEFF*Np(1-p)]/ [(d2/Z21-α/2*(N-1)+p*(1-p)] where: for a response rate of 50%. Respondents were predominantly female
Population size (for finite population correction factor or fpc) (67.53%) with a mean age of 32.2 years (range 23-60 years old). Less than
(N): 352 half (42.21%) of the nurses were single. Overall, almost all nurses were
Hypothesized % frequency of outcome factor in the population part of the 12-hour shift for 8 months, wherein more than half (62.34%)
(p): 50%+/-5 were currently on day shift. Majority (89.61%) of the participants had no
Confidence limits as % of 100(absolute +/- %)(d): 5% known comorbidities. (Table 1)
Design effect (for cluster surveys-DEFF): 1 A majority (88.96%) of the participants self-reported having poor
Accordingly, the calculated sample size was 172. Stratified random sleep quality with a Global PSQI score greater than or equal to 5. Based
sampling was used for the distribution of subjects into two shifts. A on the Fisher exact test, the association between components of PSQI
sampling frame was constructed based on a complete list of nurses (subjective sleep quality, sleep latency, sleep duration, habitual sleep
meeting inclusion and exclusion criteria, with their respective assigned efficiency, sleep disturbances, use of sleeping medication and daytime
departments and shift schedules. This full list was subdivided into the dysfunction) and current shift (day shift and night shift), current shift
two shift categories: 7am-7pm followed by 7pm-7am after a seven-day was significantly associated with habitual sleep efficiency (p < .049).
off; or 7pm-7am followed by 7am-7pm after a seven-day off. Using a (Table 2)

Philippine Journal Of Otolaryngology-Head And Neck Surgery 27

 ORIGINAL ARTICLES
Philippine Journal Of Otolaryngology-Head And Neck Surgery Vol. 37 No. 2 July – December 2022

Table 1. Distribution of Participants by Current Shift and by Pittsburgh Table 2. Relationship of Demographic Characteristics of 12-hour Shift
Sleep Quality Index Components Nurses and their PSQI Scores
Day Shift Night Shift PSQI Score
Component
p-value DEMOGRAPHIC
n % n % p-value
CHARACTERISTICS 0-4 Pts 5-21 Pts
Subjective Sleep (n=17) (n=137)
Quality .199*
(n=151) Age-Group (n=154) .726*
0 10 6.62 7 4.64 20-29 y/o 6 50
1 70 46.36 33 21.85 30-39 8 57
2 14 9.27 15 9.93 >40 1 5
3 1 0.66 1 0.66 No Answer 2 25

Sleep Latency Sex .173

(n=154) .652 Male 8 42
0 5 3.25 3 1.95 Female 9 95
1 14 9.09 13 8.44
2 37 24.03 19 12.34 Civil status .555
3 40 25.97 23 14.94 Single 7 58
Married 6 35
Sleep Duration No Answer 4 44
(n=153) .071
0 7 4.58 11 7.19 Current Shift .831
1 17 11.11 7 4.58 Day Shift 11 85
2 58 37.91 28 18.30 Night Shift 6 52
3 13 8.50 12 7.84
Shift Change .829*
Habitual Sleep Changers to Night Shift 2 25
Efficiency .049 Changers to Day Shift 4 39
(n=147) Maintained Shift 11 73
0 43 29.25 17 11.56
1 23 15.65 12 8.16 Length of Time Employed NA**
2 14 9.52 9 6.12 as an 12-hour shift worker
3 12 8.16 17 11.56 0-12months 16 136
No Answer 1 1
Sleep Disturbances
(n=154) .154* Comorbidities .389*
0 3 1.95 0 - With any comorbidities 3 13
1 54 35.06 25 16.23 No known comorbidities 14 124
2 37 24.03 32 20.78
*computed using Fisher exact test
3 2 1.30 1 0.65 **no test applicable as all answers were one-sided (8 months)

Use of Sleeping getting 5-6 hours of actual sleep. Low scores in habitual sleep efficiency
Medication .973*
(n=151) were observed to be more frequent in day shift nurses (29.25% scored
0 81 53.64 50 33.11 0, equivalent to >85% habitual sleep efficiency) than those among
1 5 3.31 2 1.32
night shift nurses, of whom 11.56% had >85% habitual sleep efficiency
2 4 2.65 2 1.32
3 4 2.65 3 1.99 and 11.56% had <65% sleep efficiency.
Fairly good sleep quality was reported by 46.36% of day shift nurses
Daytime and 21.85% of night shift nurses. Only 5.97% of day shift nurses and
Dysfunction .084*
(n=154) 14.94% of night shift nurses had high scores in sleep latency, while
0 24 15.58 15 9.74 37.91% of day shift and 18.30% of night shift nurses reported a 5 to
1 56 37.09 31 20.13
16 10.39 8 5.19 6-hour duration of sleep. Most respondents were within the mid
2
3 0 - 4 2.60 ranges of the sleep disturbance score and a great proportion (86.75%)
reported non-use of sleeping medication in the past month. More
*computed using Fisher exact test
day shift (37.09%) than night shift (20.13% ) nurses had low scores for
Mean hours of sleep for all participants were 5.69 hours, ranging daytime dysfunction. Overall, most respondents (88.96%) had poor
from 1.5 hours to 10 hours, wherein 55.2% of the total sample reported sleep quality, regardless of participant characteristics.

28 Philippine Journal Of Otolaryngology-Head And Neck Surgery

 ORIGINAL ARTICLES
Philippine Journal Of Otolaryngology-Head And Neck Surgery Vol. 37 No. 2 July – December 2022

DISCUSSION relationships.
Our survey found that 88.96% of the participants self-reported This study was limited by the COVID-19 pandemic. The change
having poor sleep quality (PSQI global score > 5), with an overall mean in shifts and ward assignments of the nurses, as well as quarantine
score of 8.75 + 3.17. Only 11.04% of the group reported having good protocols made it more difficult for them to participate in the research.
sleep quality. Among the components of the PSQI, only habitual sleep The pandemic also increased stress levels of all hospital workers in our
efficiency was associated with current shift (p < .049), with lower scores institution which could have contributed to the poor sleep of nurses.
observed among day shift nurses than night shift nurses. This study was only done on nurses working in 12-hour shifts, as the
In comparison to a study among nurses working in acute hospitals in schedule of nurses were adjusted from the usual three shifts in 24 hours
South Korea, the results of the present study show a higher prevalence to two shifts to accommodate the needs of the hospital during the
of poor sleep quality (79.8%), and a higher mean PSQI global score pandemic. In the future, this study may also be done on shift workers
(6.52 + 4.23).8 These findings are also similar to a cross-sectional study working in three shifts to assess if shorter shifts, or rotating in between
in a tertiary hospital in Shanghai wherein PSQI scoring was found to three shifts provide better sleep quality for shift-workers. Also, this
be significantly associated to sleep efficiency, sleep quality and daily study was conducted in a single institution in the northern Philippines,
dysfunction.9 However, in the current study, sleep quality and daily thus, the results may not be generalizable to other institutions. Other
dysfunction were not statistically significant. tools to assess sleep quality and work quality may be used in future to
While the present study was able to determine that the majority look for associations between these.
of shiftwork nurses in the BGHMC had poor sleep quality, it was not In conclusion, this current study found that the majority of the
able to identify which individual characteristic of nurses nor which nurses at the BGHMC report low sleep quality. Given that shift work
work factor was associated with poor sleep quality. Additionally, only a remains indispensable, this finding is worthy of further consideration
total of 154 respondents were included and due to limitations in time in order to identify ways of addressing it. A future direction of this
and resources, the minimum sample size requirement was not fulfilled. study is assess sleep quality in other departments and with other
Almost all reported to have been in 12-hour shifts for eight months. This workers in the hospital such as resident physicians who go on 24-hour
corresponds to the hospital mandate of having staff nurses go into 12- duty, paramedical staff such as radiology technicians, and medical
hour shifts from the previous eight-hour-shifts to allow for a quarantine technologists. Further studies should be conducted to identify the
period in between shift changes. Prior to the COVID-19 pandemic, drivers of sleep quality, as well to identify comprehensive strategies to
nurses were assigned one of the following shifts: 7 am-3 pm, 3 pm -11 improve them among shift workers.
pm and 11 pm-7 am. The assigned shift for 15 days was followed by
another 15 days in another shift, depending on their arrangement with ACKNOWLEDGEMENTS
their immediate supervisor. The change in schedule was due to the The author acknowledges the invaluable contributions of Beverly Carbonell, MD, FPSO-HNS,
FPSSM for her guidance and insight, and of Mr. Roy Revilla and Ms. Karell Calpito who provided advice
emergence of the COVID-19 virus and need to provide a dedicated area and statistical support for this study.
of the hospital for infected patients. REFERENCES
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