Original article

Med. Lav. 2023, 114 (3): e2023023

DOI: 10.23749/mdl.v114i3.14033

Evaluation of Sleep Quality, Work Stress and Related

Factors in Hospital Office Workers
Nejdiye Güngördü1,*, Seher Kurtul2, Mehmet Sarper Erdoğan3
1
Medical Doctor, Occupational Diseases Physician, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Department
of Occupational Disease, Istanbul, Turkey
2
Medical Doctor, Occupational Diseases Physician, University of Health Sciences, Bozyaka Training and Research Hospital,
Department of Occupational Disease, Izmir, Turkey
3
Medical Doctor, PhD, Professor, Public Health Physician, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Department
of Public Health, Istanbul, Turkey

Keywords: Sleep Quality; Work Stress; Hospital; Office Worker

Abstract
Background: Occupational factors, working conditions, age, gender, exercise, acquired habits, and stress affect a
person’s sleep quality. The aim of this study was to investigate sleep quality, work stress, and related factors among of-
fice workers in a hospital. Methods: This cross-sectional study was conducted with office workers actively working in
a hospital. A questionnaire consisting of a sociodemographic data form, the Pittsburgh Sleep Quality Index (PSQI),
and Swedish Demand-Control-Support Scale were used to assess the participants. Results: The mean of PSQI score
was 4.32±2.40 and 27.2% of the participants had poor sleep quality. In the multivariate backward stepwise logistic
regression analysis, it was found that shift workers were 1.73 times (95% CI: 1.02-2.91) more likely to have poor
sleep quality, and a one-unit increase in work stress score increased the risk of having poor sleep quality by 2.59 times
(95% CI: 1.37-4.87). An increase in age was found to decrease the risk of poor sleep quality in workers (OR=0.95;
95% CI: 0.93-0.98). Conclusion: This study suggests that reducing workload and increasing work control as well
as enhancing social support will be effective in preventing sleep disturbances. It is important, however, in terms of
providing guidance for hospital employees in planning future measures to improve working conditions.

1. Introduction sleep disorders are associated with diseases, occupa-

tional accidents, and long-term health problems; It
Occupational factors, working conditions, age, has been shown to affect both qualities of life and
gender, exercise, acquired habits, and stress could af- productivity [3]. Shift work patterns are becoming
fect a person’s sleep quality. Although many factors, an increasingly common concept in many occupa-
such as sociodemographic and occupational charac- tions in modern society. One-fifth of the working
teristics, could affect the prevalence of sleep disor- population is estimated to perform a job at differ-
ders, very common among healthcare ­workers [1]. ent working hours or night [4]. Shift work can be
Sleep disorders can lead to decreased immunity, performed in three shifts of 8 hours each and in
adaptability, anxiety, depression, and other physical two shifts beginning in the morning and ending at
and mental disorders [2]. It has also been found that midnight. According to the International Labour

Received 05.12.2022 - Accepted 14.04.2023

*Corresponding Author: Nejdiye Güngördü, Medical Doctor, Occupational Diseases Physician, Istanbul University-Cerrahpasa,
Istanbul, Turkey; E-mail: nejdiyegungordu@gmail.com
2 Güngördü et al

Organization’s (ILO) Night Work Convention, among the priority groups among healthcare work-
which came into force in 1995, the night shift is de- ers. For this reason, the employee health practices
fined as “work performed during a period of not less of hospital office workers are ignored. The aim of
than 7 hours, including from midnight to 5 a.m.” this study was to investigate sleep quality, work
[5]. Shift work is mandatory for 24-hour health care stress, and related factors among office workers in
service, and night shifts are more common than in hospitals.
other sectors [6]. Sleep disturbance is a common
problem among night shift workers. As a result of 2. Methods
the disruption of circadian rhythms caused by shift
work, the quality, and quantity of sleep decrease [7]. 2.1. Study Settings and Population
It has been determined that the night shift can af-
fect not only their personal health but also the qual- This cross-sectional study was conducted be-
ity of their work, their psychological health, and the tween August 2022 and October 2022 with 512 of-
treatment of their patients and may cause related fice workers working at the Cerrahpaşa School of
accidents. Medicine Hospital. The participants included the
Due to many factors in the working environment, medical secretary, data entry, and administrative
workers are exposed to stress and experience physi- staff. The study questionnaire was administered to
cal, mental, and social changes due to their stress. face-to-face hospital employees who attended a pe-
Organizational factors such as work schedules and riodic health examination. No sample selection was
shift systems are among the causes of stress in the made, and it aimed to reach the entire population.
workplace. While continuous daytime work is the Of the 512 office workers working at the hospital,
least stressful, shift workers are the most stressed. about 368 people attended the periodic health ex-
Failure to participate in regular activities due to amination and agreed to participate in the study.
shift work, inability to engage in regular social and Thus, 71.8% of the individuals in the study popu-
community activities, and decreased job satisfaction lation could be reached. Written informed consent
can lead to stress [8]. The shift work system has was obtained from each individual participant in the
been reported to cause stress and decrease workers’ study. Inclusion criteria included registered office
ability to cope [9]. There is a bidirectional relation- workers with more than one year of work experi-
ship between poor sleep quality and stress. Stressful ence. The study had no exclusion criteria. The night
work environments lead to sleep problems [10]. Re- shift group included those who worked for at least
searchers have found that nurses from various med- five hours after midnight. On the other hand, the
ical departments are more likely to experience poor day shift group included those who worked for at
sleep quality due to work stress. Work stress has least eight hours between 8 a.m. and 11 p.m. Work-
been found to affect job satisfaction and sleep qual- ing in night shift office workers, the group works in
ity among employees. Chronic work stress can lead rotation. Those working in shifts of at least 1 year
to weakness, anxiety, depression, and other psycho- were included.
logical problems that affect sleep quality [11, 12].
Most of the studies investigating sleep quality in 2.2. Research Instruments
hospital employees were conducted on nurses and
doctors, and poor sleep quality was found [13-15]. A questionnaire consisting of a sociodemographic
When we think of shift work in health sector, the data form, the Swedish Demand-Control-Support
first groups that come to mind are healthcare work- Scale (DCSQ), and the Pittsburgh Sleep Quality
ers, such as nurses and physicians, and office work- Index (PSQI) were used to obtain information in
ers also work in shifts. The number of studies that the study. The sociodemographic data form included
have been conducted on office workers in hospitals questions on individual characteristics, lifestyle, and
is insufficient. In developing countries such as Tur- occupational data in the first section. In the second
key, hospital office workers do not come to mind section, DCSQ is used to evaluate the work stress of
 Sleep Quality and Work Stress in Hospital Office Workers 3

the participants. The DCSQ, conducted in Turkish variables are expressed as the mean ± standard de-
by Yücel et al., is a widely used scale to evaluate psy- viation, and categorical variables are expressed as the
chological demands, decision-making freedom, and frequency and percentage. In comparing two groups
social support in the workplace. The scale consists of continuous variables, Student’s t-test and Mann‒
of three main subsections. It includes five questions Whitney U test were used in independent groups.
for workload, six for work control (skill utilization Categorical data were compared by the chi-square
and freedom of decision), and six for social support. test. As a result of these two-variable analyses, the
Response options for the subdivisions of workload, independent variables found to be related to sleep
skill utilization, and freedom of decision consist of quality were included in the backward stepwise lo-
“frequently, sometimes, rarely, and never” responses. gistic regression analysis model, and multivariate
For social support, options include “totally agree, analysis was performed. The relationship of the
partially agree, partially disagree, and completely variables determined to be related to sleep quality
disagree”. In the scale evaluation, the answers were in the backward stepwise logistic regression analysis
coded between 1-4 Likert, and the total score of with the subcomponents of sleep quality was evalu-
the relevant subsection is obtained by summing the ated with the Pearson correlation test and Student’s
scores of each subsection with higher values indi- t-test. The results were considered significant at
cating higher psychological demands (range 5-20), p<0.05.
higher decision latitude (range 6-24), and higher
social support at work (range 6-24). All scale scores 2.4. Ethical Considerations
were calculated by summing up the respective un-
weighted item scores after appropriate reverse scor- The study was approved by the Cerrahpaşa
ing of item 4 (overtime work) and item 9 (variety of School of Medicine Hospital Ethics Committee at
work). High scores indicate a high workload, work Istanbul University-Cerrahpaşa (Date: 04.05.2021
control, and social support. Work stress was evalu- No: 94540).
ated as the ratio of workload to work control [16].
In the third section, PSQI is used to evaluate sleep 3. Results
quality. The PSQI is a measure of subjective sleep
quality. The PSQI was developed by Buysse et al. in The study included 368 hospital office workers,
1989 [17]. The validity and reliability studies for the mostly men (70.9%, n=261). The mean age of the
Turkish version were carried out by Ağargün et al. participants was 37.27±4.2 years. The mean body
bjective sleep quality, sleep latency, sleep duration, mass index (BMI) was 26.74±8.8. Of the partici-
habitual sleep efficiency, sleep disorders, hypnotic pants, 68.8% (n=253) were married. Regarding oc-
drugs, and daytime function, seven factors were rated cupational characteristics, 63% (n=232) had ten or
on a 4-point Likert scale from 0 (no difficulties) to more years of working experience. When partici-
3 (very difficult). The cumulative score of each factor pants were compared by sleep quality, female gen-
was the total score of the PSQI, with the total score der, singles, and shift workers had a significantly
ranging from 0 to 2l. The higher the score, the worse higher frequency of poor sleep quality. In contrast,
the sleep quality. Scores greater than five indicated the mean age and total working time was signifi-
poor sleep quality [18]. cantly lower among workers with poor sleep quality
(Table 1).
2.3. Data Analysis When comparing participants’ mean work stress
scores as a function of their sleep quality, the mean
The data were analyzed by using SPSS v24.0 work stress scores of employees with poor sleep
(SPSS Inc., Chicago, IL, USA). In descriptive anal- quality were significantly higher than those with
yses, number and percentage values for categorical good sleep quality, while the social support score was
variables and mean and standard deviation values significantly lower (p<0.001, p=0.001, and p=0.014,
are presented for continuous variables. Continuous respectively) (Table 2).
4 Güngördü et al

Table 1. Individual, lifestyle, and occupational characteristics and sleep quality of hospital office workers.
Total PSQI≤5 PSQI>5
(n=368, 100%) (n=268, 72.8%) (n=100, 27.2%) p
Age (mean±SD) 37.27 (±4.2) 38.41 (±8.10) 34.22 (±9.89) <0.001
Gender (n, %) Female 107 (29.1) 70 (65.4) 37 (34.6) 0.041
Male 261 (70.9) 198 (75.9) 63 (24.1)
Marital status, n (%) Married 253 (68.8) 200 (79.1) 53 (20.9) <0.001
Single 115 (31.3) 68 (59.1) 47 (40.9)
Education (n, %) Primary School 75 (20.4) 58 (77.3) 17 (22.7) 0.541
High School 184 (50.0) 130 (70.7) 54 (29.3)
University 109 (29.6) 80 (73.4) 29 (26.6)
Shift work (n, %) Yes 180 (48.9) 122 (67.8) 58 (32.2) 0.033
No 188 (51.1) 146 (77.7) 42 (22.3)
Total working time, y (mean±SD) 11.85 (±6.7) 12.53 (±6.43) 10.03 (±7.09) 0.002
Weekly working time, h (mean±SD) 44.47 (±1.5) 44.46 (±1.56) 44.50 (±1.51) 0.821
BMI (mean±SD) 26.74 (±8.8) 26.82 (±3.90) 26.52 (±4.85) 0.540
BMI: Body mass index.

Table 2. Relationship between DCSQ scores and sleep quality among hospital office workers.
Total PSQI≤5 PSQI>5
(n=368) (n=268, 72.8%) (n=100, 27.2%)
(mean±SD) (mean±SD) (mean±SD) p
Workload 12.88(±3,06) 12.54(±3.14) 13.8(±2.67) <0.001*
Work control 15.42(±3.69) 15.59(±3.68) 14.97(±3.69) 0.153*
Social support 19.60(±4.02) 19.91(±3.95) 18.76(±4.12) 0.014*
Work stress 0.89(±0.36) 0.86(±0.34) 0.99(±0.38) 0.001°
*Student’s t-test, °Mann-Whitney U test.

When we compared the mean scores of PSQI shift workers were 1.73 times (95% CI: 1.02-2.91)
sub-parameters according to shift work status, the more likely to have poor sleep quality, and a one-unit
mean scores of sleep duration, effective sleep habits, increase in work stress score increased the risk of
and total PSQI score were found to be statisti- having poor sleep quality by 2.59 times (95% CI:
cally significantly higher in shift workers (p=0.010, 1.37-4.87). An increase in age was found to decrease
p=0.006, p=0.014, respectively) (Table 3). the risk of poor sleep quality in workers (OR =0.95;
The final model obtained from the multivariate 95% CI: 0.93-0.98) (Table 4).
backward stepwise logistic regression analysis cre- A weak positive correlation was found between
ated with the variables determined to be associated workload and subjective sleep quality, sleep duration,
with sleep quality in the binary analyzes is presented sleep disturbance, daytime functions, and total sleep
in the table. Accordingly, age, gender, marital status, quality score. On the other hand, a weak negative
shift work, total working time and stress score were correlation was found between the social support
included in the first step of the analysis. In the sec- score and subjective sleep quality and daytime func-
ond step, the total working time; in the third and tions. In addition to that, a weak positive correlation
last step, it was exited from the marital status re- was found between the total stress score and daytime
gression model. In the final model, it was found that functions and total sleep quality score (Table 5).
 Sleep Quality and Work Stress in Hospital Office Workers 5

Table 3. Pittsburgh Sleep Quality Index (PSQI) score for hospital office workers.
Total Shift worker Daytime worker
(n=368) (n=180, 49%) (n=188, 51%)
(mean±SD) (mean±SD) (mean±SD) P*
Subjective sleep quality 0.93(±0.63) 0.97(±0.70) 0.88(±0.55) 0.177
Sleep latency 0.98(±0.88) 1.10(± 0.92) 0.86(±0.83) 0.010
Sleep duration 0.73(±0.66) 0.71(±0.72) 0.76(±0.59) 0.523
Habitual sleep efficiency 0.17(±0.49) 0.240.59 0.10(±0.36) 0.006
Sleep disturbance 1.04(±0.61) 10.5(±0.60) 10.4(±0.63) 0.843
Use of sleep medications 0.06(±0.37) 0.09(±0.48) 0.03(±0.22) 0.115
Daytime dysfunction 0.40(±0.66) 0.47(±0.75) 0.35(±0.55) 0.082
Global PSQI 4.32(±2.40) 4.63(±2.79) 4.01(±1.91) 0.014
*
Student’s t-test.

Table 4. Multivariate analysis with a backward stepwise regression model of factors associated with sleep quality.
Step 1 Step 2 Step 3* (Final model)
OR (95% CI) p OR (95% CI) p OR (95% CI) p
Age 0.97 (0.93-1.01) 0.103 0.96 (0.93-0.99) 0.020 0.95 (0.93-0.98) 0.001
Gender Female 1.66 (0.94-2.93) 0.079 1.66 (0.94-2.92) 0.079 1.71 (0.98-3.01) 0.061
Male (ref )
Marital status Single 1.61 (0.91-2.86) 0.105 1.61 (0.91-2.86) 0.101 - -
Married (ref )
Shift work Yes 1.63 (0.96-2.77) 0.073 1.63 (0.96-2.76) 0.069 1.73 (1.02-2.91) 0.041
None (ref )
Total working time (years) 1.00 (0.95-1.05) 0.912 - - - -
Stress total score 2.51 (1.33-4.75) 0.005 2.51 (1.33-4.74) 0.005 2.59 (1.37-4.87) 0.003
*R2= 0.084 (Cox&Snell), 0.124 (Nagelkerke).

4. Discussion healthcare workers were found to have poor sleep

quality [26]. In this study, it was found that the
This study evaluated sleep quality, work stress, frequency of those who had PSQI scores and poor
and related factors in hospital office workers. The sleep quality was lower, and it is suggested that the
results of this study showed that all participants possible reason for this is the different occupational
had a mean PSQI score of 4.32±2.40, and 27.2% groups of the participants in this study.
had poor sleep quality. Besides, it revealed that In this study, married participants were found to
poor sleep quality was more common in females, have better sleep quality than single participants.
singles, and shift workers, while participants with Consistent with our study, in the study conducted
poor sleep quality had a lower mean age and total by Bingöl, single nurses had poorer sleep quality
working time. In studies conducted with nurses, the than married nurses [27]. Furthermore, other stud-
PSQI score was 6.80±3.39 in Spain, 6.0±2.130 in ies on this subject have also shown that the sleep
Japan, and 9.10±2.78 in China [19-21]. Studies in quality of married healthcare workers is better than
the literature report that the quality of sleep is poor that of single healthcare workers [22, 28]. In the
in studies conducted on healthcare workers [22-26]. study conducted by Üstün et al., it was seen that the
In a study conducted in Saudi Arabia, 42.3% of reason for the good sleep quality of the nurses was
6 Güngördü et al

Table 5. The relationship between PSQI and the subdimensions of the DCSQ scores.
Workload Work control Social support Work stress
Subjective sleep quality r 0.216 0.032 -0.126 0.084
p <0.001 0.542 0.016 0.106
Sleep latency r 0.094 -0.010 0.002 0.045
p 0.071 0.853 0.975 0.389
Sleep duration r 0.138 0.052 0.029 0.074
p 0.008 0.322 0.582 0.158
Habitual sleep efficiency r 0.054 0.006 0.002 -0.034
p 0.302 0.902 0.962 0.519
Sleep disturbance r 0.125 0.066 -0.016 0.028
p 0.016 0.205 0.759 0.593
Use of sleep medications r 0.021 0.066 0.027 0.081
p 0.694 0.205 0.602 0.119
Daytime dysfunctions r 0.217 -0.090 -0.203 0.207
p <0.001 0.085 <0.001 <0.001
Global PSQI r 0.213 0.002 0.082 0.129
p <0.001 0.967 0.116 0.013
(Pearson correlation test), r→correlation coefficient.

that the majority (61.9%) were single and that those night shifts more frequently, and want more time
who were married had children aged four years and to rest as they age.
older (with low care burden) [28]. These findings Consistent with the literature, this study found
suggest that the level of sleep quality should not that sleep quality increased over working year [27].
be evaluated only with marital status; they should It has been concluded that this situation negatively
be evaluated together with factors such as having affects the quality of sleep because those who are
children, the number of night shift workers, and the new in their professional life are usually employed in
department where they work. night shift work and busy healthcare facilities, and
Although the effects of gender on sleep qual- their coping skills are insufficient. In this study, ‘age’
ity in healthy adults are controversial in the litera- may have been a confounding factor in the poorer
ture, it has been stated that women may have more sleep quality of participants with fewer total work-
sleep problems, albeit partially. Some studies have ing years. In this study, it was found that the sleep
found that men have better sleep quality [29, 31]. It quality of younger participants was worse. The fact
is supposed that the reason for lower sleep quality that a low number of total working years was re-
in women is that they have other social obligations moved from the model in the regression analysis,
besides the workplace factor and that factors such but age remained, supports this.
as housework and children increase sleep problems. Sleep disturbance is a common problem among
Studies have shown that sleep quality is poor night shift workers. Consistently with the literature,
in workers younger than 35 and improves with we found that night shifts are more likely to have
age [27]. In addition, nurses’ ability to cope with poor sleep quality than day shifts [33, 34]. Nurses
sleep problems has increased with age [32]. It is working night shifts had low sleep efficiency, sleep
thought that the improvement of sleep quality disorders, daytime dysfunction, and longer sleep
with the advancement of age is because young latency [35]. In addition, the sleep-wake cycle is
nurses work in more intensive departments, work negatively impacted by shift work. As such, sleep is
 Sleep Quality and Work Stress in Hospital Office Workers 7

more likely to be disrupted in the daytime, which were used in this study, and all data were collected
may result in shorter sleep periods. This was in line using self-report questionnaires, which may affect
with previous studies indicating that specific char- the results. Thirdly, non-occupational determinants
acteristics of night shift work can lead to poor sleep of sleep quality, such as caffeine intake and drug use,
quality. Consistent with these results, shift workers were not asked. Fourthly, this study was conducted
had a long time to fall asleep and a lower score for in a university hospital in Turkey, and hospital of-
effective sleep habits in this study. Furthermore, in fice workers working in this hospital were included.
the retrospective stepwise regression model, the risk Because of this reason, the generalization cannot be
of poor sleep quality was 1.73 times higher in shift made. However, apart from these limitations, this
workers than in day workers. study is the first to investigate sleep quality, work
In particular, the health sector includes many fac- stress, and related factors among hospital office
tors that cause stress, such as the difficulty of serving workers in Turkey.
patients who experience intense stress and the fre-
quent occurrence of stressful events in the daily work 5. Conclusions
of those working in this sector. While work stress
increases sleep disturbance, sleep disturbance also In this study, it was found that 27.2% of hospi-
causes employees to perceive work stress more with tal office workers had poor sleep quality; poor sleep
mechanisms such as concentration problems [36]. quality was more common in single and shift work-
In this study, it was found that the mean workload ers as well as in female gender, and the mean age
and work stress score of the participants with poor and total working time were lower in participants
sleep quality was higher, the social support score was with poor sleep quality. In addition, it was found
lower, and a 1-unit increase in the work stress score that the increase in shift work and work stress score
in the backward stepwise regression model increased increased the risk of poor sleep quality, whereas in-
the risk of poor sleep quality by 2.59 times (95% creasing age decreased the risk. Determining the
CI: 1.37-4.87). Similarly, in the study by Elevainio relationship between potential risk factors in the
et al., sleep problems were significantly more severe work environment and sleep disorders is necessary
in the group with a high mean work stress score [37]. for worker health. The results of this study suggest
A cohort study with a two-year follow-up stated that reducing workload and increasing work control
that there was a correlation between occupational as well as enhancing social support will be effective
characteristics such as workload, control, social sup- in preventing sleep disturbances. It is important,
port, and sleep disorders. however, in terms of providing guidance for hospital
Other studies have reported that sleep problems employees in planning future measures to improve
occur when the workload is high, but work control working conditions.
is not solely related to sleep [38, 39]. This finding is
consistent with the view that the sense of motivation Funding: This research received no external funding.
and mastery increases, and the tension-generating
Informed Consent Statement: Informed consent was
effect of a high workload decreases when both
obtained from all subjects involved in the study.
workload and work control are high compared to
the workload-control model. In the Karasek model, Declaration of Interest: No conflict of interest was
social support is a variable that reduces the effect of declared by the authors.
work stress. In this study, as in other studies, low so-
cial support was associated with sleep problems [39]. References
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