Attending Emergency Physician, Department of Emergency Medicine, Izmir Tepecik Training and Research Hospital, Izmir, TurkeyTurkey
Teaching Staff, First and Emergency Aid Program, Dokuz Eylül Üniversity Vocational Higher School of Healthcare Studies, İzmir, TurkeyTurkey
Emergency medicine resident, Department of Emergency Medicine, S.B. Izmir Tepecik Train- ing and Research Hospital, TurkeyTurkey
Also available as PDF (figures and tables appear in the PDF).
Objective: As with other people, sleep quality has an impact on a physician’s work safety. Aim of this study is determine the sleep quality among medical specialists whose working night shifts, and detect other independent factors that affect their sleep quality. This is essential for improving the physician health and their daily performance for patient care. Methods: A qualitative study was design with a cross-sectional method. Sampling was conducted with stratification among night shift physicians who work in the emergency, internal medicine and surgical departments at an education and research hospital. Scores on the Pitts burgh Sleep Quality Index (PSQI) and the Swedish Demand-Control-Support Questionnaire (DCSQ) were assessed. Results: One hundred eight physicians who worked night shifts responded to the questionnaire. The average age of the physicians was 31.3±5.9, and 40.7% were women. The average PSQI score in male participants was significantly higher (8.1±3.7 vs. female 7.6±3.9; p=0.014). The majority of physicians (83.3%) had high PSQI values, i.e., scores of 5 or more. No significant difference was found in the average PSQI values between the emergency and internal medicine physicians and surgeons (p>0.05). The most important factors that affected physicians’ sleep quality were the number of night shifts per month, age, gender and the existence of a chronic disease. Conclusion: The sleep quality of medical specialists who work night shifts is equally low. The existence of a chronic disease, age, gender and higher numbers of night shifts affect sleep quality as powerful independent factors.
Keywords: Sleep quality; Sleep disorder; Medical specialties; Emergency physician; Night shift work
body rhythm is restored, but also, it is an unalterable and inevitable period of reconstruction 1,2 and regain the energy for humans daily routine, as by physicians working on night shifts. of sleep is important for increase the productivity. The Pittsburgh
the sleep quality.
Sleep health of a physician, as they are a part of the society and healthcare system, is very important. Sleep can affect, in short term quality of their work performance, and in long term the academic career and their health. Background studies mostly have assessed the effect of sleeplessness on the performance of 7-10 physicians.7-10 But the differences and effecting factors on the sleep quality between the specialties in medicine is not investigated. Emergency physician’s sleep quality (who must passed all the nigh sleepless) compared to medical colleagues in other specialties are unknown. A qualitative data must be determined for follow the sleep quality and make an improvement in healthcare and patient outcome with the healthy physicians. These reasons led us to perform this study of physicians from different specialties working night shifts from a workload management perspective by assessing scores of sleep quality.
The primary object in this study is to determine the sleep quality of nightshift worker physicians (emergency medicine, internal medicine and surgical branches) and to propound the meaningful differences. And the secondary object is to determine the factors, that could effect the sleep quality, originated from social life and working conditions. Than after the effecting factors are decided, can healthcare thinker give better policy for accomplish the objectives.
A qualitative study was design, which was cross-sectional conducted in January, 2014, was applied as a face-to-face questionnaire to nightshift worker physicians who were volunteers and are working at the third level health care.
The study population is composed of 146 physicians who worked night shifts. Three stratums were constituted; emergency, internal medicine branches and surgical branches with stratified sampling in population. All the emergency physicians were taken into study (n=37), and samples were randomly chosen from internal (total n=39; infectious disease, internal medicine, cardiology, neurology, pediatrics, or radiology), and surgical branches (total n=39; neurosurgery, general surgery, orthopedics, otolaryngology, urology, ophthalmology, and anesthesiology): they were approached for participation from the monthly night on-call list whish was prepared double blind.
Besides the demographical data (age, sex, years employed in work, chronic disease, sleep problems), physicians were administered the Pittsburgh Sleep Quality Index (PSQI) and the Swedish Demand Control Support Questionnaire (DCSQ).3-6 Approval from Katip Çelebi University Medical School ethics committee was obtained before commencement of the investiga-
tion. Physicians were illuminated with informed consent form before they agree their consent to the study. Emergency medicine physicians worked a 16-hour night shift (4 p.m. to 8 a.m.) whereas those from other physicians worked a 32-hour shift (8 a.m. until 4 p.m. the next day). Other than emergency physicians have had a small sleepy time period in the late night and were on call.
Sleep quality was measured with PSQI questionnaire, consists of 19 questions. PSQI assesses the sleep quality with questions asked under 7 different components (subjective sleeping quality, sleep latency, sleeping time, habitual sleep efficiency, sleep disorders, usage of sleeping pills and daytime disfunc- 11,12 tions). Each question was given a score interval of 0-3. Points
of 7 components were collected. If total score are 5 or more, the sleeping quality was considered to be low. Study of validity and reliability of the scale in Turkish was conducted before.
Primary outcome of the study is to assess the sleep quality among night shift worker physicians with PSQI. Secondary outcome is determining the other factors that can affect the sleep quality such as from social live or workplace. This paper focuses on the results of the PSQI; the results DCSQ will be published in a separate research paper.
Statistics were assessed in the software of Statistics Package for Social Sciences (SPSS for Windows Ver. 20.0, SPSS Inc., IL. USA). Homogeneity of variables and normalcy of distribution were assessed by histogram. Mann-Whitney U and Kruskal-Wallis significance tests were used for the comparison of dependent and independent variables. Independent variables with pearson correlation less than 0.50 were taken into multiple regression model as a result of normative correlation. Quantitative data were given as percentage (%) and qualitative data as mean ± Standard Deviation (SD). Statistically analysis value of p<0.05 was accepted to be significant by confidence interval of 95%.
115 physicians were taken into study (78.8% of night shift worker physician). While, two declined to participate, and the questionnaires of five physicians were incomplete, thus
data from 108 physicians were evaluated. Mean age of the participants was 31.3±5.9 (25-52 years), 40.7% were women and 21.3% were specialists and associate professors. In responses to socio-demographic questions, 84.3% of the physicians did not 3-6 state any complaints of sleeping problem, 9.3% had restless leg syndrome and 0.9% had sleep apnea. Other socio-demographic properties were shown in table 1 and table 2.
Age; Under 31 years of 65.7% Mean 31.3±5.9 (25-52 years)
Sex; female of 40.7% Female’s mean PSQI: 7.6±3.9 >0.05 Male’s mean PSQI: 8.1±3.7 PSQI total score of Resident 7.3±2.9 vs. >0.05 Faculty physcian 8.1±3.1
Years employed in work 0-4 years: 50.0% 5-9 years: 30.6 % 10-14 years: 11.1% >=15 years: 8.3%
Average time spent with a patient /hour < 30 min: 43.5% 30 min-1 hour: 28.7% >0.05 1-2hour: 11.1% >2hour: 16.7% Average sleeping time (hour): 5.6±1.4 (min-max:5.4-5.9) Emergency physician: 5.7±1.8 (5.1-6.3) Internal branches: 5.4±1.1 (5.0-5.8) >0.05 Surgical branches: 5.9±1.1 (5.4-6.2)
Chronic Diseases (Marked more than one) None: 63.0% HT 1.9% Lung Disease0.9% Depression, anxiety, or psychotic disorders 17.5% <0.001 Hypothyroidy, Diabetes or obesity 6.5% Sleep disorder 15.7% Other (loss apetite, rash, piruritus, dispepsi) 6.5%
Complaints of sleep disorder None: 84.3% Sleep disorder: Restless leg syndrome 3.7% Sleep latency 9.3% Other; obstructive apnea, oversleeping 2.7%
Table 1. Socio-demographic and work properties and the significance of the PSQI total score.
Total average of PSQI was 7.9±3.8 (interval 4-18).
Physicians of 83.3% had a bad PQSI total score (>=5). No difference between specialists and resident physicians was found with regard to sleep quality (mean PSQI total score 7.3±2.9 vs. 8.14±3.79, p>0.05). No significant difference was found between total average point of PSQI and specialty groups of physician (p>0.05) (Table 1). Emergency physicians were compared to other specialties by PSQI total point, no significant difference was detected (Table 3). Correlations with factors lower than 0.5 were sex, age, number of night shifts in a month and existence of a chronic diseases besides physician’s specialty, found to be strong determining factors in PSQI total scores (95% CI, constant total PSQI values, Models 1 and 2, p<0.05, R2=0.12 and 0.16 and Durbin Watson=1.97) (Table 4A and Table 4B).
=0.001 p * PQSI total score: 7.9±3.8 (7.1-8.6) Emergency physician: 8.21±3.9 (6.9-9.5) Internal branches: 8.63±3.9 (7.3-10.0) >0.05 Surgical branches: 6.69±3.4 (5.5-7.8) 75% of employer’s sleep were below 6.0 hour/night
More than 4 night shift/month Emergency medicine 68% <0.001 Internal Branches 3% Surgery %33 >0.05 Marital status: Single 44.4% >0.05 Married 31.5% Married and have children 20.4% Widow 3.8% Habits out of routine in the night shift work Coffee or tea more than 2 glasses 54.6% Cigarette 21.3% >0.05 None 7.4% Routine 16.7%
Irregularity in self-care None 38.0% Positive: Postponing the need to use the toilet 32.3% >0.05 Negligence in personal hygiene for sleep 19.4% Other: bath, and all of the above 11.3%
Social inhibition None %25.9 Positive: Social activity (cinema, theater etc.) 13.9% Visiting friends and relatives 13.0% >0.05 Conflict with family 25.2% All of the above %25.0
Sick leave: None (75.9%) >0.05 Leave: 1-3 days (13.9%) >0.05 4-14 days (10.3%) >=15 days (1.9%)
Table 2. PSQI and Socio-demographic properties among 3 group of physician’s specialty.
Studies expose that a person needs eight hours of sleep per day.13 Sleep withdrawal is a state of insufficiency for needed 1,2 daily performance.1,2 Chronic nonoptimal levels of sleep duration or poor sleep quality leads to sleep withdrawal. Such circumstance in medicine increases the possibility of malpractice 12-15 amongst its harm for health professionals. Also it can worse residents training process and their supervision by their instruc- 16-18 tor, while they have to work on nightshifts together. This study present results, that night shift worker physicians have poor sleep quality and it is not different among their specialty’s or seniority’s in work. This result is new than in literature.
Factors affecting the sleep quality are sleep time during
Group Emergency Physicians 7(18.9%) 30(81.1%) 37(100.0%)
Internal medicine and 11(15.5 %) 60(84.5%) 71(100.0%)
Total 18(16.7%) 90(83.3%) 108(100.0%)
Odds R=1.3, %95 CI;0.3-2.2, p>0.05
Table 3. Distribution of PSQI total component by points between emergency physician and other specialties.
Age ,016
Sex ,064
3 speciality groupsc -,163a
Chronic Disease ,357b
Number of night shifts/month ,190a
a<0.05, b<0.01, c=Groups:Emergency, İnternal Medicine and Surgery
Table 4B. Regression estimates for PSQI total point.
laying on bed (in percentage and duration) and number of awak- 19,20 ing and disruption from sleep. But for emergency physicians compared to other’s night shift, sleeping is mostly impossible and they must be awake whole the night. Even one single disrupt from sleep can drop the sleep quality can cause sleepiness during the day and decrease in performance. In case of recurrence 19,20 this leads to sleep withdrawal. Sleep withdrawal have negative effects on cognitive functions. Accidents, death risk and hazardous effects on psychological and physical health have been seen as consequences of sleep withdrawal. Sleep withdrawal can cause sleep diseases by accumulating and symptoms
0-4 >=5
,101 c a a a -,191a -,180a b a a ,198a -,040 -,183a a b b -,253b ,069 -,414b -,066
* ** Variable Model 1* Model 2**
B B
Age -0.057 -0.003
Sex 0.079 0.065
3 Specialty groups -0.101 -0.008 a Cronic Deseasea 0.42 0.43 b - 0.96
Constant 6.91 4.88
F 15.45 10.97
R2 0.119 0.157
1,2,19-23 such as sleep apnea and involuntary leg movements. Also, it was mentioned that poor sleep hygiene is a part of sleep disorder stated under insomnia.2 In our questionnaire research, sleeping time was found to be below 6 hours in 65.7% of participants. Symptoms of sleep withdrawal such as restless leg syndrome and sleep apnea were on our physicians. The call of nature sleep hygiene was neglected, too.
11,21-25
Mortality and morbidity have connection with sleep- 21-23 26,30 ing time. Blood pressure and cardiac vascular structure might be negatively affected due to hypoxemia, and respiration re-
sponse to hypercarbia in sleep withdrawal syndromes was found 26-30 decreased. Sleeping 5 hours ccompared to 7, risk of acute myocard injury, serebrovasculary event and angina was found 2.2 times more.30 40 hours of sleeplessness increases the energy need of body 32%, and then decreases it 4% according to basal.31 In our study, rate of occurrence of at least one chronic disease by night shift physicians was found 37%, despite low mean age. Depressive and psychotic diseases could be common. It is essential to consider this subject, especially, in terms of “burn out”. Literature demonstrated that the rate of “burn out” with low sleeping quality came out high.8,32 Depending upon sleep withdrawal, heat regulation of body changes, circadian rhythm breaks down, immune disorders, sleeping disease, obesity and endocrinal problems might occur.33 In PSQI questions for heat changes in our questionnaire research, the physcians stated that they experienced chill during sleep once a week or more were determined to be 32.4% and those who felt increase in heat were to be 21.3%. Physcians endocrinal problems represented 6.5% of them. Hence in this study was found, existence of chronic diseases is an important independent factor which determines the sleep quality in night shift worker physicians.
Basic on literature is clear, that regulating the working hours, including education, with law and joint councils due to negative effects of night shift worker is a necessity. Suggestion is physicians won’t be pass 80 hours in a week and 16-30 hours at once a shift. Thus, sleep withdrawal, medical mistakes and accidents can be avoided. On the other hand, this suggestion hinders medical studies which require a long process, including education, and patient care.34 It can take more shift number in a month. But, this study suggest that more night shifts number in a month will more overcome decrease in sleep quality.
Our questionnaire study is significant in recognition of stating the PSQI level between physician’s specialties by night shift worker. There aren’t many data on this subject in international literature. Average score of PSQI was stated to be 6.96±3.19 in anesthesia residents, and 7.32±3.42 in nurses from 6,35 Turkey. The PSQI level of paramedics in international studies was detected 6.9±0.6.5 This study reveal, that sleep quality do not change on physicians specialty or profession in work (both in residents and attending physicians). Despite participants had lower complaints of sleep disorder, sleep quality was found to be unwell. This situation shows that physicians suffered from sleep withdrawal are not aware of their poor sleep quality. In this state, others care will be badly affected as a result of reduced performance. In this study we found the disarray in physicians sleep quality was independent from their productivity and habits in social and work life (number of patient care, consumption of coffee and tea, conflict with family, low social activity). Just the night shift seems to be the problems of poor sleep quality. Therefore we recommend that physicians may have to spend a short sleepy period during the night shifts.
A strong connection was found in the modeling design
in night shift physicians between sleep quality and their chronic diseases, number of nightshifts in a month, age, sex and speciality. Chronic diseases in participant physicians were determined to be hypertension, endocrine disease, depression and obesity. This result provides the prescience that sleeplessness will directly affect the physician’s health and therefore their productivity.
Why wasn’t a meaningful difference on sleep quality among speciality groups is an interesting point. In generally accepted application in Turkey, emergency physicians work 16 8,32 hours at night shift and rarely on 14-24 hours midshifts. Other branch physicians usually work 30 hours without a break, but have mostly a short sleep period in the night. For education are emergency medicine residents and instructors 32 hour in work (once in a week). The exposure of sleep withdrawal seemed to be the same, according to PSQI results. But, similarity of sleep quality of physicians in the three specialty groups might be a result of similarly arduous workload they had. Probably they might be stress caused by night shifts.31 Emergency physicians are far more likely to see over 60 patients in a shift which is half the length and much more likely to work over 9 shifts per month. We have assessed the stress level of the night shifts physician with DCSQ too, and will give the results in a separate paper. The working conditions on night shifts seems to be hard 16-18 in emergency medicine, at least as in other physician specialty 16,32 groups. When health care managers want to improve working standards for night shift worker physicians, they could assess the sleep quality and their healthy.
This study is conducted in a single-center. But a big sample was being better to detect more details. Most participants were residents of the specialty programs naturally. A questionnaire of sleep quality by nightshift worker compared on non night shift worker physician should be done further.
We believe that our results can be valuable to other physician-staffed hospital services as well as when comparing the sleep quality by PSQI, especially by emergency physicians with different hospital systems and different staffing. Assessing sleeping quality with scoring method is suitable.
Sleeping quality of night shift worker physicians is equally low in all specialties. Disarray in physicians sleep quality pointed as a problem, which might affect their performance, health, labor force and academic success. All medical professions should be informed on sleep disorders and factors affecting it. It is important to eliminate the manageable factors for the productivity and safety of the health professions.
Thanks to Prof. Dr. Y. Demiral, who was instrumental in this study design.
Authors intellectual contributions on this study were as listed: 1) Dr. Feriyde Çalışkan Tür performed the study, acquisition of data, analysis and interpretation of data 2) Drs. Feriyde Çalışkan Tür, Ibrahim Toker and Bamsı Tür made substantial contributions to conception and design, 3) Drs. Feriyde Çalışkan Tür, Ibrahim Toker, Bamsı Tür, Serkan Hacar and Burcu Türe made acquisition of data 3) Drs. Feriyde Çalışkan Tür and Bamsı Tür drafted the manuscript and revised it critically for important intellectual content; 4) Dr. Feriyde Çalışkan Tür gave final approval of the version to be published; and 5) Drs. Feriyde Çalışkan Tür, Ibrahim Toker, Bamsı Tür, Serkan Hacar, Burcu Türe, all agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
There is no source of funding and funders for the present study. The study is funded by the authors.