|Year : 2021 | Volume
| Issue : 1 | Page : 19-23
Are rotational night shifts taking its toll on health-care professionals? A pilot study
AY Nirupama, D Vinoth Gnana Chellaiyan, G Ravivarman
Department of Community Medicine, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Chennai, Tamil Nadu, India
|Date of Submission||04-Aug-2020|
|Date of Decision||01-Sep-2020|
|Date of Acceptance||16-Sep-2020|
|Date of Web Publication||13-Jan-2021|
Dr. D Vinoth Gnana Chellaiyan
Department of Community Medicine, Chettinad Hospital and Research Institute, Chettinad Academy of Research and Education, Kelambakkam, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Background: It has always been suggested that sleep deprivation has a deleterious effect on the ability of health workers who are involved in multitude of life-saving tasks, which often require more attention and concentration. The Centers for Disease Control and Prevention and the national health portal (Government of India) have now recognized sleep deprivation as a public health epidemic. Materials and Methods: A cross-sectional study was done including health-care professionals working night shifts on rotation at a tertiary level health-care facility, using a semi-structured questionnaire to test the status of their sleep deprivation, cognitive ability, and quality of life as a pilot study. Stratified random sampling was used to select the study participants and health-care professionals with other factors which may interfere with sleep deprivation testing were excluded. Data were analyzed using IBM-SPSS, and required statistical tests were applied (Pearson Chi-square, Fisher exact, Spearman correlation, and Wilcoxon signed-rank test). Results: About 95.12% of participants reported < 6 h of sleep post night shifts, of which 51.2% were found to show signs of sleep deprivation. Of this 51.2%, 28.57% were also found to have lower cognitive function scores, and statistically significant lower cognitive scores were observed during night shifts than during day shifts. The median value of the Montreal cognitive assessment (MOCA) score during the night shift was 27 (interquartile range [IQR] = 4) and the median value of MOCA score during the day shift was 29 (IQR = 1). A poor QOL was observed in 17.07% of the study participants, and it was found to have a significant positive correlation with hours of sleep obtained. Conclusion: The results from the present study points towards a significantly high burden of sleep deprivation among health-care professionals working rotational shifts (51.2%). This warrants a need for further evaluation on larger populations and adoption of comprehensive measures including preventive and promotive aspects like sleep counselling and yoga/meditation for management.
Keywords: Cognitive ability, health-care professionals, quality of life, sleep deprivation
|How to cite this article:|
Nirupama A Y, Chellaiyan D V, Ravivarman G. Are rotational night shifts taking its toll on health-care professionals? A pilot study. Curr Med Issues 2021;19:19-23
|How to cite this URL:|
Nirupama A Y, Chellaiyan D V, Ravivarman G. Are rotational night shifts taking its toll on health-care professionals? A pilot study. Curr Med Issues [serial online] 2021 [cited 2021 Jan 15];19:19-23. Available from: https://www.cmijournal.org/text.asp?2021/19/1/19/306931
| Background|| |
“Like good eating, drinking and breathing habits; good sleeping habit and adequate duration of sleep are key factors of a healthy lifestyle.” According to the national health portal India and the Centers for Disease Control and Prevention US, sleep deprivation disorders are now considered as a public health epidemic., Humans can survive several days of continuous sleeplessness, experiencing deterioration in well-being and functioning. Economic loss due to sleep deprivation has made it a major public health problem globally. The Sleep Health Foundation in Australia estimated the economic burden due to health costs of conditions attributable to sleep deprivation (such as hypertension, vascular disease, depression, and motor vehicle and workplace accidents) at $409 million.
Sleep deprivation is defined as, “obtaining inadequate sleep to support adequate daytime alertness.”, Sleep deprivation affects the ability of health workers who are involved in multitude of life-saving tasks which need more attention and concentration. Extended work shift of 12 h or longer is common with health-care professionals, whose insufficient sleep puts patients' health and their health at risk making it one of the major reasons for sickness absenteeism in the health-care profession. By understanding these factors better, we will be able to create a work environment “fit” for the health-care professionals (ergonomics).
Sleep loss is often associated with disturbances in cognitive and psychomotor function including mood, thinking, concentration, memory, learning, vigilance, and reaction times., The appearance of micro-episodes of sleep during wakefulness leads to lower efficiency of task performance, increased number of errors, and emotional disturbances such as deteriorated interpersonal responses and increased aggressiveness. Sleep deprivation and altered circadian rhythm lead to fatigability, decline in attention, and deteriorating mental health status which in turn affected their quality of life (QOL). The present study, thus, aims to determine the effect of sleep deprivation on cognitive function and QOL of health-care professionals working night shifts on rotation.
| Materials and Methods|| |
A cross-sectional study is planned to be conducted including health-care professionals (doctors and paramedical staff; including nurses, pharmacy staff, and technicians) aged 18–60 years, working night shifts on rotation in a tertiary level health-care facility in North Tamil Nadu. As a predecessor, a pilot study was carried out in a tertiary level superspecialty hospital in the same region over a period of 3 months, and the observations from the same are enumerated below.
Of those who had night shifts between 11 pm and 6 am, irrespective of their shift timings, participants with other sleep interfering factors such as history of self-reported sleep disorder, medications, pregnant or breast-feeding mothers, and other major life events in the past 6 months were excluded from the study.
The sample size for the original study was calculated to be 366 (expected prevalence [P] of cognitive impairment: 66% from a study by Kaliyaperumal et al. and 7% [L] allowable error) using the formula 4PQ/L2 assuming 95% confidence limit and a design effect of 2. 10% of original (37) sample size was assumed as the target sample size for the pilot study. Stratified random sampling was done, where the study participants were stratified according to their designation into doctors, nurses, technicians, and pharmacists.
A semi-structured, 4-part interview method was used to collect information about their basic demographic details, details of their shift work, status of sleep deprivation (Epworth sleepiness scale [EPSS]), cognitive function (Montreal cognitive assessment [MOCA]), and a QOL (SF-12 QOL questionnaire). Data were recorded using Microsoft Excel and analyzed using IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp. The normality of the data was assessed using the Shapiro–Wilk test for normality. Qualitative variables are described in proportions. Quantitative variables are described in mean and standard deviation/median and interquartile range (IQR). Required statistical tests were applied (Pearson Chi-square, Fisher exact, Wilcoxon, and Spearman correlation). The significance of P value was taken as P < 0.05.
The institutional human ethics committee approval was obtained before the commencement of the study. The purpose of the study was clearly explained to all the participants, and informed consent was obtained. The confidentiality of the participants was maintained through all phases of the study.
| Results|| |
Data were collected from 44 willing participants at the end of the pilot study period. Three out of the 44 were not available for the 2nd round of interview which occurred during day shifts and hence were excluded from the study. Data collected from the remaining 41 participants are enumerated below. The mean (standard deviation) age of the participants was calculated to be 27.76 (4.65) years in a range of 19–42 years. A female predominance was noted among the participants with 29 (70.73%) being females.
During the study, 39 (95.12%) participants reported <6 h of sleep post night shifts. The EPSS scoring identified 21 (51.2%) to be sleep deprived and showing signs of day time sleepiness. 21 (53.8%) of the participants who had <6 h of sleep post night duties were also found to have a significant EPSS score showing signs of day time sleepiness. Furthermore, a statistically significant relation was identified between the hours of night shift and sleep deprivation by EPSS (Pearson Chi-square: P = 0.048). Six out of the 21 participants (28.57%) who had signs of sleep deprivation were also found to have cognitive impairment, but a significant relation between the 2 could not be established (Pearson Chi-square: P = 0.440) [Table 1]. As the number of years of working night shifts increased, the prevalence of sleep deprivation was found to decrease (61% in those who worked for <2 years, 42% in those working for 2–4 years, and 25% in those working >4 years) suggesting a possible adaptability of the biological clock.
The median value of MOCA score during the night shift was 27 (IQR = 4) and the median value of MOCA score during the day shift was 29 (IQR = 1), and a significant difference was observed between the cognitive assessment scores during the night and day shifts (Wilcoxon: P < 0.001). The prevalence of cognitive impairment was found to decrease with increase in years of working night shift (may be suggestive of adaptability with experience) with 39% prevalence in those who have been working night shifts for <2 years, followed by 36% among those working night shifts for 2–4 years.
A poor QOL was observed only in 17.07% of the study participants, with 95.12% showed the poor quality of mental health. QOL was found to have a significant association with sleep deprivation (P = 0.009) [Table 1]. On individual analysis of the physical and mental components of QOL, physical component was found to have a statistically significant association with sleep deprivation (P = 0.048).
A positive correlation was noted between hours of sleep obtained and QOL scores (Spearman rho ± 0.523, P = 0.003). A positive correlation was also noted between hours of sleep and MOCA scores but was not found to be statistically significant. About 17% of the participants reported poor work satisfaction which failed to show a significant association with sleep deprivation (P = 0.566) [Figure 1].
| Discussion|| |
The prevalence of sleep deprivation was observed to be 51.2%, which is similar to 69% in a study done by Kaliyaperumal et al. and 56% in a study done by Johnson et al. 95.12% of the participants reported < 6 h of sleep post night shifts, which is < 7 h of sleep recommended by the sleep health foundation for healthy adults.
The presence of cognitive impairment was noted in 34.8% of the participants, which falls in between the 66% noted in the study by Kaliyaperumal et al. and the findings from another study done by Patrick et al. noted that there was no significant difference in cognitive testing after just one night of sleep deprivation. This may be due to the fact that Kaliyaperumal et al. studied only nurses, while the present study includes more categories of health-care professionals, including doctors, technicians, and pharmacists. Most of the work patterns noted in the study suggested that the participants had more than one night of continuous work which suggests that they have more than one night of sleep deprivation, thereby differentiating the study population from that of the study by Patrick et al.
An apparent improvement noted in cognitive impairment and status of sleep deprivation with increase in years of working night shifts could be suggestive of development of adaptability as noted by Arendt when he reported that melatonin levels suggested adaptability of the biological clock to shift work. A poor QOL was noted in 17.07% of the participants, which is less than the >50% reported in studies by Angerer et al. and Al-Ameri where the impact of the night shift on QOL was assessed which points toward a smaller decline in QOL in rotational shift work when compared to regular night work.
Most of the previous literature concentrates on nurses or residents and there also, more emphasis was given to night shift work rather than rotational shift work. The present study is a comprehensive evaluation of the effects of sleep deprivation including the various cadres of health-care professionals such as doctors, nurses, technicians, and pharmacists. The major limitation of the study is due to the fact that the results enumerated here are from a pilot study, hence the generalizability of the results cannot be definite as a consequence of the small sample size.
| Conclusion|| |
A high burden of sleep deprivation (51.2%) was noted in the present study, and a significant difference was observed in the cognitive testing done during night shifts and day shifts. Patients with shift work sleep disorders need an individualized and comprehensive approach which should include counseling and behavioral therapy along with pharmacological management where required. Results obtained in the current study look promising, and a better understanding of the situation will be obtained from the future study.
Research quality and Ethics statement
All authors of this manuscript declare that this scientific study is in compliance with standard reporting guidelines set forth by the EQUATOR Network. The authors ratify that this study required Institutional Human Ethics Committee review, and hence prior approval was obtained IHEC approval Ref. No. 485/IHEC/3-19 dtd. 19.04.2019. We also declare that we did not plagiarize the contents of this manuscript and have performed a Plagiarism Check.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kaliyaperumal D, Elango Y, Alagesan M, Santhanakrishanan I. Effects of sleep deprivation on the cognitive performance of nurses working in shift. J Clin Diagn Res 2017;11:CC01-CC03.
Colten HR, Altevogt BM, Institute of Medicine (US) Committee on Sleep Medicine and Research, editors. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington (DC): National Academies Press (US); 2006.
Dembe AE, Erickson JB, Delbos RG, Banks SM. The impact of overtime and long work hours on occupational injuries and illnesses: new evidence from the United States. Occup Environ Med 2005;62:588-97.
Dinges DF, Pack F, Williams K, Gillen KA, Powell JW, Ott GE, et al
. Cumulative sleepiness, mood disturbance, and psychomotor vigilance performance decrements during a week of sleep restricted to 4-5 hours per night. Sleep 1997;20:267-77.
Orzel-Gryglewska J. Consequences of sleep deprivation. Int J Occup Med Environ Health 2010;23:95-114.
Reinberg A, Ashkenazi I. Internal desynchronization of circadian rhythms and tolerance to shift work. Chronobiol Int 2008;25:625-43.
Johnson AL, Jung L, Song Y, Brown KC, Weaver MT, Richards KC. Sleep deprivation and error in nurses who work the night shift. J Nurs Adm 2014;44:17-22.
Patrick Y, Lee A, Raha O, Pillai K, Gupta S, Sethi S, et al
. Effects of sleep deprivation on cognitive and physical performance in university students. Sleep Biol Rhythms 2017;15:217-25.
Arendt J. Shift work: coping with the biological clock. Occup Med (Lond) 2010;60:10-20.
Angerer P, Schmook R, Elfantel I, Li J. Night Work and the Risk of Depression: A Systematic Review. Deutsches Aerzteblatt Online. 2017;114:404-411.
Al-Ameri MI. Night shift and its impact upon the quality of life of nurses working at the teaching hospitals of the medical city complex in Baghdad city, Iraq. J Nurs Care 2017;06:1-5.