Assessment of Sleep Quality in Healthcare Workers as Part of the COVID-19 Outbreak

Tuba Akıncı1, Hatice Melek Başar2

1Beylikduzu State Hospital, Clinic of Neurology, Istanbul, Turkey
2Beylikduzu State Hospital, Clinic of Psychiatry, Istanbul, Turkey

Keywords: Sleep quality, healthcare staff, COVID-19 pandemic

Abstract

Objective: We aimed to evaluate the sleep quality and affceting factors of the healthcare professionals working in our hospital during the coronavirus disease-2019 (COVID-19) pandemic.

Materials and Methods: One hundred fifty-two healthcare professionals, 95 females and 57 males working during the COVID-19 pandemic, were included in our study. In the study, the factors affecting sleep quality were statistically evaluated by using the patients’ demographic features, the Pittsburgh Sleep Quality Index (PSQI), Fatigue Severity Scale, and Beck Anxiety and Beck Depression Scale.

Results: According to the PSQI results, the participants of our study were divided into two groups as PSQI ≥5 (n=109, 71.7%) and PSQI <5 (n=43, 28.1%). In the group with poor sleep quality (PSQI ≥5), there were more females (p=0.003), the average age was younger (p=0.013), and the rate of anxiety and depression was higher (p<0.001 and p<0.001).

Conclusion: According to the results of our study, during the COVID-19 pandemic, the quality of sleep of the healthcare staff was significantly impaired. The health of health professionals is also important in this long process. Practices for improving the quality of sleep of healthcare staff will contribute to the long-term struggle by strengthening the immune system in the fight of health workers against the virus.

Introduction

The new coronavirus disease is a viral infection with high pathogenicity and contagiousness caused by severe acute respiratory syndrome (SARS)-coronavirus-2. It was first defined in Wuhan, China, in December 2019, and spread all over the world (1). Pneumonia caused by the new type of coronavirus was named coronavirus disease-2019 (COVID-19) by the World Health Organization on February 11th, 2020. It has affected approximately 4 million people worldwide (2).

The risk of transmission with COVID-19 increases due to the close contact of healthcare professionals with patients affected by COVID-19. More than 16,000 healthcare workers in Italy were infected with COVID-19 (3,4). According to the recently announced data in our country, around 7.000 healthcare workers were reported to be infected (5). Healthcare workers are concerned about both their health and their family’s health during the pandemic. Factors such as being infected by the virus, concern for infecting others, loneliness, and increased self-expectation put the physical and psychological health of healthcare personnel at risk. The use of airtight personal protective equipment for hours every day has increased the workload. The need for frequent contact with patients in isolation units has exhausted healthcare professionals both physically and psychologically (6). The lack of a vaccine with proven efficiency against COVID-19 and the presence of only symptomatical treatment increase the stress. In the previous pandemic of SARS, it was reported that the sleep cycles of healthcare personnel returned to normal only two weeks after the crisis ended (7,8). Work-related stress, sleep deprivation, shift work, and fatigue often cause sleep disturbances and poor sleep quality (PSQI) in healthcare workers (9). In this study, we aimed to evaluate the sleep quality and fatigue of healthcare workers during the COVID-19 pandemic in our hospital and to determine the factors that affected them.

Material and Methods

This study was conducted in accordance with the Declaration of Helsinki. All participants signed consent forms. The Ethics Committee of Istanbul Health Sciences University, Kanuni Sultan Suleyman Training and Research Hospital approved the study (KAEK/2020.06.60). Healthcare personnel working in the emergency department, inpatient ward, and intensive care units, where patients with COVID-19 were treated, between April and May 2020 were included in our study. People who volunteered for the study and could cooperate with the survey were included in the study. A semi-structured sociodemographic data form was administered by the interviewer, in which socio-demographic characteristics and questions about COVID-19 were asked, and the Pittsburgh Sleep Quality Index (PSQI), Fatigue Severity Scale (FSS), Beck Anxiety Inventory (BAI) and Beck Depression Scales (BDI) and scoring systems were used in the study.

Socio-demographic Data Form: Individuals were asked questions about age, sex, marital status, occupation, educational status, chronic disease history, children, working hours, working years, COVID-19 test results, and the COVID-19 pandemic (Table 1).

The Pittsburgh Sleep Quality Index

To determine the sleep quality of individuals in the last month, the PSQI, which is a self-consistent and repeatable, reliable test, was used (α: 0.77). The PSQI contains 19 questions that enable an individual to evaluate the quality and quantity of sleep, presence and severity of sleep disorders. It is a questionnaire consisting of seven items evaluating subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbance, use of sleeping medication, and impairment in daytime work (10). A total PSQI score below 5 indicates “good sleep quality”. The PSQI questionnaire was adapted to the Turkish language by Agargun et al. (11) (Figure 1).

Figure 1. Pittsburgh Sleep Quality Index

The Fatigue Severity Scale

The FSS was developed by Krupp et al. (12) in 1989, and its validity and reliability study was conducted in 2007 by Armutlu et al. (13). A 9-item FSS was created by selecting fatigue characteristics. The score for each question ranges between 1-7. The total score is obtained as the sum or average of all answers (Figure 2).

Figure 2. Fatigue Severity Scale

Beck Anxiety Inventory

It is a self-assessment scale developed by Beck et al. (14) to determine the frequency of anxiety symptoms experienced by individuals. The scale consists of 21 items. It is a Likert-type scale with a score ranging from 0 to 3 for each question. A reliability and validity study in Turkey was performed by Ulusoy et al. (15) in 1998 (Figure 3).

Figure 3. Beck Anxiety Inventory

Beck Depression Inventory

The BDI was created to measure the physical, emotional and cognitive symptoms seen in depression. It is a self-assessment scale consisting of 21 items. The score for each question ranges from 0 to 3. The total score of the scale is between 0-63. Scores of 21 or above indicate the presence of moderate or severe depression (16). The Turkish validity and reliability study of this scale was conducted by Hisli (17) (Figure 4).

Figure 4. Beck Depression Scale

Statistical Analysis

After the data of the research were collected, they were evaluated on a computer by the researcher. The Statistical Package for the Social Sciences-PC Version 21.0 (SPSS) package program was used for the statistical analysis of the data. Mean ± standard deviation and percentage values were calculated for all variables. The chi-square test was used to compare the difference between categorical variables for analysis. The differences between the two groups in terms of numerical variables were determined using the Mann-Whitney U test, which was a non-parametric test. The results of the research were evaluated by accepting the value of p≤0.05 at the 0.95 confidence interval as significant.

Results

In our study, 152 healthcare professionals working in our hospital during the COVID-19 pandemic were included. The average age of the participants was 35.8±9.29 (range, 19-59) years. Of the participants, 95 (62.5%) were women and 57 (37.5%) were men. When classified according to occupational groups, there were 40 (26.5%) physicians, 72 (47%) nurses, and 40 (26.5%) other healthcare professionals. Of the participants, 118 (78.3%) were undergraduates, 18 (11.8%) had an associate degree, and 14 (9.2%) had high school or lower education level.

Sleep quality was evaluated according to the total PSQI score. The sleep quality of those with a total PSQI score of <5 was considered good, and the sleep quality of those with a score of ≥5 was considered poor. The participants were divided into two groups as PSQI <5 (n=43, 28.1%) and PSQI ≥5 (n=109, 71.7%). Those with PSQI <5 were named as group 1, and those with PSQI ≥5 as group 2. The mean total PSQI value was 6.55±3.40. The mean values of PSQI components were compared between the groups (Table 2).

In group 2, PSQI total score and subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disorder, and daytime dysfunction component scores were significantly higher than subjects without sleep disorders (p≤0.05). No significant difference was found in terms of the use of sleeping pills (Table 2).

The groups were compared in terms of age, sex, marital status, educational status, weekly working hours, and years of work, COVID-19 test result, childbearing status, and chronic disease status. It was shown that there were significantly more females in the group with poor sleep quality (group 2) (p=0.003). It was observed that the average age was significantly older in those with good sleep quality (group 1) (p=0.013). No significant difference was found in terms of marital status, children, chronic disease history, working years and working hours. Again, there was no significant difference in terms of sleep quality between healthcare personnel (physicians and nurses) who directly intervened with patients and other healthcare personnel (e.g. secretary, laboratory, technician) who were not involved in treatment (p=0.272) (Table 3).

Groups were evaluated in terms of depression and anxiety using the BDI and the BAI.

In group 1, 37 (86%) participants had no depression and six (14%) had mild and moderate depression. In group 2, 56 (51%) participants had no depression, 52 (48%) had mild and moderate depression. Severe depression was found in one (1%) participant. In group 1, 11 (26%) participants had moderate and mild anxiety, and 32 (74%) had no anxiety. Of the individuals in group 2, 61 (56%) had mild-moderate anxiety, nine (8%) had severe anxiety, and 39 (36%) had no anxiety. It was observed that anxiety and depression rates were significantly higher in the group with poor sleep quality (p<0.001) (Table 4).

When evaluated in terms of fatigue severity scale, no significant difference was observed between the groups (p=0.652) (Table 4).

Participants were asked questions about the COVID-19 pandemic. The percentages of the answers given to the questions in groups 1 and 2 were compared respectively: “I do not have a shortage of protective equipment (62.8%-58.7%), I use protective equipment correctly (95.3%-86.2%), I believe that protective equipment protects me adequately (74.4%-67%), I follow current publications during the pandemic (79%-59.6%), I think I have received sufficient training to prevent the transmission of COVID-19 disease (65.1%-51.3%), since I take care of patients with COVID-19, I am afraid that the disease will infect me (48%- 44%), I think we are successful as a health system in combating the pandemic (83%-67.8%)” (Graphic 1). No significant difference was observed between the two groups in terms of the questions, except for those who followed the current publications and thought that they were successful as a health system in combating the pandemic, which was found to be significantly higher in the group with PSQI <5 (p=0.020 and p=0.019, respectively) (Table 4)

Graphic 1. Comparison of answers to questions about the COVID-19 pandemic between groups
PSQI: Pittsburgh Sleep Quality Index, FSS: Fatigue Severity Scale, COVID-19: Coronavirus disease-2019

Discussion

According to our study, it was observed that in the COVID-19 pandemic, a significant part (71.7%) of the healthcare personnel working in the units related to this disease had deterioration in sleep quality. It was found in the group with poor sleep quality that female sex was prominent, that the average age was younger, that the rates of anxiety and depression were higher, that the rate of following current publications was less, and that the rate of thinking that they were successful as a health system in combating the pandemic was lower.

COVID-19 is a highly contagious disease. This virus particularly threatens healthcare workers. Healthcare workers struggle against the virus by working more intensively with personal protective equipment. However, when examining the relationship between the pandemic and healthcare workers, it is clear that other factors should be examined for the maintenance of the health system and the health of healthcare professionals. The most important defense in COVID-19 infection, for which there is no vaccine and no obvious treatment, is a strong immune system. An indispensable element of a healthy immune system is quality sleep (9,18,19). Therefore, sleep quality in healthcare workers was evaluated in our study. According to our study, a significant deterioration in sleep quality was observed in the COVID-19 pandemic in the healthcare personnel working in the units related to this disease. Experiences obtained in the previous SARS pandemic indicated that 34.2% of healthcare workers had insomnia in Hong Kong and 37% in Taiwan (20,21). In a study conducted in Tehran, it was found that 43% of healthcare workers had sleep disorders (22). In a study conducted in China, the origin of the pandemic and the center of the pandemic for a long time, it was found that 64% of healthcare workers had sleep disorders (23). The results in our country were compatible with the literature, and it was reported that there was a deterioration in sleep quality in healthcare workers in many countries of the world.

The most important reason for the deterioration in sleep quality in healthcare professionals is their fight against the virus, for which there is no proven vaccine and which has very high contagiousness. As the COVID-19 pandemic spreads, millions of people are recommended to work from home due to social distance, but healthcare professionals continue to work at high risk in hospitals and clinics to minimize the risk of transmission. In China, it was shown that a total of 1716 healthcare workers were diagnosed as having COVID-19 and five died until February 11th, 2020, with a case mortality rate of 0.3% (24). Reports from Italy indicated that 20% of healthcare workers were infected, while in Spain, healthcare workers infected with COVID-19 accounted for about 12% of all patients (25,26). The stress factor is increasing as thousands of healthcare professionals become infected and some die. Previous studies have confirmed that stress is closely related to sleep quality (27). Increased stress can increase environmental alertness levels, which reduces sleep quality (28). Stress occurs in response to increased physical and psychological activation and causes sleep disturbance due to the activated hypopituitaryadrenal system (HPA) (29). The resulting sleep disturbances also lead to more activation in the HPA system, so a vicious cycle of insomnia and stress appears.

Isolation is one of the main treatment steps during the COVID-19 pandemic. In previous studies, it was stated that prolonged isolation led to negative behaviors (30). Healthcare personnel are also unfortunately affected by the isolation and quarantine processes due to the contamination effect on family members, friends, and colleagues. This emerges as a factor that increases psychological stress (31).

During the SARS pandemic in 2003, studies conducted in Beijing, Taiwan, Hong Kong, Singapore, and Canada showed that health personnel had post-traumatic stress disorder, anxiety or depression, which were affected by psychological conditions (32,33,34,35,36). In our study, it was observed that anxiety and depressive symptoms were significantly higher in healthcare workers with impaired sleep quality (p<0.0001 and p<0.0001, respectively).

In our study, no significant difference was found between those with poor sleep quality and those without in terms of FSS, which was conducted to evaluate physical fatigue, and it was noted that psychological effects were more pronounced.

In a study conducted by Suzuki et al. (37) on 4.407 nurses in Japan in 2005, it was revealed that sleep quality impairment adversely affected the work efficiency of nurses. Factors such as sex and age can affect the prevalence of sleep disorders. Women are diagnosed as having insomnia almost twice as often as men. In our study, it was found that female healthcare professionals working in COVID-19 units had significantly impaired sleep quality (p=0.003).

In previous studies, the relationship between sleep disorder and education level was evaluated, and it was found that personnel with a low level of education reported insomnia more (38,39). In our study, no significant difference was found between education levels and sleep quality. This can be explained by the low number of personnel who graduated from high school and lower school. In a study on SARS, it was stated that low education level was associated with fear of SARS (40). In our survey questions, it was noticed that people who were afraid of the transmission of COVID-19 had a lower education level, in line with the literature.

Factors related to insomnia during the COVID-19 pandemic include uncertainties such as not following the COVID-19 pandemic and current publications adequately and the feeling of insecurity about the health system during the COVID-19 pandemic.

In addition to stress, circadian rhythm disturbances in healthcare professionals can lead to insomnia symptoms. As it is known, some researchers have argued that because circadian rhythm disorder can disrupt immune system function, it may increase the susceptibility to infection (18,19). Good sleep quality for healthcare professionals helps them work better to treat patients and maintains optimal immune function to prevent infection (41). Therefore, sleep quality is an important indicator of health.

Study of Limitations

The number of healthcare personnel evaluated was small because it was limited to healthcare personnel in a single center. Accordingly, it was thought that conducting similar multi-center studies that could represent all healthcare professionals would be beneficial.

Conclusion

One of the most important factors in ensuring the continuity of the health system in this long process is the health of health workers. Reducing stressor factors in healthcare professionals will reduce anxiety and depressive symptoms and improve sleep quality.

Few studies have been conducted on the physical and psychological effects of serious infectious disease outbreaks on healthcare professionals in situations of stress associated with increased workload and risk of infection. More studies on this population should be conducted to understand the causes of increased risk of transmission and high mortality in healthcare workers. Given that the pandemic will continue for weeks, research data are urgently needed to provide timely and supportive psychosocial interventions.

Ethics Committee Approval

The Ethics Committee of Istanbul Health Sciences University, Kanuni Sultan Suleyman Training and Research Hospital approved the study (KAEK/2020.06.60).

Peer Review

Externally peer-reviewed.

Author Contributions

Concept: T.A., Design: T.A., Data Collection or Processing: T.A., Analysis or Interpretation: T.A., H.M.B., Literature Search: T.A., H.M.B., Writing: T.A.

Conflict of Interest

No conflict of interest was declared by the authors.

Financial Disclosure

The authors declared that this study received no financial support.

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