A survey on the quality of sleep among new nurses

Abstract

Background

New nurses’ transition to clinical work involves challenges affecting their sleep quality, health, and work efficiency.

Objective

The aim of this study was to survey the quality of sleep among new nurses and suggest strategies to improve their sleep to help them adapt better to their work roles.

Methods

We adopted the questionnaire method and convenience sampling for this study. Using the Pittsburgh Sleep Quality Index (PSQI), we surveyed the sleep quality of 118 new nurses in four tertiary grade A hospitals in Harbin City, China.

Results

We found a statistically significant difference in sleep quality between the new nurses and normal adults (P < 0.05). The nurses had statistically significant differences in sleep quality, sleep disturbance, and daytime dysfunction between the first and third months of joining their job (P < 0.05). There were no statistically significant differences in sleep latency, sleep duration, sleep efficiency, use of sleep medication, or overall scores among the nurses (P > 0.05).

Conclusions

The sleep quality of new nurses needs to improve, and this can be facilitated through specific techniques. Improving the sleep quality of new nurses requires joint efforts from individuals, organizations, and community support.

Keywords

sleep improvement interventions new nurses’ adaptation shift work impact sleep duration & latency sleep disturbance factors

Introduction

The transition for new nurses from graduation to entering jobs involves adaptation and facing challenges arising from the change of roles, environments, and interpersonal communication. Being unable to adapt well to their new posts can take a toll on their physical and mental health.¹ This directly affects the quality of nursing care, their professional development, and the stability of the nursing workforce. From a physiological perspective, adequate sleep is essential for individuals to attain optimal learning, memory, and problem-solving skills, thereby improving work efficiency.² In recent years, the issue of sleep disturbances among nurses has gained widespread attention among hospital administrators and is a shared social concern. Due to the unique challenges of their job, clinical nurses shoulder stressful and demanding tasks and are often overburdened with work for long periods of time. Their daily schedules are irregular, and they experience varying degrees of sleep disturbance.³ Therefore, it is particularly important to study the sleep quality of nurses and the correlative articles is reportered very less. The aim of this study was to survey the quality of sleep among new nurses and suggest strategies to improve their sleep to help them adapt better to their work roles.

Materials and methods

Study participants

Using the convenience sampling technique, we identified 118 new nurses who had recently taken up job positions between July 2013 and May 2015 in four tertiary grade A hospitals in Harbin City, China. We distributed questionnaires and assessment scales to the nurses. The nurses answered a survey instrument on their general working conditions and a Chinese-translated version of the Pittsburgh Sleep Quality Index (PSQI)⁴ within three days prior to or following the first day of the first or third month after they entered their posts. The questionnaires and scales were collected immediately. We excluded nurses who had previously interned in the same department before joining for a job at the four hospitals, nurses with previous independent nursing experience, and nurses who had recently experienced a major life event. All the nurses voluntarily participated in this study.

Study methods

We used the questionnaire method for this study. The questionnaires were distributed to the nurses with the help of the relevant departments they were working in. Each questionnaire contained instructions for completing the survey. The questionnaires were collected within three days of being distributed to the nurses. We gave out a total of 240 questionnaires in this study, and 233 were returned, with an effective return rate of 97%.

Study tools

The general work condition survey questionnaire

Researchers involved in this study developed a specific questionnaire that consisted of details such as gender, age, education level, graduation time, and duration of work experience.

The Pittsburgh sleep quality Index (PSQI)

The PSQI⁴ is a popular tool to assess sleep quality. For this study, we used a version of the PSQI which was translated into Chinese by Liu et al. and revised,⁵ and has recently been extensively used in China. This scale consists of seven components and 23 items. The seven components pertain to subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbance, use of sleep medication, and daytime dysfunction. There are four grades of scoring for each item (0 to 3 points). The global PSQI score is obtained by summing up all the scores on the seven components and ranges between ⁠0–⁠21 points.

In most previous studies, a score of five has been regarded as the cut-off value for sleep disturbance. However, recent research has shown that a score of seven is highly sensitive and specific in recognizing sleep disturbances among Chinese individuals.^6–8 According to sleep research norms for China, a score of seven is the reference cut-off value for sleep quality problems in Chinese adults. Adults with a score > seven have poor sleep quality, while those with a score ≤ seven have good sleep quality; the higher the score, the worse the sleep quality.⁹

Statistical analysis

All data were analyzed by SPSS 17.0 software package. Measurement data were expressed as mean ± SD, and t test was used to compare between groups to determine whether there were differences. If P < 0.05, the difference was statistically significant. If P > 0.05, the difference was not statistically significant.

Results

Sleep quality scores of new nurses

There was a statistically significant difference in the sleep quality of new nurses when compared to that of normal adults in China. A normal adult is defined as a Chinese person who is 18 years of age or older, in good health, and free of sleep disorders or other psychological and mental disorders (P < 0.05) (Table 1).

Table 1.

Comparison of sleep quality scores between new nurses and normal Chinese adults (Scores, `x ± s).

Item	New nurses (n = 118)	Normal Chinese adults (n = 112)
Sleep quality	0.95 ± 0.49	0.63 ± 0.67	<0.05
Sleep latency	1.00 ± 0.85	0.70 ± 0.86	<0.05
Sleep duration	0.98 ± 0.76	0.70 ± 0.58	<0.05
Sleep efficiency	0.32 ± 0.70	0.15 ± 0.47	<0.05
Sleep disturbance	0.86 ± 0.60	0.45 ± 0.44	<0.05
Sleep medication	0.02 ± 0.15	0.06 ± 0.24	<0.05
Daytime dysfunction	1.35 ± 0.83	0.73 ± 0.83	<0.05
Total score	5.78 ± 2.47	3.88 ± 2.52	<0.05

Comparison of sleep quality in new nurses between the first and third months of joining work

The differences in sleep quality, sleep disturbance, and daytime dysfunction between the first and third months after the nurses entered their posts were statistically significant (P < 0.05). There were no statistically significant differences in sleep onset latency, sleep duration, sleep efficiency, use of sleep medication, or total scores (P > 0.05) (Table 2).

Table 2.

Comparison of sleep quality scores of new nurses between the first and third months of joining work (Scores, `x ± s).

	First month (n = 118)	Third month (n = 115)
Sleep quality	0.95 ± 0.49	0.70 ± 0.53	<0.05
Sleep latency	1.00 ± 0.85	0.92 ± 0.68	>0.05
Sleep duration	0.98 ± 0.76	0.95 ± 0.58	>0.05
Sleep efficiency	0.32 ± 0.70	0.30 ± 0.66	>0.05
Sleep disturbance	0.86 ± 0.60	0.58 ± 0.88	<0.05
Sleep medication	0.02 ± 0.15	0.01 ± 0.76	>0.05
Daytime dysfunction	1.35 ± 0.83	0.98 ± 0.24	<0.05
Total score	5.78 ± 2.47	5.32 ± 2.30	>0.05

Discussion

New nurses had worse sleep quality when compared to normal adults in China

The results of this study show that the overall sleep quality of the 118 new clinical nurses was worse than that of normal adults in China. Lim S, Han K found that the biological clock within the human body regulates various physiological activities and changes to maintain a specific rhythm. Working in shifts that alternate between day and night can disrupt this rhythmic cycle, thus causing negative impacts on sleep quality.² Feng HL¹⁰ found that exposure to night shifts is an occupational risk factor that influences sleep quality and impacts the health of nurses which is consistent with our study.

The reasons for this phenomenon are analyzed in the following aspects: most of the new nurses are from one-child families. They are likely to experience significant stress at the stage when they just graduate and enter institutions to undertake important responsibilities.¹¹ The transition to clinical work involves nurses readjusting their schedules from a previous normal rhythm to alternate day and night shifts, and new nurses face a lot of challenges and pressures in coping with this change, resulting in poor sleep quality in the early stages of their nursing career.¹

These characteristics are risk factors that may lead to an abrupt deterioration of sleep quality among new nurses in their transition to clinical nursing work and may manifest as sudden changes in their sleep characteristics or as sleep disturbances.³ In turn, the sleep characteristics and changes in sleep quality, as well as their new identities as nurses, can negatively impact their physical and mental health.¹² Fatigue, daytime dysfunction, changes in emotions, and excessive sleepiness are consequences of poor sleep quality frequently mentioned in the literature.

In addition, research highlights the relationship between sleep quality and anxiety and depression. Sleep disturbances can lead to cognitive disorders.¹³ In nurses, disruptions in sleep disturbances reduce their work efficiency and productivity.¹⁴ Nurses with disturbed sleep are at a higher risk of making medical errors in patients care or sustaining occupational injuries.¹⁵ It is widely acknowledged that the negative consequences of these sleep disturbances are barriers that newly graduated nurses encounter in their adaptation to the transition into clinical nursing work.

There were differences in new nurses’ sleep quality between the first and third months after joining their job

We found differences in sleep quality, sleep disturbance, and daytime dysfunction between the first and third months after new nurses joined their jobs. This result was consistent with that of Kim et al.³ In the third month of their work, new nurses showed significant improvements in sleep quality, sleep disturbance, and daytime dysfunction when compared to the first month. These results suggest that they showed signs of physiological and psychological adaptation after three months of being on the job and coped by making adjustments in their lives. However, there were no evident improvements in their sleep latency, sleep duration, sleep efficiency, use of sleep medication, or total scores between the two time periods.

It is important to improve the sleep quality of new nurses and facilitate a smooth physiological and psychological transition with time

Among the factors related to their work environment, interpersonal relationships correlate most closely with sleep disturbances among nurses.³ Individuals enjoying good sleep quality report receiving significantly more social support than those with poor sleep quality. This is attributed to fewer complaints about sleep and higher perceived sleep quality.¹⁶ A prospective study also showed that one year after nurses have been working in their posts, the social support they receive from their work administrators is a protective factor for preventing chronic insomnia.¹⁷ It is important that head nurses and other senior colleagues in the nursing department proactively guide and assist new nurses to reduce their physiological and psychological disturbances due to poor coping with role transformations.

Godinez et al.¹⁸ observed that in the first three weeks of their job, the nature of the work of new nurses involves repetitive tasks. One of the challenges they face is acquiring essential communication skills, and they rely largely on the support of experienced nurses for this. Therefore, support from colleagues helps new nurses reduce work stress arising from dealing with real-world situations. As new nurses are likely to feel isolated, it is recommended that head and senior nurses frequently communicate with new entrants to offer the novices constructive feedback and guide them on how to seek help. New nurses may also encounter violence in their workplace. Nursing departments are recommended to train new nurses on strategies for coping with such unpleasant and stressful crisis situations.¹⁹

Administrators of nursing departments should pay attention to the effects of night shifts on reducing sleep quality among nurses and take measures to improve their occupational health. It is recommended that the shift system be refined. When compared to 12-h shifts, eight-hour shifts have been found to have a higher occurrence rate of adverse events. A longer interval between night shifts provides nurses with longer periods of restful sleep and sufficient recovery time, which are essential for nurses to deal with the demands of their job. One rationale for fewer errors on the job is a longer interval between night shifts.²⁰

Additionally, it has been shown that the duration of night shifts has a greater impact on health than the frequency of night shifts.²¹ Two large-scale cohort studies on female nurses found that the duration of night shifts and non-healthy lifestyles, either independently or jointly, were associated with a high risk of developing type 2 diabetes mellitus.²² It is recommended that administrators of nursing departments arrange for nurses to exit night shifts before their sleep quality deteriorates significantly or before they show signs of adaptation to night shifts. In addition, increasing the number of nurses and optimizing the allocation of nursing resources are also effective measures to confront the negative influences of night shifts.¹

Monitoring how newly graduated nurses adapt to excessive sleep disturbances, supervising their working hours, and preventing unauthorized overtime and night shift changes are also recommended strategies for nursing department administrators to take up. To support new nurses in transitioning into their new environment, interventions to prevent sleep disturbances and educational inputs on sleep hygiene should be included in their training prior to their posting for clinical nursing work. A comprehensive curriculum for sleep hygiene sensitization should essentially include management of proper nutrition and time management, basic sleep management, information on signs and symptoms of sleep disturbance, reactions to fatigue, and physical and mental preparedness for shifts.¹⁴

New nurses should proactively cope with the impact of new environments on their sleep and understand the triggers of sleep disturbances. Sadock et al. found that noise, heat, cold, noise and activities of their roommates, and perceived dangers are factors leading to sleep disturbance.²³ Nurses should enhance their capacity for psychological regulation and identify and cope with work pressures constructively; they should cultivate and improve self-awareness, identify their stresses, learn positive countermeasures for stresses, increase their psychological resilience, utilize the scientific knowledge of psychology for enabling adjustment and catharsis, and promptly resolve unfavorable stress.

Mindfulness-based stress reduction has been shown to have a positive influence on sleep latency and significantly increase daytime sleepiness. Additionally, online mindfulness-based stress reduction programs are cost-effective and easily accessible, and people are more likely to participate in and benefit from such courses.²⁴ Nurses should face night shifts with a relaxed mindset. It is recommended to eat easily digestible semi-liquid hot foods for night shift meals and avoid functional beverages, coffee, etc.^25,26 After completing a night shift, nurses are advised to have a nutritious, high-protein breakfast and avoid overeating. They should rest as soon as possible after work. Strategies such as listening to soothing music before sleeping and soaking their feet in hot water help promote sleep. Apart from getting adequate sleep, engaging in appropriate physical exercises to maintain a healthy physique is also suggested.^27–29

Therapies in traditional Chinese medicine (TCM) have also been found to have significant efficacy in improving the quality of sleep.³⁰ Yishen Anmian paste (a Chinese herbal paste to tonify the spirit and promote sleep) contains Milkvetch Root (Huang Qi in Chinese Pinyin), Chinese Angelica (Dang Gui in Chinese Pinyin), Sichuan Lovage Rhizome (Chuan Xiong in Chinese Pinyin), Common Aucklandia Root (Mu Xiang in Chinese Pinyin), Benzoin (An Xi Xiang in Chinese Pinyin), and other Chinese herbs that nourish yin, enrich the blood, tonify the spirit, and promote sleep. This paste can significantly improve sleep quality when applied at the Shenque acupoint (CV 8). The Shenmen acupoint (HT 7) in the ear has the function of calming and soothing the mind. Massaging this acupoint before going to bed can promote better sleep. A combination of the two methods can significantly improve sleep quality.³¹

Aromatherapy has also been found to have a significant impact on improving the sleep quality of nurses on shifts, as it minimizes discomfort during sleep, induces adequate deep sleep, and reduces the effects of sleep disturbances.³² In addition, with smartphones and smart media becoming widely prevalent, they are more and more frequently used in bed, and this prevents the fast onset of sleep. Therefore, nurses must be aware of the proper usage of smartphones and smart media.

The findings of the above study are consistent with our findings and our advocacy for improving the sleep patterns of newly recruited nurses: we find that the new nurses who had worse sleep quality when compared to normal adults in China. There were differences in new nurses’ sleep quality between the first and third months after joining their job. Meanwhile, we find that it is important to improve the sleep quality of new nurses and facilitate a smooth physiological and psychological transition with time. Finally, our study had certain limitations, including cross-sectional study, low sample size, and lack of measurement of major confounding factors, which we will correct in subsequent studies.

Conclusion

The occupational characteristics, work stresses, frequent alternate day and night shifts, and other factors that accompany the role transition of new nurses alter the characteristics and quality of their sleep, resulting in negative impacts on their physical and mental health. As a result, the risk of adverse event occurrence increases, particularly in the first three months after new nurses take up a job. Our recommendation is that head nurses and nursing staff from nursing departments provide the novice nurses with proper mentoring and help, as well as training on coping with unfavorable or stressful work situations, interventions for preventing sleep disturbance, and educational inputs on sleep hygiene and healthy sleep. We also suggest that administrators of nursing departments optimize shift patterns and monitor the working hours of newly hired nurses. New nurses should also face new environments with a positive mindset and facilitate a smooth transformation for themselves both physiologically and psychologically. This issue needs to be approached from the perspective of understanding sleep disturbances, psychological adjustment and coping skills, and daily self-care, among other aspects.

Footnotes

Acknowledgements

We would like to acknowledge the hard and dedicated work of all the staff that implemented the intervention and evaluation components of the study.

ORCID iDs

Song Jiang

Lingling Ji

Ethics considerations

This study was conducted with approval from the Ethics Committee of The Second Affiliated Hospital of Harbin Medical University. This study was conducted in accordance with the declaration of Helsinki.

Author contributions

Conception and design of the research: Dan Xu, Lingling Ji

Acquisition of data: Juan Zhang, Qun Yu

Analysis and interpretation of the data: Song Jiang, Qun Yu

Statistical analysis: Juan Zhang

Obtaining financing: Lingling Ji

Writing of the manuscript: Dan Xu, Song Jiang

Critical revision of the manuscript for intellectual content: Lingling Ji

All authors read and approved the final draft.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by Humanities and social science project of Education Department of Heilongjiang Province. And the supported project's name is Investigation and analysis of physiological and psychological adaptation of new nurses to nursing work (No. 12532228).

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The datasets used or analysed during the current study are available from the corresponding author on reasonable request.

Informed consent

Written informed consent was obtained from all participants.

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