Improving Sleep Quality in Nurses Who Work Irregular Shifts: Necessity and first steps towards intervention
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Date
2024
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Maastricht University
Abstract
The primary aim of this dissertation was to develop and design a sleep health promotion intervention to improve sleep quality among nurses working irregular shifts, including night shifts. The initial step involved conducting an umbrella review to provide an overview of existing sleep health promotion interventions aimed at improving sleep quality and/or duration among healthy populations and to identify under-researched areas, one of which is nurses working irregular shifts. While the effects of shift work on health and sleep quality among shift workers are well-documented, the impact of irregular shifts specifically on nurses’ sleep quality has not been adequately evaluated. Moreover, the association between sleep quality and the need for recovery—often detrimental to health—remains largely unexplored. This significant research gap has not received sufficient attention. Given the limited evidence on how nurses cope with irregular shifts, understanding their coping mechanisms is crucial for developing effective sleep health promotion strategies to enhance their sleep quality and overall health. Although sleep hygiene strategies have been proposed for the general population, these do not all apply to nurses working irregular shifts, and the effectiveness of such strategies may vary from individual to individual. Additionally, the literature lacks clear guidelines on sleep hygiene strategies specifically tailored for nurses coping with this shift type. Therefore, it is essential to first develop personalized sleep hygiene strategies and assess their feasibility and effectiveness in improving sleep quality among these nurses.
Description
Chapter 1 provides a comprehensive background on the critical role of sleep in health, detailing the extensive impacts of poor sleep, including its link to chronic diseases and economic burdens. It outlines key factors influencing sleep quality, categorized into biological, behavioral, environmental, and personal/socio-economic determinants. Further, it explores the emerging field of sleep health promotion interventions aimed at improving sleep quality and duration, highlighting the necessity of reviewing existing efforts in this domain. The chapter addresses the health and sleep quality consequences of shift work, particularly night shifts, using Knutsson’s model to elucidate the mechanisms through which these shifts can affect health. It underscores the unique challenges faced by nurses working irregular shifts and the lack of sufficient research on their sleep quality. Additionally, the chapter discusses the possible relation between sleep quality and need for recovery, which has implications for long-term health, as the need for recovery may serve as a proxy for health risks. It emphasizes the research gap regarding how nurses cope with irregular night shifts and the existing efforts to improve their sleep quality. The chapter concludes by establishing the primary research focus: to assess first the necessity of, and then to develop and design sleep hygiene interventions specifically tailored to enhance the sleep quality of nurses working irregular shifts, including night shifts. This sets the stage for the subsequent chapters, which aim to address this critical need through targeted research and intervention strategies.
Chapter 2 presents an umbrella review conducted to evaluate sleep health interventions across the general population. This review aimed to identify common intervention types, target groups, settings, and their effects on sleep duration and/or quality. Systematic searches in five electronic databases yielded 6,505 records, from which 35 articles met the following eligibility criteria: (1) systematic reviews or meta-analyses of (2) sleep health interventions in (3) primarily healthy populations. The review uncovered a wide range of interventions, including sleep education, behavior change methods, relaxation techniques, and environmental modifications, highlighting variations in methodological quality among the studies. Sleep education, particularly aimed at school-aged populations, and behavior change methods were notably emphasized. Certain interventions, such as behavior change methods, mind-body exercises, and later school start times for adolescents, were particularly effective. Despite the diversity in intervention types and target demographics, these three categories consistently showed significant improvements in sleep outcomes. However, the review also underscored the challenges of generalizing these findings due to the heterogeneity of study designs and populations, advising caution in interpreting the results.
Chapter 3 details a cross-sectional survey conducted among 405 nurses working irregular shifts, including night shifts. The study aimed to investigate the sleep quality of these nurses and determine whether it is associated with their need for recovery. Data were collected on sociodemographic characteristics, sleep quality using the Sleep-Wake Experience List, sleep problems, sleep duration, and the Need for Recovery scale. The findings revealed that nurses working irregular and night shifts experienced significantly poorer sleep quality and greater difficulties in daily functioning compared to those working irregular shifts without night shifts. Additionally, sleep quality was significantly associated with the need for recovery, even after controlling for confounding variables. This may indicate that poorer sleep quality increases the need for recovery after shifts. These results suggest that improving sleep quality in nurses working irregular shifts could reduce their need for recovery, potentially enhancing their overall health.
Chapter 4 presents a qualitative descriptive study aimed at assessing the sleep strategies of nurses working irregular night shifts. Participants were classified as good or poor sleepers based on the Sleep-Wake Experience List, with the study involving 34 nurses evenly divided between the two groups. Thematic analysis of semi-structured interviews was used to explore their approaches to improving sleep quality. Both groups reported various strategies to enhance sleep and work performance during night shifts. However, good sleepers detailed a broader range of strategies and demonstrated more thoughtful planning. Commonly reported strategies included establishing a clear structure, organizing sleep times, maintaining consistent daily routines, and adjusting sleep environments. The findings suggest that nurses working irregular night shifts could potentially improve their sleep quality by adopting personalized plans, which may include structured daily activities and optimized sleep environments.
Chapter 5 details a pilot study designed to develop and implement a personalized sleep hygiene intervention for nurses working irregular night shifts. The study assessed the feasibility of the individualized “Shift your Sleep!” intervention, which allows nurses to tailor and adapt strategies that work best for them. Additionally, the study aimed to evaluate the effectiveness of this approach in improving sleep quality. The participant in the study maintained sleep diaries over several months, using data from an Emfit QS device to obtain 30 baseline and 30 post-intervention measurements. During the “Shift your Sleep!” intervention, the participant received personalized sleep hygiene advice and tips based on her baseline data, discussed in a face-to-face meeting. She was instructed to create weekly plans outlining the sleep strategies she intended to use and to provide daily reports on the strategies she actually implemented. The participant also completed general socio-demographic questionnaires. The findings indicate that the personalized “Shift your Sleep!” intervention is feasible for nurses working irregular night shifts. The participant effectively customized the provided sleep hygiene strategies to her preferences, successfully selecting, planning, and experimenting with these strategies. She demonstrated relatively high performance to the planned strategies, avoiding activities before bed that could prevent sleep and making a clear plan for shifts, particularly regarding sleep and wake times. Some strategies, like improving the sleep environment and avoiding worried thoughts before bedtime, were already in use before the intervention. However, she also adopted new strategies, such as regulating her sleep and wake times on days off, using lavender oil, and consistently taking power naps or staying physically active during night shifts to maintain alertness. Despite the participant’s high performance and thoughtful planning, the study did not find significant changes in sleep quality. Nonetheless, this pilot study lays the groundwork for future research that could refine and expand the “Shift your Sleep!” approach, incorporating recommendations based on the findings of this study.
Chapter 6, the final part of this dissertation, contextualizes the dissertation’s main findings, highlighting the critical importance of improving sleep quality among nurses working irregular shifts. This chapter thoroughly examines key methodological considerations, including the heterogeneity present in the umbrella review, the cross-sectional design’s limitation in establishing causality, and the potential biases inherent in semi-structured interviews and the generalizability of the findings of the N-of-1 pilot study. These factors are essential for ensuring accurate interpretation of the results. The chapter also explores the practical implications, emphasizing the necessity of individualized intervention to enhance sleep quality and minimize the need for recovery among nurses. The “Shift your Sleep!” intervention is particularly noted as a promising approach that, while showing feasibility and positive reception, requires further refinement and validation in larger, more comprehensive studies. The chapter concludes with a general conclusion, reinforcing the significance of targeted sleep interventions and the potential of personalized approaches to significantly improve the health and well-being of nurses working irregular shifts.
Keywords
Sleep health, Sleep quality, Nurses working irregular shifts, Sleep hygiene, Sleep health promotion