Sukhpal kaur, Amarjeeet Singh, Sandhya Ghai, Gunjan Grover
Abstract: Academic demands and workload may create sleep debt amongst the nursing students. The resultant Excessive Daytimes Sleepiness (EDS) might impact the health and safety of patients. Studies regarding EDS, sleep hygiene and work hours among nursing students are limited Objective: To ascertain the prevalence and determinants of excessive daytimes sleepiness among nursing students. Methodology: this cross sectional study was conducted on 400 nursing students of National Institute of Nursing Education (NINE), Post Graduate Institute of Medical Education and Research (PGIMER),Chandigarh, India using convenience sampling technique. An 8 items Epworth Sleepiness Scale (ESS) was used to measure EDS. Practice of sleep hygiene behaviors was assessed using 13 item Sleep Hygiene Index (SHI).
Result : Mean age of respondents was 21.99 ±3.51yrs. Prevalence of EDS was 43.5% among nursing students. There was significant difference in mean SHI scores of EDS group and no EDS group(p=0.01). Those who worked for more than 40hours a week, had 1.7 times risk of developing EDS (p=0.03). Conclusion : workload due to extended work hours combined with poor sleep hygiene contributes of EDS among nursing students.
Excessive daytime Sleepiness, Sleep Hygiene, Nursing students
Sound sleep is important for good health. It acts as food for the brain and contributes considerably to cognitive, emotional, and performance-related functions. Proper and regular sleep-walk schedules help in maintaining good physical and mental health, which in turn improves quality of life. On the other hand, irregular sleep-wake patterns lead to sleep deficiency or sleep debt. It disturbs normal body processes, thus causing problems with metabolism, cardiovascular health and immune system etc. this is common among people having work in shifts, truck drivers, resident doctors, nurses, patients, students during examination days, business Processing Organization (BPO) and information Technology (IT) professionals, Shift workers are more likely to fall asleep on the job than employees with regular, daytime hours. Other factors like emotional disorders, alcohol and drug abuse and some health problems also contribute to disruption of sleep. Sleep deprived individuals are less alert; less attentive and not able to concentrate effectively. It interferes with performance and has physical and social effects on their life.
Among students also, academic demands are strenuous. Day to day workload, being busy on mobiles and internet, academic demands and 24×7 lifestyle do not allow students to take normal sleep. They enter colleges with limited knowledge regarding the value of sleep. Some studies have shown that sleep. Some studies have shown that sleep derivation is linked to decreased physical health, mental health and academic performance. Same is applicable to medical healthcare students and professionals.
When personal sleep requirements of people are not met, sleep debt is created. They experience sleep problems. There are gender difference in sleep patterns, stress levels, and level of fatigue. Nurisng students have to work for days and nights in order to provide care to patients in hospitals. They aremore likely to experience Excessive daytime Sleepiness (EDS) which is defined as Sleepiness in a situation when an individual would be expected to be awake and alert. According to a study on Japanese graduate students, prevalence of EDS was 4.1%. The most common causes of excessive daytime sleepiness are sleep deprivation, obstructive sleep apnea, and sedating medicatons. It has a negative effect on memory, safety,mood ,decision making and overall health of an individual, thereby making them at high risk of motor vehicle accidents, work related incidents and other health problems. Responsibilites of nursing students are linked with care of patients in hospitals . EDS may have negative impact on it. There is significant association between irregular shift work among nurse having poor mental health and experience of medical errors.
Sleep hygiene is defined as the practices and conditions of following guidelines in an attempt to ensure more restful and effective sleep. It helps avoid certain kind of sleep disorders. Good sleep hygiene practices are associated with better sleep across several age ranges. Sleep hygiene index is a method used to assess sleep hygiene. Variable sleep schedules along with alcohol and caffeine consumption are associated with poor sleep hygiene.
Sleepiness during duty ours of nurses is of major issue concerning overall health and safety of patients. Studies to explore daytime sleepiness have been conducted in Australia, Pennsylvania ,Colorado in U.S, Michigan, Bur literature on such studies that have observed excessive daytime sleepiness and sleep hygiene among nursing students is limited in indie. Therefore, the present study was conducted with an objective to ascertain the prevalence and determinants of excessive daytime sleepiness among nursing students.
Methods and materials
This cross-sectinal stuydy was conducted at Naitnal Instiute of Nursing Education (NINE),Post Graduate Instiute of medical Education and Research (PGIMER), Chandigarh, Inida. It is a prmier nursing instiute which runs three nursing programs, that is ,MSc Nursing, Bsc Nursing of four years nd BSc Nursing (Post Basic) of two years duration.Using convenience sampling technique 400 nursing studetns out of 501 were enrolled in the study. Among them, 71% were from Bsc Nursing 4yrs,18.8% from Bsc Nursing (post Basic) and 10.2% from MSc Nursing.
All participants were administered a questionnarir containgng socio-demographic and lifestyle habits; Epsworth Sleepiness Scale (ESS) and Sleep Hygiene Index (SHI)
Tools:Socio demographic and lifestyle profile:It was used to gather the information of the participants regarding their age, sex,matrial status etc.and lifestyle habits including performance of physical activity,consumption of coffee and liquor etc.
ESS: It is a simple and reliable tool for measuring excessive daytime sleepiness among adults. It has high level of internal consistency as measured by Cronbach’s alhpha (0.88). it was used for assessing average sleep propensity in an individual. It is an eight item scale which shows the chances of falling asleep in different situations. The score range from 0 to 24. Low score indicates low sleepiness and high score indicates more chances of dozing off. For the purpose of this study, a score 0 to 9 was taken as normal, 10-12 mild EDS, 13-14 moderate EDS and >14 severe EDS.
SHI: It is a 13 item, five point index which was used to assess the practice of sleep hygience behaviours. Sleep hygiene is storngly associated with sleep quality.The score range from one to 65.For this study ,a score less than 26 was taken as good,25-44 as averae and >45 as poor sleep hygiene.
Data Collection: Prior permission to conduct the study was taken from the principal of the institute. The study was approved by the institute Ethics Committee. At one time only one class was contacted. The students were explained about the purpose of the study. They were assured that the data collected would be kept confidential and used only for research purpose. After obtaining the research purpose. After obtaining the infromed verbal consent they were administered the questionnaires. They were also asked to rate themselves on the scale of 0-10 for tiredness and sleepiness.
The data was entered and analyzed using SPSS.
Socio demographic and lifestyle profile
Almost all (96.8%) the students were female. Among them ,6.5% were married and 93.5% were unmarried. Mean age was 21.99yrs ±3.51. of the 400 subjects included in the survey,93.2% worked in clinical deparetments,and 6.8% in non-clinical departments at he time of data collection.
Majority (73%) of participants used to consume 1-2 cups of coffee/tea;34.2% paritcipants reported 1-3 days of physical activity per week and 22.6% reported more than 4 days of physical activity per week.
Mean weight of the students was 51.84 kg±7.68 and mean height was 159.32 cm±7.72 . Two third (66.5%) of the subjects were of normal weight and 8% were overweight.
Table 1: Distribution of the Participants as per ESS and SHI score
Normal (0-9 score)
Mild EDS (10-12 score)
Moderate EDS (13-14 score)
Severe EDS (>14 score)
Good sleep hygiene(<26score)
Average sleep hygiene (25-44 score)
Poor Sleep hygiene (>45 score)
Distribution of the participants as per ESS and SHI score
the distribution of the participants as per their ESS and SHI is shown in table 1. As per their ESS, more than half participants (56%) were in the normal category. Around one fourth reported having mild EDS. 7% were in the severe category of EDS with the score of more than 14. As per SHI, majority reproted having average sleep hygiene. Only 1.2% of participants were having poor sleep hygiene.
There was no significant difference in EDS and SHI status among married and unmarried subjects. Those who consume coffee and do physical activity also showed no difference in EDS and SHI when compared with subjects who neither take coffee nor do physical activity. Statistically,marital status, coffee consumption and physical activity showed no association with EDS and SHI
On a scale from 0 to10,40.25% study participants self-rated themselves as moderately sleepy and 34% as extremely sleepy at the time of data collection. Similarly ,45.5% were extremely tired at the same time when they were asked to rate their tiredness on a scale 0 to 10.
Item Wise Response to Epworth Sleepiness Scale amongst the subjects.
Table 2 shows that around one third, (38.2%) participants reported “high” chances of dozing off when they lied down to rest in the afternoon when circumstances permitted. Proportion of response to slight to high chance of dozing was higher with items-“siting and reading’(87.2%), as a passenger in a car for an hour without a brak’ (78.6%) and siting quiety after lunch without alcohol’(75.5). More than 75% reported no to slight chances of falling asleep while “Watching” TV and 70% response to would never doze’ were reported for sitting and talking to someone’ and ‘In a car while stopped for a few minutes in traffic’ (69%),sitting quietly after the lunch without alcohol (24.5%)
Table :2 item wise Responses to Epworth Sleepiness Scale
|Situation|| Participants reported
chances of dozing n (%)
would never zone
Slight Chance of dozing
Moderate chances of dozing
Severe chances of dozing
|Sitting & Reading
Sitting inactive in a public place
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting &Talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in traffic
Sleep hygiene index (SHI) with and without EDS
Table 3 indicated that the mean SHI scores for 226 (56.5%) respondents with No
+EDS was 26.69±6.78 and for 174 (43.5%) respondents with EDS was 31.37±6.04. The difference in means was statistically significant (p=0.01)
Table:3 Sleep hygiene index (SHI) with and without EDS among the study subjects
|EDS N Mean±SD SE T P
No 226 29.69±6.78 0.45 -2.57 0.01
Yes 174 31.37±6.04 0.46
Item wise ratings of SHI by study participants
Nursing students reported higher proportion of frequently to always responses for the items –‘I think, plan or worry when I am in bed, ‘I do important work before bedtime,’ and ‘I use my bed for things other than sleeping or sex (Table 4)
Some behaviors in which maximum of them had shown to be engaged ‘rarely to sometimes’ are taking daytime naps pastime for two or more hours, Getting out of bed at different time form day to day to day ,Staying in bed longer than one should two or three times a week, Doing something that may wake you up before bedtime, I go to bed at different times from day to day’ and Going to bed feeling stressed, angry, upset or nervous.
More than half nursing students indicated that they had never engaged in some behaviours. These are ‘Exercising to the point of sweating within one hour of going to bed. Using tobacoo,alcohol ,or caffeine iwhin four hours of going to bed or after going to bed, sleeping on uncomfortable bed and sleeping in an uncomfortable bedroom.
Table 4: Item wise ratings of SHI by study participants
|1.||I take daytime naps lasting two or more hours.||14(3.5)||40(10)||116(29)||130(32.5)||100(25)|
|2.||I go to bed at different times from day to day||39(9.7)||77(19.2)||106(26.5)||100(25)||78(19.5)|
|3||I get out of bed at different times from day to day||17(4.2)||45(11.2)||108(27)||135(337.)||95(23.7)|
|4||I excersie to the point of sweating within one hour of going to bed.||6(1.5)||9(2.2)||35(8.7)||68(17)||282(70.5)|
|5||I stay in bed longer than I should two or three times a week||18(4.5)||36(9)||114(28.5)||141(35.2)||91(22.7)|
|6||I use alcohol,tobacoo , or caffeine within four hours of going to bed or after going to bed.||8(2)||3(0.7)||23(5.7)||18(4.5)||348(87)|
|7||I do something that may wake me up before bedtime (For eg-play video game, use the internet, or clean)||17(4.2)||42(10.5)||99(24.7)||71(17.7)||171(42.7)|
|8||I go to bed feelings stressed, angry,upset, or nervous||21(5.2)||46(11.5)||135(33.7)||113(28.2)||85(21.2)|
|9||I use my bed for thing other than sleeping or sex(for example-watch TV,read, eat, or study)||109(27.2)||118(29.5)||63(15.7)||42(10.5)||68(17)|
|10||I sleep on an uncomfortable bed (For eg-Poor mattress or pillow, too much or not enough blanket)||21(5.2)||9(2.2)||36(9)||80(20)||254(63.5)|
|11||I sleep in an uncomfortable bedroom (for eg-too bright, too study, too hot, too cold, or too noisy)||18(4.5)||13(3.2)||50(12.5)||101(25.2)||218(54.5)|
|12||I do important work before bedtime (for eg-Pay bills, schedule, or study)||78(19.5)||109(27.2)||111(27.7)||55(13.7)||47(11.7)|
|I,think ,plan, or worry when I am in bed.||61(15.25)||94(23.5)||122(30.5)||67(16.7)||56(14)|
The differences in means were statistically significant for ‘i take daytime naps lasting two or more hours (p=0.001) and ‘I sleep in an uncomfortable bedroom’(p=0.0037) in the EDS group, mean sleep duration for 174 subjects was 6.96±1.70 hours whereas it was 7.53±1.23 for 226 students in No EDS group. No EDS group reported more adaptive sleep hygiene than EDS group. There was significant difference than EDS group. There was significant difference in means for sleep duration in the recent past between EDS and No EDS group (p=0.011)
Among the respondents who worked for more than 40 hours per week and have maladaptive sleep hygiene ,nearly half of them had probability of develpong EDS. Wheresas among students, who worked 40 hours or less per week, good sleep hygiene was associated with less likehood of developing EDS. Ther were 1.7 time risk of experiencing EDS among those who work for more than 40 hours a week and have poor sleep hygiene. (Table 5)
Table 5: Stratified analysis for association between EDS and weekly work hours
Functioning of all systems in the body depends on relaxed mind and health brain. This in turns depends on adequate and normal sleep since it helsp to maintain normal activity level of CNS. Normal sleep wake cycles consist 8 hours of nocturnal sleep and 16 hours of wakeful time. It is regulated by coordination of sleep homeostasis and circadian rhythms. In the late evening , homeostasis system makes us sleepier by mainting a steady state of bodily internal conditions (blood pressure, temperature etc.) Circadian rhythms are driven by biological clock of brain. It si affected by external forces such as sunrise and suset,internal body temperature, hormone levels and sleep,when the time set by this biological clock is deisrupted, it leads to Excessive Daytime Sleepiness (EDS) in addition to other problems.
Excessive daytime sleepiness (EDS) is a major public health problem. it is quite common in doctors, nurses ,students and other people who work in shifts. The present study indicated that more than 40% of the nursing students had shown EDS suggesting that they are sleep deprived. This is because of the wok culture in healthcare setting where healthcare professional provide care to patients regardless of their sleep. As a result cognitive abilities like vigilance decision making and judgement etc required in nursing care may get deteriorated. It may have adverse consequences on their own health as well as on patients safely .Consequently the process of delivery of care to patient may get compromised.
In our study , nursing student on an average reported 57.85±2.95 hours of work per week. This is much more than 40 hours per week decided for nursing interns .there is thus a chance that EDS as linked with working hours a syndicated by our result also. Working for extended hours or shifts increased the risk of making an error in one ‘s job. Most (79.5%) nursing students worked for more than 40 hours per week while 20.5% first 40 hours of less. Among the subjects who work of more than 40 hours per week, neatly half of them reported EDS with maladaptive sleep hygiene. This is likely the result of need of recovery after ling hours of work. A study on civil servants showed similar findings that long working hour had been associated with sleep disturbance. Moreover, there were grater chances of making an error when nurses worked more than 40 hours a week.
Most respondents in this study reported more chances of falling asleep after lunch. After having meals, brain automatically switches to relaxing mode due to circulation of blood towards stomach. Hence, there is high probability of falling asleep when body is in resting state. Most of them also stead that they tend to fall asleep while sitting and reading. This may be attributed to bordom felt during reading text books. Majority of them reported slight of higher chances of dozing off while travelling in a car. This may liikely be dur to rocking motion. However, they also reported that they would never feel drowsy in a car, while it stopped for few minuted in traffic. This may also be due to the reasion thato one has to ramain alert, attentive and there is loudness all around in traffic. Moreover the rocking motion suddenly stops when the care stops.
Majority of them reproted that they wouyld never fall asleep while talking to somone and watching TV obviously students find these activities intersting and entertaining. They also stated slight chances of falling asleep while sitting inactive in a publeic place. This reveals aletness and careful attiutde of nurses for their belongings .Also it is not socially acceptable for females to sleep at a public place.
Our results also revealed that most of the respondents had maladaptiv sleep hygiene (SHI>26). This reflects malpractice of sleep hygiene behaviours among them. Working in shifts in addition to strenous academic demands may not allow half of them to follow regular sleep-wake routine. It may likely be due to thelocally prevaliling situaion inhosstels where two girls are alloted a single room. They may have different plans of their daily routine, thus hindering sleep patterns of one another. Going ot bed strssed due to heavy worklead in government healthcare seting make them irritated and frustrated. This interferees with the quantity and quality of their sleep. In order to recover the sleep debt, they were more likely to take daytime naps and stayed in bed longer two to three times a week. This findign is consisitant with reuslt of study on nurses suggesting that they try to obtain sleep on weekends which theylost on weekdays.
Students have limited hostel room space where two beds, table and chairs occupied whole of the area, for being most comfortble in their rooms, they had touse their bed for studying,eating, reading and other things in addition to sleeping. They may not eant ot admit hteir habits of consuming alcohol, tobacco etc because such things are banned in hostels. Also,it is a taboo for girls in Indian culture. Rather than doing exercises, playing video games and using internet, many of them reported doing important work before bedtime. This may likely be related to their effort in regulating schedules to avoid pending tasks. It was ofund thatomore than half of hte respondents never slept on an uncomfortable bed and in bedroom suggesting that being well educated, they are more concering about their body and health.
Results indicated that EDS gourp, in general ,had less adaptive sleep hygiene as ocmpared to no EDS group. Nursing studetns who worked for more than 40 hours per week with maladaptive sleep hygiene were 1.7 times at risk for development of EDS. Thus,it appears that workload and poor sleep hygiene put together contribute to EDS. However, furthr studies are needed on this aspect.
- Abdalkader RH.Effect of Night shift on Nurse working in intensive care units at Jordan University Hospital .European Journal of Scientific Research 2008;23:70-86.
- Guilleminault C,Brroks SN Excessive daytime sleepiness: A challenge for the practising neruologist, Brain 2001;124:1482-91.
- Brown FC, Buboltz WC,Soper B. Development and Evaluation of the Sleep Treatment and Education Program for Students (STEPS).Journal of American College Health 2006;54:231-17
- Dement WC, Vaughan CC. The promise of Sleep. New York: Delacorte Press, 1999.
- American Psychoogical Association.Gender and stress http://www.apa.org/news/press/releases/stress/2010/gender-stress.aspx.Accessed on 26 Feb 2017.
- Arand D, Bonnet M, hurwitz T,Mitler M, Rosa R,Sangal R. The clincial use of the MSLT and MWT.Sleep2005;28:132-444.
- Pallos H, yamada N, Doi Y,Okawa M. Sleep habits, prevalence and burden of sleep disturbances among japanese graduate students. Sleep and Biological Rhythms 2004;46:448-54.
- Suzukki K, Ohida T,Kaneita Y,et al. Mental health staus,Shift work, and occupational accidents among hospital nurses in Japan. Journal of Occupational health 2004;46:448-54
- American Academy of Sleep Meidcine,international classification of sleep disorders,revised:Dignostic and codling manual,chicago,illinois: American academy of Sleep Medicine,2001.
- Mindell JA, Meltzer LJ, Carscadon MA,Chervin RD. Development aspects of sleep hygiene. Findings from the National sleep Foundation Sleep in America Poll. Sleep Medicine 2009;10:771-9
- Brown FC, Raltionship of Sleep hgyiene Awareness. Sleep Hygiene Practices, And sleep Quality in University Students. Behavioural Medicine 2002;28:33-8.
- Murray J, Hocking B. Daytime Sleepiness and Sleep
Habits of Australian Works, Sleep 1997,20;844-9
- Bixler,EO, vgontza AN, Lin HM,Calhoun SL
- Pagal JF.Excessive Daytime Sleepiness. American Family Physicician 2009;79:391-6
- Breslau N, Roth T, Rosenthal L, Andreski P.Daytime sleepiness: an epidemiological study of young adults.Ameican Journal of Public Health 1997;87:1649-53
- John MW. Reliability and Factor Analysis of the Epworth Sleepiness Scale. Sleep 1992 ;15:376-81
- Mastin DF, Siddalingaiah H, Singh AJ,lal V.Excessive daytime Sleepiness, Sleep Hygiene, and work Hours Among Medical Residents in India Journal of Tropical Psychology 2012;2:1-11
- National Sleep Foundation. Sleep –wake Cycle: its Psysiology and Impact-Sleep Research and Education. sleepfoundation.org.2006
- Ownens JA. Sleep Loss and Fatique in Healthcare Professionals. Journal of Perinatal and Neonatal Nursing 2007;21:92-100.
- Indian Nursing Council.B.Sc Nursing Syllabus and Regulation (Basic Programme.) Now Delhi:Indian Nursing Council,2002.
- Hinshaw AS.Keeping Patients Safe: A collaboration among nurse administrators and researchers Nursing Council,2002.
- Virtanen M, Ferrie JE,Gimeno D, Vahtera J, Elovainio M, Singh-Manoux A. Long Working hours and sleep distrubances: the whitehall II prospective cohort study. Sleep 2009;32:737-45
- Rogers AE,Hwang WT, Scott LD,Aiken LH,Dingers DF. The working hours of Hospital Staff Nurses and Patient Safety. Health Affaris 2004:23:202-12
- Rogers AE. The effects of fatigue and sleepiness of nurse Performance and Patient Safety. In:Room HG, ed. Patient Safety and Quality: An Evidence Based handbook for Nurses. Agency for healthcare Research and Quality .US 2008:2509-45.