Sleep Disturbances Among Nurses in Iran: A Meta-Analysis

AUTHORS

Kourosh Sayehmiri ORCID 1 , 2 , Ehsan Mohammadi 3 , *

1 Psychosocial Injuries Research Center, Ilam University of Medical Sciences, Ilam, Iran

2 Department of Community Medicine, Faculty of Medicine, Ilam University of Medical Sciences, Ilam, Iran

3 Student Research Committee, School of Nursing and Midwifery, Ilam University of Medical Sciences, Ilam, Iran

How to Cite: Sayehmiri K, Mohammadi E. Sleep Disturbances Among Nurses in Iran: A Meta-Analysis, Iran Red Crescent Med J. 2018 ; 20(11):e62089. doi: 10.5812/ircmj.62089.

ARTICLE INFORMATION

Iranian Red Crescent Medical Journal: 20 (11); e62089
Published Online: November 4, 2018
Article Type: Review Article
Received: September 23, 2017
Revised: February 8, 2018
Accepted: March 31, 2018
Crossmark

Crossmark

CHEKING

READ FULL TEXT
Abstract

Context: Sleep disorder is a crucial occupational problem for nurses that not only makes health problems for them but also affects job performance and patient’s safety. The status of sleep disorders in nurses is reported variously in Iran.

Objective: This study aimed to provide an accurate, precise, and reliable estimate of sleep disorders among nurses using a meta-analysis.

Methods: To find relevant studies, international (PubMed, Web of Sciences, and Scopus) and Iranian (Magiran, IranMedex, SID, IranDoc, and Medlib) databases were systematically searched until June 2017. Statistical analysis was performed using Stata Statistics Software version 11 (Stata Corp., College Station, TX., USA). The heterogeneity of studies was calculated using the I-square test. The analysis of data was conducted using a random-effects model.

Results: Overall, 6894 subjects were enrolled from 26 reviewed studies. The pooled rate of poor sleep quality among nurses in Iran was 64% (95% CI: 55 - 73), and the average score of the Pittsburgh sleep quality index (PSQI) was estimated to be 8.72 (95% CI; 7.80 - 9.65). The prevalence of daytime sleepiness was 36% (95% CI: 23 - 48). The rate of hypnotic drug consumption was 28% (95% CI: 17 - 38), the sleep latency was 30.84 minutes (95% CI: 27.98 - 33.70), and the mean sleep duration was estimated to be 6.43 hours (95% CI: 5.29 - 7.56).

Conclusions: The prevalence of sleep disorders was high among Iranian nurses. It seems necessary to implement appropriate measures, such as optimal scheduling of work shifts, sleep hygiene education, and day rests after night shifts.

Keywords

Depression Meta-Analysis Nurses Prevalence Sleep Disorder

Copyright © 2018, Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited

1. Context

Sleep is a biological function, which is essential to human health and wellbeing (1). Sleep disorders are among the most important public health concerns around the world (2, 3). Shift work is a necessity for most groups of healthcare workers (4, 5). The previous studies show that shift working can lead to important sleep disorders (1, 5-7). Shift work is associated with significant physiological and psychological impacts such as anxiety, depression, and mental health problems (8, 9), insomnia, impaired focus, fatigue, mood disorders, low quality of care, reduced job performance, job dissatisfaction, accident, and family problems (4, 10, 11).

Nurses, as one of the most prominent groups of health professionals, had a critical role in healthcare systems (12). They often have rotating work shifts (13-15), which can lead to adverse effects such as physical and psychological problems, accidents, injuries, circadian rhythm asynchronies, and sleep disorders (16-18).

Generally, sleep disorders are among crucial occupational health issues for nurses that can lead nurses to not only health problems, but also lower job performance (19), medical errors (20, 21), depression (20), low-quality performance (22), and reduced patient safety (23).

The rate of low sleep quality in healthcare workers was reported to be 42.3% in a study in Najran, Saudi Arabia (24) and 54.2% in Kano, Nigeria (25).

Overall, nurses are more vulnerable to sleep disorders compared to other health care workers (26). The literature shows that sleep problems are prevalent among nurses. In this regard, in a study from Taiwan (2013), poor sleep quality in nurses was reported as 75.8% (19). In addition, in a study from China, the rate of poor sleep quality was 72.1% among nurses (6). In another study from Corpus Christi (USA), 63% of nurses reported poor sleep quality, and 22% of the nurses experienced daytime sleepiness (27). Moreover, in Nigeria, 61% of nurses reported poor sleep quality (28).

Considering the importance and crucial role of sleep for nurses, the evaluation of the status of sleep disorders is essential for hospital managers and policymakers to plan and employ preventive strategies and improve sleep quality. In Iran, many studies have been performed on sleep disorders among nurses. Nonetheless, the status of sleep disorders among nurses has been varied in different studies. So far, no systematic review has been performed on sleep problems among nurses. Therefore, this study aimed to present an accurate and reliable estimate of sleep disorders among Iranian nurses using a meta-analysis.

2. Methods

2.1. Data Source

This study is a systematic review and meta-analysis of the literature on sleep disorders in Iranian nurses following the PRISMA guidelines (29).

2.2. Search Strategy

To identify relevant studies, both international (PubMed, Web of Science, and Scopus) and national (SID, Medlib Magiran, IranMedex, and IranDoc) databases were systematically searched until June 2017. The keywords included “sleep quality,” “sleep disturbances,” “sleep disorders,” “Iran” and “nurses.” To improve the search sensitivity, all possible combinations of Persian and English keywords were also searched. The reference list of the papers was also manually reviewed to detect relevant studies.

2.3. Inclusion and Exclusion Criteria

Descriptive and cross-sectional studies on sleep disorders among nurses were included in the meta-analysis. Studies with inadequate data and those with no access to full texts were eliminated from the search. Studies on nurses’ attitudes, knowledge, or awareness of sleep disorders, as well as interventional and qualitative studies, were excluded. Regarding duplicate publications, the most recent studies with more detailed information were included. The recruited studies were reviewed independently by two reviewers and disagreements were solved by discussion. In this review, studies populations were nurses, and the outcome was sleep quality.

2.4. Data Extraction

Data were extracted using a designed checklist that included authors’ names, the study place, year of study, sample size, the poor sleep quality rate, PSQI score, the rate of daytime sleepiness, hypnotic drug consumption, sleep latency, and sleep duration. The researchers extracted the data from the selected studies. To reduce the risk of publication bias, blinding and task separation methods were applied.

The quality was assessed using the STROBE (the strengthening the reporting of observational studies in epidemiology) checklist, which determines the methodological characteristics of studies (30). This checklist is a valid and reliable tool for reporting of studies (31).

This checklist had 22 items, and according to the previous study, we considered the quality of studies as high (score 17 - 22), moderate (score 8 - 16), and low (score 1 - 7) (32).

2.5. Statistical Analysis

Statistical analyses were carried out by STATA Statistics Software version 11 (Stata Corp., College Station, TX., USA). The heterogeneity index of studies was calculated using the I-square (I2). Since the heterogeneity index was significant in the current study (P = 0.000), the analysis of data was conducted using a random-effects model.

3. Results

3.1. Study Selection

Using the search strategies, a total of 384 articles were retrieved on sleep disorders among Iranian nurses. 175 duplicates were excluded, and the titles of the remaining 209 articles were screened. Then, 153 articles were found irrelevant and excluded. In the next step, after reviewing the full texts of the remaining 56 articles, 30 other irrelevant studies were also excluded. Finally, 26 studies with a sample size of 6894 were included in this review (Figure 1).

Flow diagram of the selected studies
Figure 1. Flow diagram of the selected studies

The Egger’s plot was used to assess the publication bias in the included studies (Figure 2).

Egger’s plot of selected studies
Figure 2. Egger’s plot of selected studies

The poor sleep quality prevalence ranged from 14% to 91% in different studies from Iran. The combined results of 22 studies showed that the pooled rate of poor sleep quality was 64% among nurses in Iran (95% CI; 55 - 73) (Figure 3).

The rates of poor sleep quality in Iranian nurses
Figure 3. The rates of poor sleep quality in Iranian nurses

In the present study, the mean score of PSQI was estimated at 8.72 (95% CI; 7.80 - 9.65) in the range of poor sleep quality (Figure 4).

The overall PSQI score means in Iranian nurses
Figure 4. The overall PSQI score means in Iranian nurses

Meta-regression showed that poor sleep quality prevalence according to year had an increasing trend (Figure 5).

The meta-regression of poor sleep quality trend
Figure 5. The meta-regression of poor sleep quality trend

The overall prevalence of daytime sleepiness ranged from 16% to 58% in different studies among nurses. The combined results of seven studies showed that the prevalence of daytime sleepiness was 36% among Iranian nurses (95% CI; 23 - 48) (Figure 6).

Daytime sleepiness rate in Iranian nurses
Figure 6. Daytime sleepiness rate in Iranian nurses

In the present study, the rate of hypnotic drug consumption was approximately 28% (95% CI: 17 - 38) among Iranian nurses. In addition, sleep latency was 30.84 minutes (95% CI: 27.98 - 33.70) among nurses, and the mean sleep duration was 6.43 hours (95% CI: 5.29 - 7.56) among study subjects.

4. Discussion

Previous studies on sleep disorders among nurses in Iran show various finding. In our study, the overall estimation of poor sleep quality was 64% among nurses in Iran, which is consistent with some similar studies. In this regard, a study from China on 4951 nurses reported a poor sleep quality rate of 63.9% (26). Moreover, 61% of nurses had poor sleep quality in Nigeria that is similar to our study (28).

In a study in China, the poor sleep quality rate was 72.1% among nurses (6). In addition, in a study in Taiwan, the poor sleep quality rate was 57% among nurses, which is similar to the present study (33). In another study from Taiwan, 75.8% of nurses reported poor sleep quality (19), which is higher than the value found in the present study.

Moreover, in a study on sleep disorders among nurses in Norway, the prevalence of poor sleep quality was 70%, which is slightly higher than the rate in the present study (34). In addition, in a study from Corpus Christi (USA), the poor sleep quality rate was 63%, and 22% of nurses complained of sleepiness, which is similar to the findings of the present study (27).

Han et al. conducted a study on 2,033 nurses in Harbin Medical University and reported that the poor sleep quality rate was 42.9% (35), which is lower than the rate in the present study. In a study in Germany, the rate of poor sleep quality among female nurses was reported to be 33% (36), which is lower than the rate in the present study. In their study, an analog scale was used to evaluate sleep quality, which may be the reason for the lower rate of poor sleep quality.

The prevalence of sleep disorders among nurses is a prevalent problem, suggesting that nurses are at risk of sleep disorders, thus necessitating more attention. Since nurses should work in different shifts, the sleep-weak-up patterns are disrupted, making them more susceptible to develop sleep disorders.

The mean total PSQI score in our study was 8.72, which is indicative of poor sleep quality. In a study performed in Turkey on 418 nurses, the mean PSQI score was 7.46 ± 3.58, which is consistent with the present study (37). Moreover, in a Norwegian study, the average score of PSQI was 7.5 ± 3 among nurses working in the intensive care unit, which is similar to the present study (34). Furthermore, the mean score of PSQI was 7.32 ± 3.24 among Chinese nurses, which is similar to the score found in the present study, indicating poor sleep quality (26).

In a study from Taiwan, the sleep quality score was greater among nurses working in nightshifts (9.04) than in those who worked in dayshifts (7.32) (8). The higher PSQI scores of nurses indicate poor sleep quality in this group. In a study from Portugal, the mean PSQI score was 7.02, which is slightly better than that in the present study (10). Moreover, in a study from Sao Paulo, the overall score of PSQI was 6.8, which indicates a better sleep status, compared to the present study (38).

In the present study, the overall daytime sleepiness rate was 36% among nurses. The rate of daytime sleepiness was 26% among 4407 nurses in Japan, which is lower than the rate of the present study (39). In another study from Norway, the rate of sleepiness among nurses was 25%, which is lower than the rate reported in the present study (34). In addition, in the study from Corpus Christi (USA), the rate of sleepiness was 22% among nurses, which is also lower than the present findings (27).

The rate of hypnotic drug consumption among nurses was 28% in our study. In a previous study from Brazil, approximately 17.7% of nurses used sleep medications, which is lower than the rate in the present study (40). In the present study, sleep latency was 30.84 minutes among nurses, which is longer than the finding reported from Taiwan (18.33 minutes) (19).

In addition, the average sleep duration was 6.43 hours for nurses, which is similar to the study from Taiwan (6.11 hours) (19). In another study from Portugal, sleep duration was reported about 7.5 hours per day among nurses, which is similar to the present study (10).

Sleep disorders can affect the nurse’s performance, care quality, and patient’s safety (15, 17). Therefore, the sleep problem is of great importance among nurses. The results of the present study, as well as research from other countries, show that nurses are at risk of sleep disorders. Therefore, comprehensive programs are needed to overcome sleep problems among nurses. Moreover, planning for improving work shift schedules by head nurses can be helpful. In addition, the use of day rest after night work can improve the nurses’ sleep quality (8).

4.1. Limitations

The rate of poor sleep quality among nurses in different wards was not clearly reported in some studies. The studies were not conducted evenly in all regions of Iran. Moreover, the subscales of PSQI were not reported in several studies. Despite these limitations, the present review is the first meta-analysis of sleep problem among nurses. In this study, we performed a comprehensive search of published and unpublished reports, as well as grey literature, in international and national databases.

4.2. Conclusion

The prevalence of sleep disorders was high among Iranian nurses. Because sleep can affect the personal and professional lives of nurses, it seems necessary to implement appropriate measures, such as optimal scheduling of work shifts, sleep hygiene education, and day rests after night shifts.

Acknowledgements

Footnotes

References

  • 1.

    Caruso CC. Negative impacts of shiftwork and long work hours. Rehabil Nurs. 2014;39(1):16-25. doi: 10.1002/rnj.107. [PubMed: 23780784]. [PubMed Central: PMC4629843].

  • 2.

    Hsieh ML, Li YM, Chang ET, Lai HL, Wang WH, Wang SC. Sleep disorder in Taiwanese nurses: A random sample survey. Nurs Health Sci. 2011;13(4):468-74. doi: 10.1111/j.1442-2018.2011.00641.x. [PubMed: 22011090].

  • 3.

    Leger D, Poursain B, Neubauer D, Uchiyama M. An international survey of sleeping problems in the general population. Curr Med Res Opin. 2008;24(1):307-17. doi: 10.1185/030079907X253771. [PubMed: 18070379].

  • 4.

    Burch JB, Tom J, Zhai Y, Criswell L, Leo E, Ogoussan K. Shiftwork impacts and adaptation among health care workers. Occup Med (Lond). 2009;59(3):159-66. doi: 10.1093/occmed/kqp015. [PubMed: 19270043].

  • 5.

    Alshahrani SM, Baqays AA, Alenazi AA, AlAngari AM, AlHadi AN. Impact of shift work on sleep and daytime performance among health care professionals. Saudi Med J. 2017;38(8):846-51. doi: 10.15537/smj.2017.8.19025. [PubMed: 28762438]. [PubMed Central: PMC5556302].

  • 6.

    Zhang L, Sun DM, Li CB, Tao MF. Influencing factors for sleep quality among shift-working nurses: A cross-sectional study in china using 3-factor Pittsburgh sleep quality index. Asian Nurs Res (Korean Soc Nurs Sci). 2016;10(4):277-82. doi: 10.1016/j.anr.2016.09.002. [PubMed: 28057314].

  • 7.

    Akerstedt T, Wright KP Jr. Sleep loss and fatigue in shift work and shift work disorder. Sleep Med Clin. 2009;4(2):257-71. doi: 10.1016/j.jsmc.2009.03.001. [PubMed: 20640236]. [PubMed Central: PMC2904525].

  • 8.

    Lin PC, Chen CH, Pan SM, Pan CH, Chen CJ, Chen YM, et al. Atypical work schedules are associated with poor sleep quality and mental health in Taiwan female nurses. Int Arch Occup Environ Health. 2012;85(8):877-84. doi: 10.1007/s00420-011-0730-8. [PubMed: 22207296].

  • 9.

    Oyane NM, Pallesen S, Moen BE, Akerstedt T, Bjorvatn B. Associations between night work and anxiety, depression, insomnia, sleepiness and fatigue in a sample of Norwegian nurses. PLoS One. 2013;8(8). e70228. doi: 10.1371/journal.pone.0070228. [PubMed: 23950914]. [PubMed Central: PMC3737208].

  • 10.

    De Martino MM, Abreu AC, Barbosa MF, Teixeira JE. The relationship between shift work and sleep patterns in nurses. Cien Saude Colet. 2013;18(3):763-8. doi: 10.1590/S1413-81232013000300022. [PubMed: 23546203].

  • 11.

    Tahghighi M, Rees CS, Brown JA, Breen LJ, Hegney D. What is the impact of shift work on the psychological functioning and resilience of nurses? An integrative review. J Adv Nurs. 2017;73(9):2065-83. doi: 10.1111/jan.13283. [PubMed: 28229469].

  • 12.

    Tabatabaee SS, Vafaee-Najar A, Amiresmaili MR, Nekoie-Moghadam M. Nurse staffing norm in Iran hospitals: What features should be included for success? Int J Prev Med. 2017;8:13. doi: 10.4103/2008-7802.201657. [PubMed: 28348723]. [PubMed Central: PMC5353769].

  • 13.

    Moreno-Casbas MT, Ruzafa-Martinez M, Rol MA, Madrid JA, Serrano Pinto A, Gonzalez-Maria E, et al. Sleepiness in Spanish nursing staff--influence of chronotype and care unit in circadian rhythm impairment: Research protocol. J Adv Nurs. 2014;70(1):211-9. doi: 10.1111/jan.12200. [PubMed: 23834526].

  • 14.

    Ferri P, Guadi M, Marcheselli L, Balduzzi S, Magnani D, Di Lorenzo R. The impact of shift work on the psychological and physical health of nurses in a general hospital: A comparison between rotating night shifts and day shifts. Risk Manag Healthc Policy. 2016;9:203-11. doi: 10.2147/RMHP.S115326. [PubMed: 27695372]. [PubMed Central: PMC5028173].

  • 15.

    Peate I. Strategies for coping with shift work. Nurs Stand. 2007;22(4):42-5. doi: 10.7748/ns2007.10.22.4.42.c4620. [PubMed: 17969663].

  • 16.

    Lee CY, Chen HC, Meg Tseng MC, Lee HC, Huang LH. The relationships among sleep quality and chronotype, emotional disturbance, and insomnia vulnerability in shift nurses. J Nurs Res. 2015;23(3):225-35. doi: 10.1097/jnr.0000000000000095. [PubMed: 26166700].

  • 17.

    Berger AM, Hobbs BB. Impact of shift work on the health and safety of nurses and patients. Clin J Oncol Nurs. 2006;10(4):465-71. doi: 10.1188/06.CJON.465-471. [PubMed: 16927899].

  • 18.

    Anbazhagan S, Ramesh N, Nisha C, Joseph B. Shift work disorder and related health problems among nurses working in a tertiary care hospital, Bangalore, South India. Indian J Occup Environ Med. 2016;20(1):35-8. doi: 10.4103/0019-5278.183842. [PubMed: 27390478]. [PubMed Central: PMC4922274].

  • 19.

    Chien PL, Su HF, Hsieh PC, Siao RY, Ling PY, Jou HJ. Sleep quality among female hospital staff nurses. Sleep Disord. 2013;2013:283490. doi: 10.1155/2013/283490. [PubMed: 23766916]. [PubMed Central: PMC3666224].

  • 20.

    Arimura M, Imai M, Okawa M, Fujimura T, Yamada N. Sleep, mental health status, and medical errors among hospital nurses in Japan. Ind Health. 2010;48(6):811-7. doi: 10.2486/indhealth.MS1093. [PubMed: 20616466].

  • 21.

    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(1):17-22. doi: 10.1097/NNA.0000000000000016. [PubMed: 24316614].

  • 22.

    Ghalichi L, Pournik O, Ghaffari M, Vingard E. Sleep quality among health care workers. Arch Iran Med. 2013;16(2):100-3. [PubMed: 23360632].

  • 23.

    Lockley SW, Barger LK, Ayas NT, Rothschild JM, Czeisler CA, Landrigan CP, et al. Effects of health care provider work hours and sleep deprivation on safety and performance. Jt Comm J Qual Patient Saf. 2007;33(11 Suppl):7-18. doi: 10.1016/S1553-7250(07)33109-7. [PubMed: 18173162].

  • 24.

    Olawale OO, Taiwo OA, Hesham A. Quality of sleep and well-being of health workers in Najran, Saudi Arabia. Indian J Psychiatry. 2017;59(3):347-51. doi: 10.4103/psychiatry.IndianJPsychiatry_241_16. [PubMed: 29085095]. [PubMed Central: PMC5659086].

  • 25.

    Kolo ES, Ahmed AO, Hamisu A, Ajiya A, Akhiwu BI. Sleep health of healthcare workers in Kano, Nigeria. Niger J Clin Pract. 2017;20(4):479-83. doi: 10.4103/1119-3077.204378. [PubMed: 28406131].

  • 26.

    Dong H, Zhang Q, Sun Z, Sang F, Xu Y. Sleep disturbances among Chinese clinical nurses in general hospitals and its influencing factors. BMC Psychiatry. 2017;17(1):241. doi: 10.1186/s12888-017-1402-3. [PubMed: 28673267]. [PubMed Central: PMC5496307].

  • 27.

    Surani S, Hesselbacher S, Guntupalli B, Surani S, Subramanian S. Sleep quality and vigilance differ among inpatient nurses based on the unit setting and shift worked. J Patient Saf. 2015;11(4):215-20. doi: 10.1097/PTS.0000000000000089. [PubMed: 24522213].

  • 28.

    Aliyu I, Ibrahim ZF, Teslim LO, Okhiwu H, Peter ID, Michael GC. Sleep quality among nurses in a tertiary hospital in North-West Nigeria. Niger Postgrad Med J. 2017;24(3):168-73. doi: 10.4103/npmj.npmj_79_17. [PubMed: 29082906].

  • 29.

    Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. J Clin Epidemiol. 2009;62(10):1006-12. doi: 10.1016/j.jclinepi.2009.06.005. [PubMed: 19631508].

  • 30.

    von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: Guidelines for reporting observational studies. Prev Med. 2007;45(4):247-51. doi: 10.1016/j.ypmed.2007.08.012. [PubMed: 17950122].

  • 31.

    Zhang T, Pope J. Cervical spine involvement in rheumatoid arthritis over time: Results from a meta-analysis. Arthritis Res Ther. 2015;17:148. doi: 10.1186/s13075-015-0643-0. [PubMed: 26026719]. [PubMed Central: PMC4449959].

  • 32.

    Tourani S, Behzadifar M, Martini M, Aryankhesal A, Taheri Mirghaed M, Salemi M, et al. Health-related quality of life among healthy elderly Iranians: A systematic review and meta-analysis of the literature. Health Qual Life Outcomes. 2018;16(1):18. doi: 10.1186/s12955-018-0845-7. [PubMed: 29347951]. [PubMed Central: PMC5774099].

  • 33.

    Shao MF, Chou YC, Yeh MY, Tzeng WC. Sleep quality and quality of life in female shift-working nurses. J Adv Nurs. 2010;66(7):1565-72. doi: 10.1111/j.1365-2648.2010.05300.x. [PubMed: 20492021].

  • 34.

    Bjorvatn B, Dale S, Hogstad-Erikstein R, Fiske E, Pallesen S, Waage S. Self-reported sleep and health among Norwegian hospital nurses in intensive care units. Nurs Crit Care. 2012;17(4):180-8. doi: 10.1111/j.1478-5153.2012.00504.x. [PubMed: 22698160].

  • 35.

    Han Y, Yuan Y, Zhang L, Fu Y. Sleep disorder status of nurses in general hospitals and its influencing factors. Psychiatr Danub. 2016;28(2):176-83. [PubMed: 27287793].

  • 36.

    Kunzweiler K, Voigt K, Kugler J, Hirsch K, Bergmann A, Riemenschneider H. Factors influencing sleep quality among nursing staff: Results of a cross sectional study. Appl Nurs Res. 2016;32:241-4. doi: 10.1016/j.apnr.2016.08.007. [PubMed: 27969035].

  • 37.

    Karagozoglu S, Bingol N. Sleep quality and job satisfaction of Turkish nurses. Nurs Outlook. 2008;56(6):298-307 e3. doi: 10.1016/j.outlook.2008.03.009. [PubMed: 19041451].

  • 38.

    da Rocha MC, De Martino MM. [Stress and sleep quality of nurses working different hospital shifts]. Rev Esc Enferm USP. 2010;44(2):280-6. Portuguese. doi: 10.1590/S0080-62342010000200006. [PubMed: 20642036].

  • 39.

    Suzuki K, Ohida T, Kaneita Y, Yokoyama E, Uchiyama M. Daytime sleepiness, sleep habits and occupational accidents among hospital nurses. J Adv Nurs. 2005;52(4):445-53. doi: 10.1111/j.1365-2648.2005.03610.x. [PubMed: 16268848].

  • 40.

    Rocha MCP, Martino MMF. [Stress and sleep quality among registered nurses who use sleeping pills]. Acta Paul Enferm. 2009;22(5):658-65. Portuguese. doi: 10.1590/s0103-21002009000500010.

  • COMMENTS

    LEAVE A COMMENT HERE: