Difference of Sleep Pattern between Ward and Outpatient Clinic Nurses in Haji Adam Malik Hospital Medan
KARANGAN ASLI
Difference of Sleep Pattern between Ward and Outpatient Clinic Nurses
in Haji Adam Malik Hospital Medan
Zuraini, Aldy S. Rambe, dan Darulkutni Nasution
Department of Neurology, Medical Faculty University of Sumatera Utara
Haji Adam Malik Hospital, Medan, Indonesia
Abstract: Background and Objective: Sleep and wake have a cycle known as circadian rhythm.
Characteristic of human circadian system is activity in daytime and sleep in night time. Sixty to
seventy percent of night shift workers had experienced sleep disturbance. The objective of this
study is to determine the difference of sleep pattern between ward and outpatient nurses at Haji
Adam Malik Hospital Medan.
Methods: A cross sectional study, conducted in Haji Adam Malik Hospital Medan between
January–April 2005. Sample was taken randomly, consisted of 120 nurses of ward and 62 nurses
of outpatient clinic at Haji Adam Malik Hospital Medan. Chi-Square test was used for statistical
analysis.
Results: Sixty nurses (50.4%) of the ward had sleep time less than 6 hours. Sleep latent period
over 30 minutes was found in 16 nurses (13.4%) and day time sleepiness was found in 90 nurses
(75.0%). While in outpatients clinic, 26 nurses had sleep time less than 6 hours(41.3%), 3 nurses
had sleep latent period more than 30 minutes (4.8%) and 43 nurses had daytime sleepiness
(69.4).
Conclusions: There is no significant difference of sleep pattern between nurses in ward and
outpatient clinics at Haji Adam Malik Hospital Medan.
Keywords: sleep pattern, circadian rhythm
INTRODUCTIONS
Sleep is an active and complex state
comprising four stages of non rapid eye
movement (NREM) sleep and rapid eye
movement (REM) sleep. Wakefulness and
sleep stage are characterized by physiologic
measures
that
are
assessed
by
1,2,3
polysomnography.
Stage 1 sleep is characterized by a lowvoltage, mixed frequency EEG and slow,
rolling eye movements. Reactivity to outside
stimuli is decreased, and mentation may occur
but is no longer reality-oriented. Stage 2
consists of moderate low-voltage back ground
EEG with sleep spindles (bursts of 12-to 14Hz activity lasting 0.5 to 2 seconds) and Kcomplexes (brief high-voltage discharge with
an initial negative deflection followed by a
positive component) heart and respiratory
rates are regular and slightly slower. Stage 3
sleep consist of high-amplitude theta (5 to 7
Hz) and delta (1 to 3 Hz) frequencies, as well
as interspersed K-complexes and sleep
spindles. Stage 4 sleep is similar to stage 3,
except that high–voltage delta waves make up
least 50% of the EEG and sleep spindles are
few or absent. Stage 3 and 4 are often
combined and referred as to delta sleep, slowwave sleep, or deep sleep. During this deeper
sleep, heart and respiratory rates are slowed
and regular. During NREM sleep, the tonic
chin EMG is of moderately high amplitude
1,2,4
but less than of quite wakefulness.
Sleepiness and wakefulness also have a
daily cycle, referred to as a circadian rhythm.
This basic biological rhythm is controlled
within the brain by neural system called the
biological clock, which is sensitive to daylight
and darkness, but is slow to adjust to changes
in routine. In general, sleepiness is greatest
during darkness, especially late at night, and
alertness is optimal during daylight, although
Majalah Kedokteran Nusantara Volume 40 y No. 3 y September 2007
160
Universitas Sumatera Utara
Karangan Asli
a secondary period of increased sleepiness
occurs over the mid afternoon. The biological
clock makes it difficult for people to sleep
during the day and to remain awake during
5,6
the night.
It is uncertain how many hours a person
needs to sleep, whereas total sleep time
depends on age. Commonly, sleeping less than
1,7
6 hours a day can cause sleep deprivation.
Approximately 20 to 25 percent of the
working population is involved in some from
5
of shift work. A wide range of important
occupations is involved in shift work (e.g.,
doctors, nurses, police, fire-man, airline pilots,
air-traffic controllers, diplomats, international
business executive, radar operators, postal
workers, long distance truck drivers, and
1
others).
No definitive studies have been done on
the precise prevalence of problem sleepiness
among shift workers, but in survey studies,
about 60 to 70 percent of shift workers,
complain of sleep difficulty or problem
sleepiness. Physiological measures during
stimulated late night shift hours indicate a
degree of sleepiness that is considered severe
and clinically pathological when present
during the day. Clearly, excessive sleepiness is
a major problem for shift workers, especially
5
night shift 8 to 8.5 hours.
The objective of this study is to determine
the difference of sleep pattern between ward
nurses who work with shift system and
outpatient clinic nurses who work without
shift system at H. Adam Malik Hospital
Medan.
components (duration of night-time sleep,
sleep latency, bedtime difficulties, sleep
quality,
night
awakenings,
nocturnal
symptoms, morning symptoms, and daytime
sleepiness). Evaluation was about sleep
8
disorder experienced in the last 6 months.
Statistical analysis was done using cross
tabulation with chi-square test. Computerized
using SPSS software, version 11.5.
MATERIAL AND METHODS
This is a cross sectional study, conducted
in Haji Adam Malik Hospital Medan between
January–April 2005. Ward nurses who did not
work on shift and outpatient clinic nurses on
shift work outside Haji Adam Malik Hospital
Medan were excluded. One hundred and
eighty two sample were eligible in this study,
consist of 120 nurses of ward and 62 nurses of
out patient clinic in Haji Adam Malik
Hospital Medan. After getting information
from us, questionnaire was given to them.
The questionnaire was adapted from a
study that conducted by Bruni O, et al.
(1997) in Rome. The questionnaire was in
two sections, The first was to obtain
demographic data about age, sex, and marital
status. The second section was made up to 45
items. The items were grouped into eight
4. Night-awakenings
There was no significant difference in
more than two awakenings per night (p =
0.76) and difficulty falling asleep after
awakenings (p = 0.179) between ward and
outpatient clinic nurses (Table 5).
161
RESULTS
Of the eligible ward nurses, 114 (95%)
were female, while in outpatient clinic nurses,
60 (96.8%) were female.
Of the 120 ward nurses, 106 (88.3%)
participants were married, of 63 outpatient
clinic nurses, 57 (91.9%) participants were
married.
1. Duration of Night-Time Sleep
There was no significant difference
between nurses who have duration of nighttime sleep < 6 hours and > 6 hours in both
ward and outpatient clinic nurses (p = 0.278)
(Table 3).
2. Sleep Latency
There was no significant difference
between nurses who have sleep latency < 30
minutes and > 30 minutes in both ward and
outpatient clinic nurses (p = 0,076) (Table 4).
3. Sleep Quality
There was no significant difference in bad
sleep quality between ward and outpatient
clinic nurses (p = 0.363) (Table 5).
5. Daytime Sleepiness
There was no significant difference of
daytime somnolence (p = 0,075), falling
asleep in hospital (p = 0.724), and sleep
attacks (p = 0.416) between ward and
outpatient clinic nurses (Table 6).
There was no significant difference ward
nurses who have shift work for < 2 years and
> 2 years who have daytime somnolence (p =
0.867), falling asleep in hospital (p = 0.489),
and sleep attacks (p = 0.633).
Majalah Kedokteran Nusantara Volume 40 y No. 3 y September 2007
Universitas Sumatera Utara
Zuraini dkk.
Difference of Sleep Pattern...
Table 1.
Demographic characteristic of samples
Sex
n
Ward Nurses
%
Outpatient Clinic Nurses
n
%
Male
Female
6
114
5
95
2
60
3.2
96.8
Status
Married
Unmarried
106
14
88.3
11.7
57
5
91.9
8.1
42
71
6
1
35
59.2
5
0.8
5
40
15
2
8.1
64.5
24.5
3.2
Age
< 30 years old
31–40 years old
41–50 years old
> 50 years old
Table 2.
Prevalence of sleep disorders (presence more than 1/week)
Variable
BEDTIME PROBLEM
3
Reluctant to go bed
4
Bedtime variations
5
Difficulty getting to sleep at night
6
Anxiety/fear when falling asleep
7
Drink stimulant beverages in the evening
8
Need for light or TV in the bedroom
9
Need for a transitional object
10
Fluids or drugs to facilitate sleep
11
Hypnic jerks
12
Rhythmic movement while falling asleep
13
Hypnagogic hallucinations
14
Falling asleep sweating
SLEEP QUALITY
15
Bad sleep quality
NIGHT AWAKENINGS
16
More than two awakenings per night
17
Waking up screaming in the night
18
Waking up to drink or eat in the night
19
Getting up to use the bathroom
20
Waking up complaining of headache
21
Waking up with leg cramps
22
Difficulty falling asleep after awakenings
NOCTURNAL SYMPTOMS
23
Nocturnal hyperkinesia
24
Unusual movement during sleep
25
Pains of unknown origin during sleep
26
Sleep breathing difficulties
27
Sleep apnea
28
Snoring
29
Night sweating
30
Sleepwalking
31
Sleep talking
32
Bed-wetting
33
Bruxism
34
Sleep terrors
35
Nightmares
36
Report of frightening dream
37
Convulsions during sleep
MORNING SYMPTOMS
38
Difficulty in waking up in the morning
39
Variation of waking time
40
Restless sleep
41
Sleep paralysis
42
Hallucinations on waking up in the morning
DAYTIME SLEEPINESS
43
Daytime somnolence
44
Falling asleep at school
45
Sleep attacks
Outpatient
Clinic Nurses
n (%)
P
23(19.2)
48(40.0)
31(25.8)
26(21.7)
16(13.3)
66(55.0)
46(38.3)
7(5.8)
31(25.8)
18(15.0)
14(11.7)
43(35.8)
6 (9.2)
15(24.2)
19(30.6)
5(8.1)
8(12.9)
40(64.5)
21(33.9)
7(11.3)
19(30.6)
9(14.5)
8(12.9)
19(30.6)
0.97
0.34
0.491
0.21
0.95
0.17
0.554
0.19
0.491
0.931
0.808
0.484
24(20.0)
9(14.5)
0.363
59(49.2)
21(17.5)
39(32.5)
88(73.3)
31(25.8)
44(36.7)
61(50.8)
29(46.8)
7(11.3)
15(24.2)
44(71.2)
19(30.6)
19(30.6)
38(61.3)
0.76
0.271
0.245
0.735
0.491
0.418
0.179
26(21.7)
16(13.3)
31(25.8)
14(11.7)
13(10.8)
44(36.7)
39(32.5)
1(0.8)
19(15.5)
5(4.2)
20(16.7)
15(12.5)
44(36.7)
31(25.8)
11(9.2)
7(11.3)
8(12.9)
19(30.6)
5(8.1)
3(4.8)
19(30.6)
17(24.4)
2(3.2)
6(9.7)
4(6.4)
4(6.4)
5(8.1)
19(30.6)
19(30.6)
5(8.1)
0.085
0.95
0.491
0.451
0.176
0.418
0.482
0.230
0.253
0.50
0.054
0.365
0.418
0.491
0.803
31(25.8)
59(49.2)
33(27.5)
13(10.8)
9(7.5)
19(30.6)
35(56.5)
13(21.0)
3(4.8)
4(6.5)
0.491
0.351
0.337
0.176
0.795
94(78.3)
17(14.2)
90(75.0)
41(66.1)
10(16.1)
43(69.4)
0.075
0.724
0.416
Ward Nurses
n (%)
Majalah Kedokteran Nusantara Volume 40 y No. 3 y September 2007
162
Universitas Sumatera Utara
Karangan Asli
Table 3.
Comparisons of duration of night-time sleep between ward and outpatient clinic nurses
Ward Nurses
n (%)
Outpatient Clinic Nurses
n (%)
< 6 hours
60 (50.4)
26 (41.9)
> 6 hours
59 (49.6)
36 (58.1)
P
0.278
Table 4.
Comparisons of sleep latency between ward and outpatient clinic nurses
Ward Nurses
n (%)
Outpatient Clinic Nurses
n (%)
P
0.076
< 30 minute
104 (86.7)
59 (95.2)
> 30 minute
16 (13.3)
3 (4.8)
Table 5.
Comparisons of sleep quality and night-awakenings between ward and outpatient clinic nurses
n
Ward Nurses
%
Outpatient Clinic Nurses
n
%
P
Bad sleep quality
24
20.0
9
14.5
0.363
more than two awakenings
per night
59
49.2
29
46.8
0.76
difficulty falling asleep
after awakenings
61
50.8
38
61.3
0.179
Table 6.
Comparisons of daytime sleepiness between ward and outpatient clinic nurses
n
Ward Nurses
%
Outpatient Clinic Nurses
n
%
P
Daytime somnolence
94
78.3
41
66.1
0.075
Falling asleep at hospital
17
14.2
10
16.1
0.724
Sleep attacks
90
75.0
43
69.4
0.416
Table 7.
Comparisons of daytime sleepiness between ward who have shift work < 2 years and > 2 years
< 2 years
n
%
Daytime somnolence
12
80
82
87.1
0.867
Falling asleep at hospital
3
20
14
13.3
0.489
Sleep attacks
12
80
78
74.3
0.633
163
> 2 years
n
%
P
Majalah Kedokteran Nusantara Volume 40 y No. 3 y September 2007
Universitas Sumatera Utara
Zuraini dkk.
DISCUSSIONS
Shift work sleep disorder consists of
symptoms of insomnia or excessive sleepiness
that occur as transient phenomena in relation
9
to work schedules.
Insomnia is defined as a sleep latency of
greater than 30 minutes and less than 6 hours
10
of sleep per night.
The prevalence depends on the
prevalence of shift work in the population. It
appears that most individuals experience sleep
difficulties after a night shift. Depending on
which country is considered between 5% and
8% of the population is exposed to night work
on regular or irregular basis. Thus, the
prevalence of shift work sleep disturbance of
2% to 5% may be a reasonable estimate. These
figures however, do not involve individual
with early morning work, which may
compressed another group at risk.9
The work is usually scheduled during the
habitual hours of sleep (i.e., shift workrotating or permanent shifts), roster work, on
irregular work hours. The sleep complaint
typically consists of an inability to maintain a
normal sleep duration when the major sleep
episode is begun in the morning (6 a.m. to 8
a.m.) after a night shift. The reduction in
sleep length usually amounts to one to four
hours (mainly affecting REM and stage 2
sleep). Subjectively, the sleep period is
perceived as unsatisfactory and unrefreshing.
The insomnia appeared despite the patient’s
attempts
to
optimize
environmental
conditions for sleep. The condition usually
persists for the duration of the work-shift
period. Early morning work shift (starting
between 4 a.m. and 7 a.m.) may also be
associated with complaints of difficulty in
sleep initiation as well as difficulty in
awakening. Work on permanent evening shift
can be associated with difficulties initiating
the major sleep episode. Excessive sleepiness
usually occurred during shift (mainly night)
and was associated with the need to nap and
impaired mental ability because of the
reduced alertness.9
Problem sleepiness in shift workers is due
to both sleep reductions and night time
working. These come about by the failure of
the unadjusted circadian system to prepare
shift workers for a restful, uninterrupted bout
of refreshing sleep, and the problem is
amplified by the demands and distractions of a
Difference of Sleep Pattern...
day-oriented society. Even in those whose
sleep is adequate, however, sleepiness will still
occur during the night shift and on the drive
home from evening shift because of the
natural cycles of sleepiness driven by the
circadian system or daily biological clock.
Whatever countermeasures are used to
improve sleep, sleepiness from this latter
cause will be present until the usually slow
process of resetting the timing of the clock
occurs.5
No know anatomic or biochemical
pathology has been described. The condition
is directly related to circadian interference
with sleep during the morning and evening,
which conflicts with the shift workers need to
sleep at these times. The excessive sleepiness
during night work appears to be partly related
to the lack of sleep and partly related to the
conflict between requirement of working at
night and the circadian sleepiness propensity
during the night hours.9
Survey studies of shift workers indicate
that they report an average of about 1 hours
less sleep per 24 hours (i.e., about 7 hours less
sleep per week) than their day-working
counterparts. Physiological measures during
stimulated late night shift hours indicate a
degree of sleepiness that is considered severe
and clinically pathological when present
during the day.5
In this study there was no significant
difference of sleep pattern including duration
of night-time sleep (p=0.278), sleep latency
(p=0.076), sleep quality (p = 0.363), more
than two awakening per night (p=0.76),
difficulty falling asleep after awakenings
(p=0.179), daytime somnolence (p=0.075),
falling asleep at hospital (p=0.724) and sleep
attacks (p=0.416) sleep between nurses in
ward and outpatient clinic. These findings
were not in accordance with the result of
previous study. This was probably due to lack
of samples and the regular rotating shift
system (i.e., alternate week of night and day
shift) so that circadian rhythm was not
constantly impaired.
Study conducted by Kawada and Suzuki
about monitoring sleep hours using a sleep
diary and errors in rotating shift workers, they
found a significant difference in the mean
length of sleep was observed for each of the
three shifts. Compared with the morning
shift, the length of sleep for workers working
Majalah Kedokteran Nusantara Volume 40 y No. 3 y September 2007
164
Universitas Sumatera Utara
Karangan Asli
evening and night shift were significantly
11
longer.
Harma et al., did a research about the
effect of an irregular shift system on sleepiness
at work in train drivers and railway traffic
controllers. Severe sleepiness was reported in
49% (train drivers) and 50% (railway traffic
controllers) of the night shift and in 20%
(train drivers) and 15% (railway traffic
controllers) of the morning shift. The risk for
severe sleepiness was 6–14 times higher in the
night shift an about twice as high in the
morning shift compared with the day shift.12
Study conducted by Sallinen et al. toward
train drivers and traffic controllers found that
the risk for dozing off during the shift was
associated only with the shift length,
increasing by 17 and 35% for each working
hour in the morning and the night shift. The
result
demonstrate
advantageous
and
disadvantageous shift combinations in relation
to sleep and make it possible to improve the
ergonomic of irregular shift systems.13
In this study there is no significant
difference between ward nurses who have
shift work for < 2 years and > 2 years who
have daytime somnolence (p = 0.867), falling
asleep at hospital (p = 0.489), and sleep
attacks (p = 0.633).
There was also no significant difference in
other sleep disturbances (bedtime problems,
nocturnal symptoms and morning symptoms)
between ward nurses and outpatient clinics
nurses.
CONCLUSIONS
In this study there was no significant
difference of sleep pattern including duration
of night-time sleep, sleep latency, sleep
quality, more than two awakening per night,
difficulty falling asleep after awakenings,
daytime somnolence, falling asleep at hospital
and sleep attacks sleep between nurses in
ward and outpatient clinic.
To obtain a better result, a further study
with large sample is needed.
REFERENCES
1. Fry JM. Sleep Disorder. In: Rowland LP,
editors. Merritt’s Neurology. 10th ed.
Philadelphia: Lippincott Williams &
Wilkins; 2000. p. 839-46.
165
2. Adam and Victor’s. Principles of
th
Neurology. 7 ed. New York: McGrawHill; 2001.
3. Mahowald MW. Disorder of Sleep and
Arousal. In. Rizzo M, Eslinger PJ, editors.
Principles and Practice of Behavioral
Neurology
and
Neuropsychology.
Philadelphia: W.B. Saunders Company;
2004. p. 701-14.
4. Dinner DS. Physiology of Sleep. In: Levin
KH, Lüders HO, editors. Comprehensive
Clinical Neurophysiology. Philadelphia:
W.B. Saunders Company; 2000. p. 589–
96.
5. National Center on Sleep Disorders
Research and Office of Prevention,
Education and Control. Working Group
Report
on
Problem
Sleepiness.
Philadelphia: National Institute of Health;
1997.
6. Winkelman JW, Fogel RB. Sleep
Disorders. In: Samuaels MA, editors.
th
Manual of Neurologic Therapeutics. 7
ed. Philadelphia: Lippincott Williams &
Wilkins; 2004. p. 93–104.
7. Lumbantobing SM. Gangguan
Jakarta: FK-UI; 2004.
Tidur.
8. Bruni O, Fabrizi P, Ottaviano S, Cortesi
F, Giannotti F, Guidetti V. Prevalence of
sleep disorders in childhood and
adolescence with headache: a case-control
study. Cephalalgia 1997; 17: 492–8.
9. America Academy of Sleep Medicine.
The International Classification of Sleep
Disorders, Revised: Diagnostic and
Coding Manual. Chicago: America
Academy of Sleep Medicine; 2001.
10. Rye DB. Sleep Disorders. In: Johnson RT,
Griffin JW, McArthur JC, editors.
Current Therapy In Neurologic Disease.
6th ed. St. Louis: Mosby; 2002. p. 12–21.
11. Kawada T, Suzuki S. Monitoring Sleep
Hours Using a Sleep Diary and Errors in
Rotating Shift Workers. Psychiatry and
Clinical Neurosciences 2002; 56: 213–
214.
Majalah Kedokteran Nusantara Volume 40 y No. 3 y September 2007
Universitas Sumatera Utara
Zuraini dkk.
12. Harma M, Sallinen M, Ranta R, Mutanen
P, Muller K. The Effect of an Irregular
Shift System on Sleepiness at Work in
Train Drivers and Railway Traffic
Controllers. Journal Sleep Research 2002;
11: 141–51.
13. Sallinen M, Harma M, Mutanen P, Ranta
R, Virkkala J, Muller P. Sleep-wake
rhythm in an irregular shift system.
Difference of Sleep Pattern...
14. Marquie JC, Foret J. Sleep, age, and shift
work experience. Journal Sleep Research
1999; 8: 297–304.
15. Inoue Y, Hiroe Y, Nishida M, Shirakawa
S. Sleep Problems in Japanese industrial
Psychiatry
and
Clinical
worker.
Neurosciences
2000;
54:
294-95.
(Abstract).
Journal Sleep Research 2003; 12: 103-12.
Majalah Kedokteran Nusantara Volume 40 y No. 3 y September 2007
166
Universitas Sumatera Utara
Difference of Sleep Pattern between Ward and Outpatient Clinic Nurses
in Haji Adam Malik Hospital Medan
Zuraini, Aldy S. Rambe, dan Darulkutni Nasution
Department of Neurology, Medical Faculty University of Sumatera Utara
Haji Adam Malik Hospital, Medan, Indonesia
Abstract: Background and Objective: Sleep and wake have a cycle known as circadian rhythm.
Characteristic of human circadian system is activity in daytime and sleep in night time. Sixty to
seventy percent of night shift workers had experienced sleep disturbance. The objective of this
study is to determine the difference of sleep pattern between ward and outpatient nurses at Haji
Adam Malik Hospital Medan.
Methods: A cross sectional study, conducted in Haji Adam Malik Hospital Medan between
January–April 2005. Sample was taken randomly, consisted of 120 nurses of ward and 62 nurses
of outpatient clinic at Haji Adam Malik Hospital Medan. Chi-Square test was used for statistical
analysis.
Results: Sixty nurses (50.4%) of the ward had sleep time less than 6 hours. Sleep latent period
over 30 minutes was found in 16 nurses (13.4%) and day time sleepiness was found in 90 nurses
(75.0%). While in outpatients clinic, 26 nurses had sleep time less than 6 hours(41.3%), 3 nurses
had sleep latent period more than 30 minutes (4.8%) and 43 nurses had daytime sleepiness
(69.4).
Conclusions: There is no significant difference of sleep pattern between nurses in ward and
outpatient clinics at Haji Adam Malik Hospital Medan.
Keywords: sleep pattern, circadian rhythm
INTRODUCTIONS
Sleep is an active and complex state
comprising four stages of non rapid eye
movement (NREM) sleep and rapid eye
movement (REM) sleep. Wakefulness and
sleep stage are characterized by physiologic
measures
that
are
assessed
by
1,2,3
polysomnography.
Stage 1 sleep is characterized by a lowvoltage, mixed frequency EEG and slow,
rolling eye movements. Reactivity to outside
stimuli is decreased, and mentation may occur
but is no longer reality-oriented. Stage 2
consists of moderate low-voltage back ground
EEG with sleep spindles (bursts of 12-to 14Hz activity lasting 0.5 to 2 seconds) and Kcomplexes (brief high-voltage discharge with
an initial negative deflection followed by a
positive component) heart and respiratory
rates are regular and slightly slower. Stage 3
sleep consist of high-amplitude theta (5 to 7
Hz) and delta (1 to 3 Hz) frequencies, as well
as interspersed K-complexes and sleep
spindles. Stage 4 sleep is similar to stage 3,
except that high–voltage delta waves make up
least 50% of the EEG and sleep spindles are
few or absent. Stage 3 and 4 are often
combined and referred as to delta sleep, slowwave sleep, or deep sleep. During this deeper
sleep, heart and respiratory rates are slowed
and regular. During NREM sleep, the tonic
chin EMG is of moderately high amplitude
1,2,4
but less than of quite wakefulness.
Sleepiness and wakefulness also have a
daily cycle, referred to as a circadian rhythm.
This basic biological rhythm is controlled
within the brain by neural system called the
biological clock, which is sensitive to daylight
and darkness, but is slow to adjust to changes
in routine. In general, sleepiness is greatest
during darkness, especially late at night, and
alertness is optimal during daylight, although
Majalah Kedokteran Nusantara Volume 40 y No. 3 y September 2007
160
Universitas Sumatera Utara
Karangan Asli
a secondary period of increased sleepiness
occurs over the mid afternoon. The biological
clock makes it difficult for people to sleep
during the day and to remain awake during
5,6
the night.
It is uncertain how many hours a person
needs to sleep, whereas total sleep time
depends on age. Commonly, sleeping less than
1,7
6 hours a day can cause sleep deprivation.
Approximately 20 to 25 percent of the
working population is involved in some from
5
of shift work. A wide range of important
occupations is involved in shift work (e.g.,
doctors, nurses, police, fire-man, airline pilots,
air-traffic controllers, diplomats, international
business executive, radar operators, postal
workers, long distance truck drivers, and
1
others).
No definitive studies have been done on
the precise prevalence of problem sleepiness
among shift workers, but in survey studies,
about 60 to 70 percent of shift workers,
complain of sleep difficulty or problem
sleepiness. Physiological measures during
stimulated late night shift hours indicate a
degree of sleepiness that is considered severe
and clinically pathological when present
during the day. Clearly, excessive sleepiness is
a major problem for shift workers, especially
5
night shift 8 to 8.5 hours.
The objective of this study is to determine
the difference of sleep pattern between ward
nurses who work with shift system and
outpatient clinic nurses who work without
shift system at H. Adam Malik Hospital
Medan.
components (duration of night-time sleep,
sleep latency, bedtime difficulties, sleep
quality,
night
awakenings,
nocturnal
symptoms, morning symptoms, and daytime
sleepiness). Evaluation was about sleep
8
disorder experienced in the last 6 months.
Statistical analysis was done using cross
tabulation with chi-square test. Computerized
using SPSS software, version 11.5.
MATERIAL AND METHODS
This is a cross sectional study, conducted
in Haji Adam Malik Hospital Medan between
January–April 2005. Ward nurses who did not
work on shift and outpatient clinic nurses on
shift work outside Haji Adam Malik Hospital
Medan were excluded. One hundred and
eighty two sample were eligible in this study,
consist of 120 nurses of ward and 62 nurses of
out patient clinic in Haji Adam Malik
Hospital Medan. After getting information
from us, questionnaire was given to them.
The questionnaire was adapted from a
study that conducted by Bruni O, et al.
(1997) in Rome. The questionnaire was in
two sections, The first was to obtain
demographic data about age, sex, and marital
status. The second section was made up to 45
items. The items were grouped into eight
4. Night-awakenings
There was no significant difference in
more than two awakenings per night (p =
0.76) and difficulty falling asleep after
awakenings (p = 0.179) between ward and
outpatient clinic nurses (Table 5).
161
RESULTS
Of the eligible ward nurses, 114 (95%)
were female, while in outpatient clinic nurses,
60 (96.8%) were female.
Of the 120 ward nurses, 106 (88.3%)
participants were married, of 63 outpatient
clinic nurses, 57 (91.9%) participants were
married.
1. Duration of Night-Time Sleep
There was no significant difference
between nurses who have duration of nighttime sleep < 6 hours and > 6 hours in both
ward and outpatient clinic nurses (p = 0.278)
(Table 3).
2. Sleep Latency
There was no significant difference
between nurses who have sleep latency < 30
minutes and > 30 minutes in both ward and
outpatient clinic nurses (p = 0,076) (Table 4).
3. Sleep Quality
There was no significant difference in bad
sleep quality between ward and outpatient
clinic nurses (p = 0.363) (Table 5).
5. Daytime Sleepiness
There was no significant difference of
daytime somnolence (p = 0,075), falling
asleep in hospital (p = 0.724), and sleep
attacks (p = 0.416) between ward and
outpatient clinic nurses (Table 6).
There was no significant difference ward
nurses who have shift work for < 2 years and
> 2 years who have daytime somnolence (p =
0.867), falling asleep in hospital (p = 0.489),
and sleep attacks (p = 0.633).
Majalah Kedokteran Nusantara Volume 40 y No. 3 y September 2007
Universitas Sumatera Utara
Zuraini dkk.
Difference of Sleep Pattern...
Table 1.
Demographic characteristic of samples
Sex
n
Ward Nurses
%
Outpatient Clinic Nurses
n
%
Male
Female
6
114
5
95
2
60
3.2
96.8
Status
Married
Unmarried
106
14
88.3
11.7
57
5
91.9
8.1
42
71
6
1
35
59.2
5
0.8
5
40
15
2
8.1
64.5
24.5
3.2
Age
< 30 years old
31–40 years old
41–50 years old
> 50 years old
Table 2.
Prevalence of sleep disorders (presence more than 1/week)
Variable
BEDTIME PROBLEM
3
Reluctant to go bed
4
Bedtime variations
5
Difficulty getting to sleep at night
6
Anxiety/fear when falling asleep
7
Drink stimulant beverages in the evening
8
Need for light or TV in the bedroom
9
Need for a transitional object
10
Fluids or drugs to facilitate sleep
11
Hypnic jerks
12
Rhythmic movement while falling asleep
13
Hypnagogic hallucinations
14
Falling asleep sweating
SLEEP QUALITY
15
Bad sleep quality
NIGHT AWAKENINGS
16
More than two awakenings per night
17
Waking up screaming in the night
18
Waking up to drink or eat in the night
19
Getting up to use the bathroom
20
Waking up complaining of headache
21
Waking up with leg cramps
22
Difficulty falling asleep after awakenings
NOCTURNAL SYMPTOMS
23
Nocturnal hyperkinesia
24
Unusual movement during sleep
25
Pains of unknown origin during sleep
26
Sleep breathing difficulties
27
Sleep apnea
28
Snoring
29
Night sweating
30
Sleepwalking
31
Sleep talking
32
Bed-wetting
33
Bruxism
34
Sleep terrors
35
Nightmares
36
Report of frightening dream
37
Convulsions during sleep
MORNING SYMPTOMS
38
Difficulty in waking up in the morning
39
Variation of waking time
40
Restless sleep
41
Sleep paralysis
42
Hallucinations on waking up in the morning
DAYTIME SLEEPINESS
43
Daytime somnolence
44
Falling asleep at school
45
Sleep attacks
Outpatient
Clinic Nurses
n (%)
P
23(19.2)
48(40.0)
31(25.8)
26(21.7)
16(13.3)
66(55.0)
46(38.3)
7(5.8)
31(25.8)
18(15.0)
14(11.7)
43(35.8)
6 (9.2)
15(24.2)
19(30.6)
5(8.1)
8(12.9)
40(64.5)
21(33.9)
7(11.3)
19(30.6)
9(14.5)
8(12.9)
19(30.6)
0.97
0.34
0.491
0.21
0.95
0.17
0.554
0.19
0.491
0.931
0.808
0.484
24(20.0)
9(14.5)
0.363
59(49.2)
21(17.5)
39(32.5)
88(73.3)
31(25.8)
44(36.7)
61(50.8)
29(46.8)
7(11.3)
15(24.2)
44(71.2)
19(30.6)
19(30.6)
38(61.3)
0.76
0.271
0.245
0.735
0.491
0.418
0.179
26(21.7)
16(13.3)
31(25.8)
14(11.7)
13(10.8)
44(36.7)
39(32.5)
1(0.8)
19(15.5)
5(4.2)
20(16.7)
15(12.5)
44(36.7)
31(25.8)
11(9.2)
7(11.3)
8(12.9)
19(30.6)
5(8.1)
3(4.8)
19(30.6)
17(24.4)
2(3.2)
6(9.7)
4(6.4)
4(6.4)
5(8.1)
19(30.6)
19(30.6)
5(8.1)
0.085
0.95
0.491
0.451
0.176
0.418
0.482
0.230
0.253
0.50
0.054
0.365
0.418
0.491
0.803
31(25.8)
59(49.2)
33(27.5)
13(10.8)
9(7.5)
19(30.6)
35(56.5)
13(21.0)
3(4.8)
4(6.5)
0.491
0.351
0.337
0.176
0.795
94(78.3)
17(14.2)
90(75.0)
41(66.1)
10(16.1)
43(69.4)
0.075
0.724
0.416
Ward Nurses
n (%)
Majalah Kedokteran Nusantara Volume 40 y No. 3 y September 2007
162
Universitas Sumatera Utara
Karangan Asli
Table 3.
Comparisons of duration of night-time sleep between ward and outpatient clinic nurses
Ward Nurses
n (%)
Outpatient Clinic Nurses
n (%)
< 6 hours
60 (50.4)
26 (41.9)
> 6 hours
59 (49.6)
36 (58.1)
P
0.278
Table 4.
Comparisons of sleep latency between ward and outpatient clinic nurses
Ward Nurses
n (%)
Outpatient Clinic Nurses
n (%)
P
0.076
< 30 minute
104 (86.7)
59 (95.2)
> 30 minute
16 (13.3)
3 (4.8)
Table 5.
Comparisons of sleep quality and night-awakenings between ward and outpatient clinic nurses
n
Ward Nurses
%
Outpatient Clinic Nurses
n
%
P
Bad sleep quality
24
20.0
9
14.5
0.363
more than two awakenings
per night
59
49.2
29
46.8
0.76
difficulty falling asleep
after awakenings
61
50.8
38
61.3
0.179
Table 6.
Comparisons of daytime sleepiness between ward and outpatient clinic nurses
n
Ward Nurses
%
Outpatient Clinic Nurses
n
%
P
Daytime somnolence
94
78.3
41
66.1
0.075
Falling asleep at hospital
17
14.2
10
16.1
0.724
Sleep attacks
90
75.0
43
69.4
0.416
Table 7.
Comparisons of daytime sleepiness between ward who have shift work < 2 years and > 2 years
< 2 years
n
%
Daytime somnolence
12
80
82
87.1
0.867
Falling asleep at hospital
3
20
14
13.3
0.489
Sleep attacks
12
80
78
74.3
0.633
163
> 2 years
n
%
P
Majalah Kedokteran Nusantara Volume 40 y No. 3 y September 2007
Universitas Sumatera Utara
Zuraini dkk.
DISCUSSIONS
Shift work sleep disorder consists of
symptoms of insomnia or excessive sleepiness
that occur as transient phenomena in relation
9
to work schedules.
Insomnia is defined as a sleep latency of
greater than 30 minutes and less than 6 hours
10
of sleep per night.
The prevalence depends on the
prevalence of shift work in the population. It
appears that most individuals experience sleep
difficulties after a night shift. Depending on
which country is considered between 5% and
8% of the population is exposed to night work
on regular or irregular basis. Thus, the
prevalence of shift work sleep disturbance of
2% to 5% may be a reasonable estimate. These
figures however, do not involve individual
with early morning work, which may
compressed another group at risk.9
The work is usually scheduled during the
habitual hours of sleep (i.e., shift workrotating or permanent shifts), roster work, on
irregular work hours. The sleep complaint
typically consists of an inability to maintain a
normal sleep duration when the major sleep
episode is begun in the morning (6 a.m. to 8
a.m.) after a night shift. The reduction in
sleep length usually amounts to one to four
hours (mainly affecting REM and stage 2
sleep). Subjectively, the sleep period is
perceived as unsatisfactory and unrefreshing.
The insomnia appeared despite the patient’s
attempts
to
optimize
environmental
conditions for sleep. The condition usually
persists for the duration of the work-shift
period. Early morning work shift (starting
between 4 a.m. and 7 a.m.) may also be
associated with complaints of difficulty in
sleep initiation as well as difficulty in
awakening. Work on permanent evening shift
can be associated with difficulties initiating
the major sleep episode. Excessive sleepiness
usually occurred during shift (mainly night)
and was associated with the need to nap and
impaired mental ability because of the
reduced alertness.9
Problem sleepiness in shift workers is due
to both sleep reductions and night time
working. These come about by the failure of
the unadjusted circadian system to prepare
shift workers for a restful, uninterrupted bout
of refreshing sleep, and the problem is
amplified by the demands and distractions of a
Difference of Sleep Pattern...
day-oriented society. Even in those whose
sleep is adequate, however, sleepiness will still
occur during the night shift and on the drive
home from evening shift because of the
natural cycles of sleepiness driven by the
circadian system or daily biological clock.
Whatever countermeasures are used to
improve sleep, sleepiness from this latter
cause will be present until the usually slow
process of resetting the timing of the clock
occurs.5
No know anatomic or biochemical
pathology has been described. The condition
is directly related to circadian interference
with sleep during the morning and evening,
which conflicts with the shift workers need to
sleep at these times. The excessive sleepiness
during night work appears to be partly related
to the lack of sleep and partly related to the
conflict between requirement of working at
night and the circadian sleepiness propensity
during the night hours.9
Survey studies of shift workers indicate
that they report an average of about 1 hours
less sleep per 24 hours (i.e., about 7 hours less
sleep per week) than their day-working
counterparts. Physiological measures during
stimulated late night shift hours indicate a
degree of sleepiness that is considered severe
and clinically pathological when present
during the day.5
In this study there was no significant
difference of sleep pattern including duration
of night-time sleep (p=0.278), sleep latency
(p=0.076), sleep quality (p = 0.363), more
than two awakening per night (p=0.76),
difficulty falling asleep after awakenings
(p=0.179), daytime somnolence (p=0.075),
falling asleep at hospital (p=0.724) and sleep
attacks (p=0.416) sleep between nurses in
ward and outpatient clinic. These findings
were not in accordance with the result of
previous study. This was probably due to lack
of samples and the regular rotating shift
system (i.e., alternate week of night and day
shift) so that circadian rhythm was not
constantly impaired.
Study conducted by Kawada and Suzuki
about monitoring sleep hours using a sleep
diary and errors in rotating shift workers, they
found a significant difference in the mean
length of sleep was observed for each of the
three shifts. Compared with the morning
shift, the length of sleep for workers working
Majalah Kedokteran Nusantara Volume 40 y No. 3 y September 2007
164
Universitas Sumatera Utara
Karangan Asli
evening and night shift were significantly
11
longer.
Harma et al., did a research about the
effect of an irregular shift system on sleepiness
at work in train drivers and railway traffic
controllers. Severe sleepiness was reported in
49% (train drivers) and 50% (railway traffic
controllers) of the night shift and in 20%
(train drivers) and 15% (railway traffic
controllers) of the morning shift. The risk for
severe sleepiness was 6–14 times higher in the
night shift an about twice as high in the
morning shift compared with the day shift.12
Study conducted by Sallinen et al. toward
train drivers and traffic controllers found that
the risk for dozing off during the shift was
associated only with the shift length,
increasing by 17 and 35% for each working
hour in the morning and the night shift. The
result
demonstrate
advantageous
and
disadvantageous shift combinations in relation
to sleep and make it possible to improve the
ergonomic of irregular shift systems.13
In this study there is no significant
difference between ward nurses who have
shift work for < 2 years and > 2 years who
have daytime somnolence (p = 0.867), falling
asleep at hospital (p = 0.489), and sleep
attacks (p = 0.633).
There was also no significant difference in
other sleep disturbances (bedtime problems,
nocturnal symptoms and morning symptoms)
between ward nurses and outpatient clinics
nurses.
CONCLUSIONS
In this study there was no significant
difference of sleep pattern including duration
of night-time sleep, sleep latency, sleep
quality, more than two awakening per night,
difficulty falling asleep after awakenings,
daytime somnolence, falling asleep at hospital
and sleep attacks sleep between nurses in
ward and outpatient clinic.
To obtain a better result, a further study
with large sample is needed.
REFERENCES
1. Fry JM. Sleep Disorder. In: Rowland LP,
editors. Merritt’s Neurology. 10th ed.
Philadelphia: Lippincott Williams &
Wilkins; 2000. p. 839-46.
165
2. Adam and Victor’s. Principles of
th
Neurology. 7 ed. New York: McGrawHill; 2001.
3. Mahowald MW. Disorder of Sleep and
Arousal. In. Rizzo M, Eslinger PJ, editors.
Principles and Practice of Behavioral
Neurology
and
Neuropsychology.
Philadelphia: W.B. Saunders Company;
2004. p. 701-14.
4. Dinner DS. Physiology of Sleep. In: Levin
KH, Lüders HO, editors. Comprehensive
Clinical Neurophysiology. Philadelphia:
W.B. Saunders Company; 2000. p. 589–
96.
5. National Center on Sleep Disorders
Research and Office of Prevention,
Education and Control. Working Group
Report
on
Problem
Sleepiness.
Philadelphia: National Institute of Health;
1997.
6. Winkelman JW, Fogel RB. Sleep
Disorders. In: Samuaels MA, editors.
th
Manual of Neurologic Therapeutics. 7
ed. Philadelphia: Lippincott Williams &
Wilkins; 2004. p. 93–104.
7. Lumbantobing SM. Gangguan
Jakarta: FK-UI; 2004.
Tidur.
8. Bruni O, Fabrizi P, Ottaviano S, Cortesi
F, Giannotti F, Guidetti V. Prevalence of
sleep disorders in childhood and
adolescence with headache: a case-control
study. Cephalalgia 1997; 17: 492–8.
9. America Academy of Sleep Medicine.
The International Classification of Sleep
Disorders, Revised: Diagnostic and
Coding Manual. Chicago: America
Academy of Sleep Medicine; 2001.
10. Rye DB. Sleep Disorders. In: Johnson RT,
Griffin JW, McArthur JC, editors.
Current Therapy In Neurologic Disease.
6th ed. St. Louis: Mosby; 2002. p. 12–21.
11. Kawada T, Suzuki S. Monitoring Sleep
Hours Using a Sleep Diary and Errors in
Rotating Shift Workers. Psychiatry and
Clinical Neurosciences 2002; 56: 213–
214.
Majalah Kedokteran Nusantara Volume 40 y No. 3 y September 2007
Universitas Sumatera Utara
Zuraini dkk.
12. Harma M, Sallinen M, Ranta R, Mutanen
P, Muller K. The Effect of an Irregular
Shift System on Sleepiness at Work in
Train Drivers and Railway Traffic
Controllers. Journal Sleep Research 2002;
11: 141–51.
13. Sallinen M, Harma M, Mutanen P, Ranta
R, Virkkala J, Muller P. Sleep-wake
rhythm in an irregular shift system.
Difference of Sleep Pattern...
14. Marquie JC, Foret J. Sleep, age, and shift
work experience. Journal Sleep Research
1999; 8: 297–304.
15. Inoue Y, Hiroe Y, Nishida M, Shirakawa
S. Sleep Problems in Japanese industrial
Psychiatry
and
Clinical
worker.
Neurosciences
2000;
54:
294-95.
(Abstract).
Journal Sleep Research 2003; 12: 103-12.
Majalah Kedokteran Nusantara Volume 40 y No. 3 y September 2007
166
Universitas Sumatera Utara