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ORIGINAL ARTICLE
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Perceived stress and quality of sleep among health-care staff working in a dedicated COVID hospital


1 Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India
2 Deputy Assistant Director Health, Panther Division, Amritsar, India

Date of Submission25-Feb-2021
Date of Decision28-Apr-2021
Date of Acceptance01-May-2021
Date of Web Publication21-Sep-2021

Correspondence Address:
Saurabh Bobdey,
Department of Community Medicine, Armed Forces Medical College, Pune - 411 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_27_21

  Abstract 


Introduction: Right from the onset of the COVID-19 pandemic, health-care workers (HCWs) have been at the forefront in combating this deadly disease. The sudden emergence of COVID-19 and its continued persistence, has led to an unprecedented psychological stress among HCWs. To assess the level of stress and its effects on sleep quality of HCWs caring for COVID-19 patients, the present study was conducted among staff working in a dedicated COVID hospital. Methodology: The cross-sectional study was conducted among HCWs at a dedicated COVID hospital in northern India from September to October 20. To assess the levels of stress and quality of sleep, the participants were administered the Perceived Stress Scale and Pittsburgh Sleep Quality Index (PSQI). Results: One hundred and forty-two HCWs out of 162 responded completely. The mean age of the participants was 31.6 ± 6 years. Ninety-one (64.1%) were doctors and the rest 51 (35.1%) were paramedical staff. The mean PSQI global score was 6.9 ± 3.19. More than 50% of participants across all age categories reported moderate-to-high stress and poor sleep quality. Conclusion: This study shows that a high proportion of HCWs working in dedicated COVID hospitals suffer from stress and its varied deleterious effect, especially on sleep. Therefore, it is prudent for all stakeholders and decision-makers to take adequate steps for provision of psychological support for stress mitigation and implement measures for prevention and early identification of stress-related symptoms among HCWs working in COVID hospitals.

Keywords: COVID hospital, health-care workers, perceived stress, quality of sleep



How to cite this URL:
Devarakonda R, Nagari N, Bobdey S, Yadav AK, Kumar S, Anand V, Kaushik S K. Perceived stress and quality of sleep among health-care staff working in a dedicated COVID hospital. J Mar Med Soc [Epub ahead of print] [cited 2021 Dec 9]. Available from: https://www.marinemedicalsociety.in/preprintarticle.asp?id=326275




  Introduction Top


The World Health Organization on January 30, 2020, acknowledged the outbreak of coronavirus disease (COVID-19) as a Public Health Emergency of International Concern and declared it a pandemic on March 11, 2020.[1] Till March 31, 2021, more than 100 million cases and 3 million deaths have been recorded worldwide.[2] As the pandemic continues to evolve, there is unprecedented psychological stress on people worldwide, especially on the health-care workers (HCWs) working relentlessly in COVID hospitals. Across the globe, HCWs have been struggling to cope with the pandemic personally and professionally. With the strenuous and challenging working hours, a sudden surge in the number of cases, nonavailability of definitive treatment, social stigmatization, ambiguity about the protection provided by the vaccine, and numerous other uncertainties about the disease has taken a toll on our medical professionals and supporting paramedical staff. In addition, health-care and frontline workers have been the worst affected, and many have even succumbed to this devastating viral disease.[3]

This pandemic has had its toll on HCWs' psychological well-being, resulting in heightened anxiety and depression.[4],[5] With the ever-increasing number of COVID-19 cases and overwhelming workload, issues of mental health and psychological impact of treating and caring for COVID-19 patients have become a major concern among the HCWs. This psychological stress can have a lasting impact on the mental health of HCWs, making them prone to posttraumatic stress disorder.[6] It is imperative to address HCWs' mental health issues on priority as there is no certainty as to when the pandemic will end. Therefore, there is a need to assess the level of psychological stress in HCWs working in COVID hospitals and formulate necessary strategies and coping mechanisms. This present study aims to determine the level of stress and sleeping patterns of HCWs working in a COVID hospital.


  Methodology Top


A cross-sectional study was conducted at a dedicated COVID hospital in northern India from September to October 2020. A predesigned, pretested, validated, semi-structured questionnaire on Google Forms was administered to the hospital staff, i.e., 162 (including both doctors and paramedical staff) through social media platform. Informed consent was taken in the Google document. The study was approved by the institutional ethical committee.

The questionnaire administered consisted of the Perceived Stress Scale (PSS) and Pittsburgh Sleep Quality Index (PSQI) questionnaire along with the demographic data of age, sex, education, and occupation. Perception of stress was evaluated by using PSS, which is one of the most widely used psychological instruments for measuring the perception of stress. It is composed of ten questions which measure the degree to which situations in one's life are appraised as stressful. The scale also includes a number of direct queries about current levels of experienced stress. The questions are easy to understand, and the response alternatives are simple to grasp. It is relatively free of content specific to any subpopulation group and is relatively general in nature. The questions ask about feelings and thoughts during the last 1-month time duration, giving different scenarios.[7] PSQI consists of 19 self-rated questions subgrouped into seven components. Each component has a score of 0–3 points with 0 indicating no difficulty and a score of 3 indicating severe difficulty. Seven components are summed up to yield one global score in range of 0–21. The participants' quality of sleep in the past 1-month time duration is given by this questionnaire.[8] The data collected in an Excel spreadsheet and were cross-checked with the physical data for any discrepancy. Data analyzed using an electronic statistical package IBM SPSS for Windows, version 20.0. Armonk, NY, USA: IBM Corp. P <0.05 was considered statistically significant.


  Results Top


A predesigned questionnaire consisting of demographic details and questions of PSS and PSQI was sent to 162 HCWs working in a COVID hospital. A total of 149 HCWs responded of which 142 responses were found to be complete and were considered for analysis. Out of 142 study participants, 91 (64.1%) were doctors and 51 (35.1%) were nondoctors comprising 12 nurses and 39 paramedical staff. The mean age of participants was 31.6 ± 6 years (range: 20–60 years). The baseline characteristics of the participants are presented in [Table 1].
Table 1: Demographic characteristics of the participants(n=142)

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The mean PSQI global score was 6.9 ± 3.19. Close inspection of the seven components of the PSQI showed that majority of HCW had disturbances in the subjective sleep quality 62% (2.08 ± 0.9), followed by problems in sleep latency 39% (1.19 ± 0.9) and then by sleep duration 29% (1.3 ± 0.86). Age group 21–30 years showed the highest level of poor sleep quality (70.2%) followed by individuals more than 41 years (66.6%) and 31–40 years (53%). 65.8% of males and 48% of female participants reported poor sleep. Poor sleep scores were reported across all categories of education status, the highest being 75% of postgraduates reporting poor sleep. The poor global PSQI score among doctors was 59.3% and nondoctors was 68.6%. More than 50% of participants across all age categories reported moderate-to-high stress. 55.3% of respondents in 21–30 years of age group had moderate-to-high stress. 56% percent of males reported moderate-to-high perceived stress as compared to only 36% of females. 52.7% of doctors and 52.9% of nondoctors reported moderate-to-high stress [Table 2]. 73.3% of individuals with moderate-to-high perception of stress were found to have poor sleep quality [Table 3].
Table 2: Distribution of sleep quality and stress as per categories

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Table 3: Quality of sleep among personnel with perceived stress

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Further analysis was done to see the correlation between the perceived stress and quality of sleep. A significant correlation was observed (r = 0.512, P < 0.001) between perceived stress and PSQI global score by the Spearman rank correlation coefficient, thus indicating that the higher the stress, the poorer is the quality of sleep.


  Discussion Top


Sleep is a natural physiological function.[8] Loss of sleep is cumulative in its effect. The buildup of which may result in complications ranging from loss of productivity, irritability, errors of judgment, etc.[9] Stress is considered as one of the leading causes of poor quality of sleep.[10] This present study attempted to determine and explore the relationship between perceived stress and quality of sleep among HCWs working in a COVID-19 environment. All the participants in the study were young HCWs between 20 and 60 with a mean age of 31.6 ± 6.2 years. As COVID-19 is known to cause severe disease in individuals in the older age group with comorbidities,[11] in our study, majority of the HCWs were <40 years of age. Sleep patterns in a similar age group of HCWs were studied by Aliyu et al. in 2018 in which almost all doctors working at a tertiary hospital in a semirural setting were found to have a poor quality of sleep.[12]

In our study, 62.7% of respondents had poor sleep quality with a mean global PSQI score of 6.9 ± 3.19. Zamanian et al., in their study of 1456 nurses working in 11 hospitals in Shiraz and Tehran (Iran), reported that 85% of their study participants (nurses) were poor sleepers,[13] Ghalichi et al. in their study of 925 health-care employees reported poor sleep quality in 43.1% of participants.[14] In addition to the quality of sleep, we also measured stress using PSS.[15] PSS has a high convergent validity with scales that measure symptoms of anxiety, depression, and burnout syndrome.[16],[17] In the present study, the mean PSS score of the participants was found to be 14.04 ± 6.6, and 52.8% of participants were found to have moderate-to-high perceived stress (PSS score of ≥14). Du et al. in their study assessed the psychosocial impact of COVID-19 on the frontline HCWs (FHCWs) working in COVID hospitals located in Wuhan city of China. They found that more than half (59.0%) of the HCWs had moderate-to-high stress (PSS scores ≥14).[18]

In our study, we found that 49.3% of the HCWs who reported low stress had good global sleep quality, whereas 73.3% of the HCWs with moderate-to-high stress were found to have poor global PSQI score. In addition, a significant positive correlation was observed (r = 0.512, P < 0.001) between perceived stress and global PSQI score. Most disturbances in the sleep quality were found in subgroups of subjective sleep quality, sleep latency, and sleep duration. Many studies conducted across the globe have shown a high degree of stress and poor quality of sleep among HCWs, especially those working in COVID care facilities. A study conducted by Nena E et al. in a tertiary care hospital in Greece in 2018 had shown that irregular working hour shifts had affected the sleep in HCWs.[19] Machi et al., in their study conducted in 2012, reported that the prevalence of poor sleep quality was 31% among HCWs working in an emergency setting in the US.[20] In a recent study by Xiao et al., 180 HCWs treating COVID-19 cases, had a mean PSQI score of 8.6 ± 4.6.[21] In Arab, Badahdah et al. have shown that 40% of the HCWs who cared or worked in the COVID hospital had poor sleep quality.[22] Another recent study in China by Zhang et al. using the Insomnia Severity Index reported that more than 36% of the HCWs in their study had reported insomnia.[23] Xiao et al. in their study have shown that HCWs, who were treating cases of COVID-19 infection, had high levels of anxiety and stress.[21] A study was done on anxiety and sleep quality during the COVID pandemic in India, by Gupta et al., using a single-item Sleep Quality Scale for quality of sleep and the Generalized Anxiety Disorder Scale-7 for anxiety. The study found that 36% of the sample had poor quality of sleep and 12.5% had moderate anxiety.[24]

HCWs involved directly in the care of COVID-19 patients are susceptible to stress and its related consequences. There are several peculiar factors of working in COVID-19 hospitals such as the use of personal protective equipment (PPE) throughout the working hours along with its effects on hydration and added exhaustion and difficulty in communicating with the patients while in PPE. The strain caused by physical isolation (quarantine after finishing the rotation of duties), the utmost necessity for constant vigilance regarding infection control procedures and the separation from family members and friends contribute to a significant stress in HCWs, which in turn has a deleterious effect on the quality of their sleep.[4] Poor quality of sleep, stress, and its consequent effect on the mental health of HCWs may impair their cognitive abilities and clinical decision-making.[25]

The present study is unique in the sense that it is one of the few studies which brings to the forefront the important issue of perceived stress and also tries to explore sleep quality among HCWs working in a COVID-19 environment. However, the study is not devoid of certain limitations, which need to be acknowledged. It is cross sectional and hence does not allow us to analyze sleep and stress over a period and therefore cannot provide insights regarding the effect of different stages of the pandemic and its variation in stress perception over time. This study has not analyzed the difference in stress levels and quality of sleep between HCWs based on their job profile and shift timings. The questionnaires used in the study did not address potential confounders such as caffeine or nicotine intakes, diets, medical history, and coexisting sleep disorders. Lack of control group outside the study population in a normal hospital setting is also a limitation of the study.


  Conclusion Top


The COVID-19 pandemic has taken the world by storm. The HCWs have been one of the worst affected in terms of physical and psychological health. However, unlike physical health, the pandemic's psychological impact on HCWs has not been adequately studied. The present study shows that a high proportion of HCWs working in dedicated COVID hospitals suffer from stress and its deleterious effect, especially on sleep. Therefore, it is prudent for all stakeholders and decision-makers to take adequate steps for implementing measures for prevention and early identification of stress and provision of psychological support to HCWs working in COVID hospitals.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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