Effect of Sleepiness and Fatigue on Nursing Performance among Intensive Care Unit and Coronary Care Unit Nurses inWestBank

4.7 Data Collection Tool 324.11 Data Analysis Operational Definition 35 5.1 Participant According To The Demographic Data 385.2 Participant According To Their Pattern Of Work 395.3 Parti

Table Of Contents

Acknowledgment

2.4.2 Factor Affecting Nursing Performance 15

4.7 Data Collection Tool 32

4.11 Data Analysis (Operational Definition) 35

5.1 Participant According To The Demographic Data 385.2 Participant According To Their Pattern Of Work 395.3 Participant To Their Quality Of Sleep 405.4 Participants Regarding Their Feeling Of Fatigue 415.5 Participants According Nursing Performance 425.6 Participants Regards Their Quality Of Sleep 435.7 Participants Regards Their Level Of Fatigue 435.8 Participants According To The Level Of Performance 435.9 Participants Regards Their Physical Performance 435.10 Participants Regards Their Metal Performance 44

5.11 Participants According To Their Level Of Performance In

Relation To Their Sleep Quality

44

5.12 Participants According To Their Level Of Performance In

Relation To Their Fatigue Level

45

5.13 Participants According To Their Level Of Fatigue In Relation

To Their Type Of Performance

Study

52

7.3 Limitations Of Study 55

List Of Tables

Table (4 1) Distributed Of Number OfNurses According To

Hospital Location

31

Table (4 2) The Result Of Cronbach's Alpha Test 34

Table (4 3) The Total Response Rate Of Participant In The Study 35

Table (5 1) Distribution Of Percentages Of Participant According

To The Demographic Data

38

Table (5 2) Distribution Of Percentages Of Participant According

To Their Pattern Of Work

39

Table (5 3) Distribution Of The Percentage Of Participant To Their

Quality Of Sleep

40

Table (5 4) Distribution Of Percentage Of Participants Regarding

Their Feeling Of Fatigue

41

Table (5 5) Distribution Of Percentages Of Participants According

Nursing Performance

42

Table (5 6) Distribution Of Percentage Of Participants Regards

Their Quality Of Sleep

43

Table (5 7) Distribution Of Percentage Of Participants Regards

Their Level Of Fatigue

43

Table (5 8) Distribution Of Percentages Of Participants According

To The Level Of Performance

43

Table (5 9) Distribution Of Percentage Of Participants Regards

Their Physical Performance

43

Table (5 10) Distribution Of Percentage Of Participants Regards

Their Metal Performance

44

Table (5 11) Distribution Percentage Of Participants According To

Their Level Of Performance In Relation To Their SleepQuality

44

Table (5 12) Distribution Percentage Of Participants According To

Their Level Of Performance In Relation To TheirFatigue Level

45

Table (5 13) Distribution Percentage Of Participants According To

Their Level Of Fatigue In Relation To TheirType Of Performance

45

List Of Annexes

List Of Abbreviations

ICU: Intensive Care Unit.

CCU:coronary care Unit.

PMC: palestenian medical complex

IRB: Institutional Review Board.

NPI: Nursing Performance Instrument.

PSQI: The Pittsburgh Sleep Quality Index

FSS: Fatigue Severity Scale.

WHO: WoridHeaith Organization.

SPSS: Statistical Package for Social Sciences.

CNA :Canadian Nurses Association.

RNAO:Registered Nurses’ Association of Ontario.

List of Conceptual Definitions

Sleep:

Is a period of rest for the body and mind, during which volition and

consciousness are in partial or complete abeyance and the bodily functions partially suspended Sleep has also been described as a behavioral state marked by

characteristic immobile posture and diminished but readily reversible sensitivity to

external stimuli “(Medical dictionary, 2007).

Sleepiness:

As defined by Stoppler (2007)is feeling sleepy at times, when sleepiness

interferes with daily routines and bodily functions or shortens the ability to function

as a person can be sleepy without realizing it

Fatigue:

As total body feelings, ranging from tiredness to exhaustion, create an

unrelenting overall condition that effect on function and capacity nursesEllis

(2008) Also, Schaffner( 2006) defined it as a subjective feeling of tiredness

Intensive care unit:

Is a specialized section ofa hospital that provides comprehensive and

continuous care for persons who are critically ill and who can benefit from

treatment(brilli et al., 2011).

Introduction: Fatigue and sleeplessness is the major problem that has an effect on nursing

performance Long work hours and less numbers of nurses and the large number of patients this lead to increase the incidence of fatigue and sleeplessness among the nurses

Aim: This study aimed at investigating the effects of fatigue and sleepiness on nursing

performance among ICU and CCU nurses in governmental hospitals at west bank

Method:Quantitative cross sectional design study was used to achive the aim of the study utilizing

a convenience sampling method A self-administration questionnaire was distributed to 175 nurse's work

in ICU and CCU in governmental hospital in West Bank; Rafidia and Al-Watany hospital on Nablus, Palestinian medical complex hospital on Ramallah and Alia governmental hospital on Hebron)

Results: The result of study concluded that 79.3% of participants have poor sleep, 50.4% of

participants have fatigue, and 41.3% of them have good performance In addition there is a relation between performance and sleep, and between fatigue and nursing performance

Conclusion:Sleep and fatigue has an effect on nursing performance, In addition the mental

performance has major effect on fatigue than physical performance And there was a negatively relation between fatigue and nursing performance Also there was a relation between sleep and nursing performance

Recommendation: Help policies to conducting study to investigate other causes affecting sleep

and fatigue of nurses, and increasing the number of nurses to ensure care establish scheduling practices and policies for nursing staff.

Keywards :Sleep , Sleepiness , Fatigue , Nursing Performance , Intensive Care Unit Nurses ,

Coronary CareUnit Nurses

Chapter one: Introduction

1 Introduction

In an attempt to define and distinguish between fatigue and sleepiness,

(Shen, Barbera, Shapiro, 2006) argued that the words “fatigue” and “sleepiness”

are often used alternately, they are distinct phenomena While sleepiness refers to atendency to fall asleep, fatigue refers to the great feeling of tiredness, lacks energy,and a feeling of exhaustion associated with somatic and / or cognitive performance

On the other hand, Chen et al (2015) said that fatigue is a subjective feeling, and

its ill effect of fatigue is frequently seen in many ways, such as task performancedecreased, cognitive impairment, and emotional disturbance.Moreover, some

studies discussed fatigue factors, (Patterson et al., 2014) found that the extended

shifts and long working hours increase the chances of negative safety outcomes

In addition Akerstedt,Kenneth, Wright (2009) found that work hours that

exchange between night sleep hours to daywork and work to the nighttime interferewith the biological clock and homeostatic regulation of sleep, these night workhours will lead to a health problem related to sleep and fatigue such ascardiovascular disease, accidents, and cancer It also has an effect on theperformance of nurses and so has an adverse effect on patients, nurses spend most

of the time with patients more than any other health care providers, and patientoutcomes are affected by nursing care quality, thus improving nurse performance

lead to improving on patient safety,)DeLucia, Ott, Palmieri, 2009).

Nursing performance is a concept describe the nursing care performance thstrepresent three nursing functionaland interconnected groups that operate together

to achieve three key functions: (1) acquiring, deploying and maintaining nursingresources, (2) transforming nursing resources into nursing services, and (3)producing positive changes in a patient’s condition as a result of providing nursing

services (Dubois et al., 2013).

Chapter Two Background

1 Study background

“Is a period of rest for the body and mind, during which volition andconsciousness are in partial or complete abeyance and the bodily functions partiallysuspended Sleep has also been described as a behavioral state marked bycharacteristic immobile posture and diminished but readily reversible sensitivity to

external stimuli “(Medical dictionary , 2007 )

A lot of study explaned the normal sleep types and stages Kryger, Roth,

Dement (2005),Judith,Owens (2007 ) explained two types of normal sleep ؛

non-REM (Nnon-REM) and non-REM non-REM sleep is, of course, rapid eye movement Nnon-REM

sleep is divided into four distinct stages Kryger, Roth, Dement (2005) clarify

these stages one through four is determined by alterations in the activity waves ofbrain as recorded and appeared in an electroencephalogram (EEG) Physiologicalchanges occur through each sleep stage During sleep, the body is defined to be in

an inactive state while the brain remains active A normal sleep pattern consist offour to five cycles throughout the night NREM and REM sleep states alternate incycles that usually continued from 90 to110 minutes Normal NREM sleepoccupies 75% of the night, and is characterized by a diminished in temperature ofbody , blood pressure, rate of breathing , and most physiologic functions REMsleep is characterized by high brain activity contribute with essentially paralyzedbody

Moreover,Judith , Owens (2007 ) explained NREM sleep stages in more

deatails as following : Stage 1 sleep (2%-5% of total sleep time), which occurs atthe sleep-wake transition and is often called “light sleep." Stage 2 sleep (45%-55%), which is characterized by bursts of rhythmic rapid activity of

electroencephalogram and high-amplitude slow wave activity Stages 3 and 4 sleep(3%-23%) also known as “deep” sleep, slow wave sleep, or delta sleep The highestarousal threshold (most difficult to awaken) occurs during stages 3 and 4 sleep.Delta sleep is considered generally as the most restorative stage of sleep, and theone that tends to be preserved if the total amount of sleep is restricted The secondstage known as (REM sleep), it take about (20%-25% of the normal sleep cycle) ischaracterized by paralysis or nearly absent muscle tone (except for control ofbreathing), high levels of cortical activity that are contributed with dreaming,irregular respiration and heart rate, and episodic bursts of periodic eye movementsthat are the hallmark of REM sleep This stage of sleep in particular is believed toplay a key role in memory consolidation.

2.1.2 Consequences of Poor sleep

A sufficient lack of restorative sleep over a cumulative period causes

physical or psychiatric symptoms and affect routine performances of tasks (Medical

Dictionary ,2012).

Many studies indicated that One of the more dangerous consequences of sleeploss is a significant decrement in attention and reaction time that has been shown tohave a measurable impact on driving a motor vehicle Car crashes are one of themost negative consequence of sleep loss in healthcare workers

(Barger,Cade,BAyas, 2005; Ruggiero, 2003; Lee, 1992 and Patel, Hu 2008 ),

Also, many studies suggested that poor sleep quality has negative effects onpersonal and family relationships , also can lead to mood disturbances, increasedstress, adverse health consequences ,it increased potential for alcohol and substanceabuse, Self-perceived negative effects on mood, motivation, and life satisfaction as

an effect of chronic sleep loss are almost occurred in occupations that involveprolonged periods without sleep For example, nurses working night shifts report

more depressive symptoms than those on day shifts (Ruggiero, 2003;Lee, 1992 )

About Circadian rhythm , many studies explained it and discuss the effect of

poor sleep on it Van Dongen,Dinges (2005), talked about Circadian rhythm

disruptions result from a mismatch between environmental demands on theindividual and endogenous circadian sleep wake rhythms (eg, working nightshifts) Because the internal periodicity of the circadian clock for human is slightlylonger than 24 hours, it is easier shifts

Moreover, Borbely ,Achermann(2005), talked about Wake fulness and sleep

are highly regulated states that are explained mby what is known as the "2-processmodel." This model basically represents the interaction between the homeostaticdrive for sleep, which regulates the length and depth of sleep, and endogenouscircadian rhythms ("biological time clocks"), which affecton the internal structure

of sleep and timing and duration of daily sleep-wake cycles Poor sleep has some

adverse effect on health Also, Mesas et al.(2010 ), talked about that Poor sleep is

a possible mechanism for adverse health outcomes, including mortality andexplained that both short and long duration of sleep are important predictors of

death in prospective population studies In addition , Patel and Hu ( 2008),

explained factor sassociated with sleep duration ,they indicated that decrease sleepduration is associated with increased risk for obesity, diabetes, hypertension,coronary heart disease, and stroke , increased risk for alcohol and substance abuse,and increased risk of motor vehicle crashes

Regarding sleep loss Judith ,Owens(2007) ,talked about sleep loss and

impairments related to resulting fatigue ,they explained that they are commonamong professionals working in healthcare settings Long continuous hours, reducedopportunities for sleep with minimal recuperation time, and shift work All of these

are contribute significantly to impairments and decrease in physical, cognitive, andemotional functioning Acute and chronic sleep loss, and whether partial orcomplete, basically impairs physical, cognitive, and emotional functioning inhuman beings The influence of circadian physiology dictates that wakefulness andalertness are at optimal levels during daylight hours, and that sleepiness ismaximized during the night Failure to adhere to this need for both adequateamounts of and appropriately timed sleep results in an increase in sleepiness andfatigue levels and a decline in waking function.

2.2.1.Sleepiness

Sleepiness as defined by Stoppler ( 2007) is feeling sleepy at times, when

sleepiness interferes with daily routines and bodily functions or shortens the ability

to function as a person can be sleepy without realizing it.Sleepiness is one of themost public sleep-related patient symptoms, and it affects an estimated 20 percent ofthe residents, individuals with excessive daytime sleepiness are at risk of motorvehicle and work-related incidents, and have poor health than comparable adults

(Pagel, 2006).Feel of sleepiness is clearly during the night shift, and may terminate

in actual incidents of falling asleep at work (Krueger, 1994).

The requirement of sleep differ according to individual, (Pilcher ,Huffcutt ,

1996) found the adults typically need between 6 and 10 hours of sleep per 24-hour,

most people requiring approximately 8 hours of sleep per day

In some occupations this clearly constitutes a hazard that may endangerhuman lives and have large financial consequences These risks clearly involve a

larger number of people and should be of great significance to society, (Akerstedt,

1988).

2.2.2.Causes of Sleepiness

There are many different causes of sleepiness, according to (Mahowald,

2011)these arechronic pain, work long hours or different shifts (morning ,evening,

night ), drugs (sedatives, sleeping pills, antihistamines), not sleeping for longenough, sleep disorders (such as sleep apnea syndrome and narcolepsy)

2.2.3.Symptoms of sleepiness

Sleepiness is subjective feeling, but there are some symptoms detect itlike ,fall asleep while driving ,difficulty to stay awake when watching television orreading, difficulty paying attention or concentrating, performance problems,difficulty remembering slowed responses , difficulty controlling your emotions

(Stoppler, 2007).

2.3.1 Fatigue

Robert ,Wachter ( 2001) talked about the effect of fatigue and sleepiness on

patient’s safety in several ways, Physicians and nurses need good attention, goodjudgment, and often quick reaction time, especially in emergency situations.Decreased attention, memory, or coordination may affect performance and lead toadverse events Research suggests that sleep requirements and patterns areindividual

Laurens et al (2015 ) said night shift work disrupts the sleep cycle and wake

up cycle and it’s concurrent with effect of body’s natural biological rhythms, whichmay lead to fatigue and sleepiness As sleepiness and fatigue increased, alertness

decreased, problemsolving and reasoning ability become slower, movement skillsdecline and the rate of false visual stimuli responses to increased Lot of studies

talked about the fatigue,Schaffner (2006) defined it as a subjective feeling of tiredness Also , Ellis ( 2008)defined it as total body feelings, ranging from tiredness

to exhaustion, create an unrelenting overall condition that effect on function and

capacity nurses Moreover,Berrios) 1990)considered fatigue from medical view as

“Subjective feeling reported by person”

Different study discussing fatigue in term causes of fatigue, and finding thatassociation with shift , as work long hours (12 hour) per different study some those

by (Geiger-Brown , Trinkoff , 2010) those the working 12-hour shifts were

significantly more fatigued Reviewed these studies found that , while employersprefer 12-hour shifts because of increased continuity of staffing, lower staffingcosts, and potential improvements in staff morale, it has more significantly offatigued And he explained about iarge scale studies in US hospitals showed therisks of making an error are significantly increased when work shifts are longer than

12 hours Reviewing the study, Calkin (2012) explained the mixed opinions

regarding 12 hours shift 12 hours shift reduced travel costs (by working doubleshift hours into fewer days), on the other side, others describe it as fatigued andtheir performance to be affected by it

A study in Illinois and North Carolina at 71 acute care hospitals of 663 nurses

by (Trinkoff et al., 2011) showed patient deaths from pneumonia and acute

myocardial infarction occurs more, where nurses worked long hours (12-hour) workshifts , a lack of time off from the job was linked to patient deaths from pneumonia

and abdominal aortic aneurysms.Also, Estabrooks et al.( 2009) explained the effect

of 12-hour shifts on quality and outcomes of care, effect on patient or healthcareoutcomes

Schaffner (2006) explained the perceived fatigue, 809 nurses identified the

factors that contributed to fatigue: sleep disturbance, lack of exercise, homeEnvironment, support (peer support, family support), work schedule (working >40hours per week, on-call), work environment (work 12-hour shifts, work

>12-hour/day, work >three 12-hour shifts in a row, rotating shifts, work 8-hourshifts, on feet 85% of shift) The 12-hour shift and shift work were also identified bynurses in the key informant interviews and focus groups as key contributing factors

to fatigue in nursing.Novak,Auvil-Novak (1996)indeated that work in the night

hours conflict with hours of sleep causes them to return to work without adequaterest, or prevent deep sleep, and need to twenty-four hours after a bout of the nightbefore rotating to another shift Nurses reported that they did not have careerperformance problems when the shifts and sleep patterns are consistent, but that'swhat they did have career performance problems when their shifts changed fromnight to day

2.3.2 Classification of fatigue

Roger, Michael(1997)explained that night work have significant and

challenging impact on the lives of nurses , because it leads to the accumulationfatigue after several days of night shift work, as the worker is deprived of deep sleep

and enough hours of sleep Krueger (1989) discussed fatigue and its relation with

workload ,and pointed that fatigue depend on workload and work requires good andcontinuous attention, and complex work increase the risk of fatigue, in additiondecrease in mental and physical performance are results from prolonged work, lack

of quality sleep or disruption of the internal body clock

Gandevia ( 2001)talked about causes of Physical fatigueas it can be caused

by a lack of energy in the muscle, by a decrease of the efficiency of theneuromuscular junction or by a reduction of the originating drive from the central

nervous system.Marcora, Staiano, Manning(2009), pointed that mental fatigue has

also been shown to decrease physical performance

Baumeister (2002) talked about sleepiness, a lack of energy and enthusiasm,

decreased awareness is known as ego depletion and occurs when the limited regulatory capacity' is depleted symptoms of fatigue include increased anxiety,decreased short-term memory, slowed reaction time, decrease work efficiency,increased variability in work performance

'self-2.3.3 Symptoms of fatigue

Kenyon, Gluesing, White, Dunkel, Burlingame (2007) discussed symptoms

of fatigue and indicated that these are; increased anxiety, decreased short termmemory, slowed reaction time, decrease work efficiency, increase space in work

performance and increased errors Hagberg ( 1981) defined Physical fatigue is the

inability of a muscle to maintain physical performance, and is made more severe byintense physical exercise or long work, and talked about Mental fatigue is temporarydecrease in maximal cognitive performance resulting from prolonged periods ofcognitive activity

Wyller (2007) indicated that chronic fatigue syndrome (CFS) is an illness

characterized by complaint fatigue of at least six months, chronic fatigue is asymptom of many diseases

2.3.4 Factors Of fatigue

From a studies, a study by Stone et al.(2006) found that on average nurses

working 12-hour shifts not satisfied with their jobs,experienced less emotionalexhaustion, were more likely to be satisfied with their work schedule and less likely

to miss shifts, and no differences in patient quality outcomes were found with hour shifts when compared with eight-hour shifts, although there was repeatedevidence that nurses who worked longer than 12.5hours were found to havedecreased vigilance and an increased risk of suffering an occupational injury ormaking an error

12-Kudo et al ( 2008)discussed fatigue factor as the lack of free time at work to

refresh oneself, resulting in physical fatigue, sleep and mental fatigue.Costa (2003 )

indicated to results of shift work that had an effects on physical and mental health,and social relationships and activities, disruption body biological clock such as thelight dark cycle, this can lead to disruptions in the normal sleep rhythm of shift

workers, causing sleep and fatigue problems Stone et al (2006) said that fatigue

can lead to increased tendency to fall to sleep, lapses , decreased attention, inability

to still focused, reduced motivation, compromised problem-solving, irritability ,increase tenseness, memory lapses, incorrect information processing, reducedreaction time, indifference and loss of empathy, and a tendency to make errors in

repetitive tasks

2.4.1 Nursing performance

DeLucia et al (2009) discussed several factors affecting performance:

including cognitive, physical, and organizational factors that affect such

performance In addition the study of performance in nurse that discuss the nurse'swork system often does not understand human border and capacity and that nurseswork under cognitive, perceptual, and physical overtask specifically nursesparticipate in multiple tasks under cognitive load and frequent interruptions, andthey face insufficient lighting, illegible handwriting, and poorly designed labels

In addition he discussed many different factors that affect on performancelike takes more time in walking, work long shifts, and experience a raise amount ofmusculoskeletal disorders Research is overdue in the areas of cognitive processes innursing, that effects of interruptions on nursing performance, communicationsduring patient hand offs, and situation awareness in nursing Human factors andergonomics (HF/E) professionals must play a key role in the redesign of the nurses'work system to identify how overloads can be reduced and how the limits andcapabilities of performance can be accommodated Collaboration between nursesand HF\E specialists is important to promote nursing performance and patientsafety

Poor sleep has an effect on performance papp et al.(2004), discussed

medical residents when they described themselves as inattentive and emotionallyunavailable in their relationships with patients, having difficulty listening topatients, and being and being more of directive in their discussions with patientswhen sleep deprived, as well as having less patience with and compassion forpatients and families Also fatigue has produce physical performance effects oncognitive functions including loss of attention, irritability, memory loss,low ability

to detect and react to subtle changes, slowed data processing, difficulties dealingwith unexpected situations, and even communication difficulties In nursing,monitoring patients' situation depend on fast assessment, diagnosis, and intervention

on their behalf There is no doubt that cognitive slowing due to fatigue

presentsthreats to the nursing process and to patient outcomes.(Harrison, Horne,

2000 andDinges et al., 1997).

According toWilson et al.(2004) discussed physically and mentally healthy

nurses can increase organizational productivity and, therefore, provide moreeffective services, and play a key role in the continued success of the organization

and in achieving its short-term objectives And (Arab et al.,2012;Kim et al., 2013)

discussed job stress and its effect; and indicated that it has an important influence

on the reduction of organizational effectiveness, although the nurses with greatestjob stress in the long term can causes harmful effects, including cardiovasculardiseases, respiratory diseases and can reduce the nurses' quality of life , and theWork environments to hospitals and their place of work to nurse have considerableeffects on the nurses ' mental health because of their stressful nature

Holden et al (2011) said that increasing number of patients and lack of

nursing personal are two main reasons for the nurses and patients' discomfort with

the provided services Queijo et al (2013) discussed the effect of large numbers of

hospitalized patients in the ICUs in each year He indicated that these patients need

to receive special care such as ventilation, injections, prescribing antibiotics, etc.And this work load on nursing and effect on performance of nurse for a long timewhich focus the role of nurses, especially after the physicians' orders wereprescribedIn the studies conducted in the ICU of hospitals, two factors have beendetermined as the main barriers to measure the workload: the nurses' interactionswith the patients and the existence of many qualitative indicators in the process ofproviding care for patients Moreover, two factors have been considered as theimportant factors affecting the failure to allocate adequate time to each patient bynurses: the increase in the load of services provided to patients, and the shortages ofnursing personnel (Kwiecien,WujtewiczandMedrzycka-

Dabrowska,2012andSpence, 2006).

2.4.2 Factor affecting nursing performance

1991;Nocera,Khursandi1998;Fahrenkopf et al., 2008 andMillenson 2003)

discussed the factors affecting on performance such as human and general factor

 Insufficient practice and experience health staff

 lack of management skills

 poor working conditions and environment

 Inadequate remuneration

 demotivated health personnel

Chapter three Literature Review

3.1 Literature Review.

This chapter presents the experiences and results of others they found thereare many studies take about fatigue and sleepiness.

The first one byScott, Arslanian-Engoren, Engoren(2014 ) who examined

the association between selected sleep variables, impairment due to fatigue, andclinical-decision self-efficacy and regret among critical care nurses Decision regretwas the major outcome variable A non-experimental, descriptive design was used

A questionnaire was use and sent to 3500 nurses, was randomly selected fromapproximately 14 000 full-time nurses (working at least 36 h/wk) The researcherfound that nurses who had decision regret were more likely to work nights and towork 12-hour shifts than were nurses without decision regret nurses with decisionregret reported significantly more acute fatigue , daytime sleepiness ,significantlyless inter shift recovery and poor sleep quality than did the nurses without decisionregret

Another study done by Griffiths et al (2014) to describe shift patterns of

European nurses and investigate whether shift length and working beyondcontracted hours (overtime) is associated with nurse-reported care quality, safety,and care left undone The target sample was 30 hospitals in each country, which wasrandomly with stratification for geographical location, type, and size Nurses wereasked to report the number of hours worked, the period of the day, and whether theyhad worked beyond their contracted hours on the last shift they worked The result

of this study indicated that 50% of nurses worked shifts of ≤ 8 hours, but 15%worked ≥ 12 hours Typical shift length different between countries and inside somecountries Nurses working for ≥ 12 hours were more likely to report poor or failingpatient safety poor/fair quality of care, and more care activities left undone.Working overtime was also associated with reports of poor or failing patient safety,poor/fair quality of care, and more care left undone

Another study Yinghui et al (2013) ,thataimedat clarifying the impact of

long working hours on patient safety culture (PSC) in countries with differentcultural backgrounds using the nurse PSC The researcher was used questionnaire

to measures PSC, with higher scores indicating a more positive PSC The researcherfound nurses who working ≥60 h/week in Japan and the US had a significantlylower OR for patient safety grade than those working<40h\week In the threecountries, nurses working ≥40 h/week had a significantly higher OR for the number

of events reported The mean score on ‘staffing’ was significantly lower in the

≥60-h group t≥60-han in t≥60-he<40≥60-h group in all t≥60-he t≥60-hree countries T≥60-he mean score for

‘teamwork within units’ was significantly lower in the ≥60-h group than in the<40 hgroup in japan and Chinese Taiwan

Another study done by Ayse, Pascale, Melanie (2009) to discuss the impact

of performance obstacles on intensive care nurses‘ workload, quality and safety ofcare, and quality of working life (QWL) A cross-sectional study design was usedand data was collected from 265 nurses in 17 intensive care units (ICUs) Theprincipal findings revealed that Performance obstacles were found to affectperceived quality and safety of care and QWL of ICU nurses Workload mediatedthe impact of performance obstacles with the exception of equipment-related issues

on perceived quality and safety of care as well as QWL

Another study done by Bahadoriet al (2014) explained the factors effect on

Intensive Care Units Nursing Workload A cross-sectional and analytical-descriptivewas used The result indicated that factors were divided into three major categoriesthrough exploratory factor analysis (EFA) including structure, process, and activity.The following factors among the structure, process and activity components hadhighest importance: lack of clear responsibilities and authorities and performing not

need work mismatch between the capacity of wards and the number of patients), andhelping the students and newly employed staff.

Another study conducted in byYaghoubi et al (2013) to determine factors

effect on the performance of nurses The authors used 7 variables: ability; clarity;assistance, motivation evaluation; validity; and environment The result of theindicated the ability and help variables were the most important factors in promoteperformance of nurses and validity and evaluation were less important

Also, Muecke ( 2005) conducted a study to examine the concept of sleep

and fatigue and the ability of nurse to cope with the demands of continuaschanging in the hours of work, their safety, and the effects of any appearances ofsleep disruption may have on the care of their patients The literature was examinedfor the 10-year period up to December 2003 With used databases searched such asOvid, EBSCO Online, with using the keywords of, shiftwork, rosters, intensivecare, fatigue, sleep deprivation and sleep studies The researcher finding reinforcesconcerns about the adverse relationship between fatigue and performance in theplace of work Optimal standards for patient care may be difficult to achieve formore mature nurses, who may suffer from sleep loss and health problemsassociated with rotational night work and disrupted physiological rhythms

Another study done by Chen ( 2014) , talked about fatigue and recovery in

12-hour dayshift hospital nurse To achieve it, the study used cross sectional designwith target sample 130 nurse work 12 hours in 3 hospital to assess the perceivedlevels of acute fatigue, chronic fatigue and inter-shift recovery, as well as theirassociations with selected organizational and individual factors The conclusion was

an unhealthy recovery process of fatigue was found for nurses who are working for12-hour shift during the day

Another study, was done by Thomas et al (2006) ,to assess the sleep and

cognitive performance of flight nurses after 12-hour evening versus 18-hour shifts aprospective desr5ign to compare the amount of daily sleep and the cognitiveperformance in flight nurses working 12-hour in evening versus 18-hour shiftsduring a 72-hour duty schedule The flight nurses were tested using aneuropsychological tests before and immediately after completing 12- and 18-hourduty schedules After the conclusion of both duty schedules, nurses were asked torate the 12- versus 18-hour duty schedules via questionnaire The result of this studyappeared that there was no difference or decline in the cognitive function of flightnurses in working either the work for a 12-hour evening or 18-hour shift during a72-hour duty schedule Eighteen-hour duty shifts may be a practical or economicalmeans of expanding the period of helicopter site coverage without adversely effect

on cognitive performance in medical crew members)

Also,Castroet al (2010)investigateed how work schedule characteristics are

associated with nurses' work-related injury and illness over and above long workhours The researchers used cross-sectional design Questionnaire data werecollected from a sample of 655 registered nurses in the Philippines The researchersconclude that the findings of study suggest that non-day shifts and mandatoryovertime may negatively impact nurses' health independent of working long hours.Mechanisms through which these work characteristics affect health, such ascircadian rhythm disturbance, nurse-to-patient ratios and work–family conflict,should be examined in future studies

Another rstudy done by barker& Nussbaum (2011)to investigate the

relationships between dimensions of fatigue and performance, as were differences infatigue across levels of several demographic and work environment variables Anonline survey was used to measure mental, physical, and total fatigue dimensions,

acute and chronic fatigue states and performance 745 registered nurses wererecruited via convenience sampling in cooperation with professional nursingorganizations and they complete the survey between February 2008 and April2009.The study results showed that mental fatigue levels were higher than physicalfatigue levels, and acute fatigue levels were higher than chronic fatigue levelsamong the participants All fatigue types and states were negatively correlated withperceived performance More shift lengths and hours worked per week wereassociated with increases in physical and total fatigue levels Mental, physical andtotal fatigue levels also differed with shift schedule.

Also,Sveinsdotti(2006) described and compared the self-assessed quality of

sleep, occupational health, working environment, illness experience and jobsatisfaction among female nurses working different combinations of shifts To

do this , A cross-sectional design was used with a sample of 348 nurses drawn fromthe registry of the Icelandic Nurses’ Association, representing 17% of the workforce

of Icelandic nurses A self-administered questionnaire, measuring occupationalhealth, quality of sleep, the illness experience, job satisfaction and workingenvironment was used Data were analysed according to type of shift (days only,rotating days/evenings, rotating days/evenings/nights) by use of analysis of varianceand chi-square the results of the study appeared that there is No difference betweenparticipants based on type of shift with regard to the illness experience, jobsatisfaction and quality of sleep Nurses working rotating day/evening/night shiftsreported a longer working day, more stressful environmental risk factors, morestrenuous work and that they were less able to control their work-pace In general,the nurses reported low severity of symptoms; however, nurses working rotatingdays/evenings shifts experienced more severe gastrointestinal and musculoskeletal

symptoms when compared with others This was explained by the short rest periodprovided for between evening and morning shifts.

Also,Gabrielle et al (2014), aimed to explore the impact of a wide array of

`demographic, employment and organizational factors related to fatigue and stress

of French ICU HCWs To do this , a cross-sectional study was conducted in ICUs ofParis-area hospitals A 682 Participants Included in the study were HCWs withpatient contact (doctors, residents, registered nurses, nurse’s aides and physicaltherapists) Temporary staff not typically assigned to the given ICU was excluded.Data were collected using an individual questionnaire administered in interviewsduring day and night shifts Stress Scale (PSS10)was use , the study resultsappeared that doctors and residents reported fewer sleep difficulties but were morelikely to report a tired current state Female gender was associated with higher stresslevels and greater fatigue for all outcomes, while greater social support of supervisor

or colleagues decreased stress and fatigue At the organizational level, longer shifts(12 h vs 8 h) were associated with tired current state and greater sleep difficulties.Personnel on rotating shifts had lower stress and a better current state, while those

on night shifts had greater sleep and energy level difficulties

Another study done by Geiger-Brown et al (2012),described sleep,

sleepiness, fatigue, and neurobehavioral performance over three consecutive 12-h(day and night) shifts for hospital registered nurses.A 80 registered nurses (RNswere obtained to measure sleep (actigraphy), sleepiness (Karolinska SleepinessScale [KSS]), and vigilance (Performance Vigilance Task [PVT]),the analysis ofdata collection appeard that Sleep was short between shifts, with little differencebetween day shift and night shift Sleepiness scores were low overall (3 on a 1-9scale, with higher score indicating greater sleepiness), with 45% of nurses havinghigh level of sleepiness (score  > 7) on at least one shift Nurses were progressively

sleepier each shift, and night nurses were sleepier toward the end of the shiftcompared to the beginning There was extensive caffeine use, presumably topreserve or improve alertness Fatigue was high in one-third of nurses, withintershift fatigue (not feeling recovered from previous shift at the start of the nextshift) being most prominent Nurses accrue a considerable sleep debt while workingsuccessive 12-h shifts with accompanying fatigue and sleepiness Certain nursesappear more vulnerable to sleep loss than others, as measured by attention lapses.

Also,Josten , Ng-A-Tham, Thierry (2003)investigated whether shifts that

are extended only slightly can combine the positive effects of the 12-hour shift withthe positive effects of the 8-hour shift And investigate the effects of 9-hour shifts

To do this, a total of 134 nurses from three nursing homes in the Netherlandscompleted a questionnaire on fatigue, health, performance and satisfaction Onegroup worked 8-hour shifts, and the other worked 9-hour shifts The study resultappeard that nurses who worked 9-hour shifts were on average more fatigued, hadmore health complaints, and were less satisfied with their working hours and freetime than those who worked 8-hour shifts, their performance was slightly poorer

Conducted byLowden et al (1998) a study aimed to evaluate the effect of a

change from a rotating 3-shift (8-hour) to a 2-shift shift (12 hour) schedule on sleep,sleepiness, performance, perceived health, and well-being usedthirtytwo shiftworkers at a chemical plant , responded to a questionnaire a few months before achange was made in their shift schedule and 10 months after the change The studyresults showed that the shift change increased satisfaction with work hours, sleep,and time for social activities Health, perceived accident risk, and reaction-timeperformance were not negatively affected Alertness improved and subjectiverecovery time after night work decreased The quick changes in the 8-hour schedulegreatly increased sleep problems and fatigue Sleepiness integrated across the entire

shift cycle showed that the shift workers were less alert than the day workers, acrossworkdays and days off (although alertness increased with the 12-hour shift.

Also,Reinkeet al (2015)investigated the effect of circadian clock and social

demographics on sleepiness, fatigue, and night shift on the performance of nurses.This was a prospective observational cohort study which assessed the performance

of 96 ICU night shift nurses during the day and night shifts in a mixed medical–surgical ICU in the Netherlands A total of 96 (25 male, 71 female) ICU nursescompleted the questionnaires and tests Morning circadian clock were more thantwofold more likely than evening circadian clock to have young children living athome and to sleep shortly before beginning a night shift, but not more likely to sleepshortly after completion of a night shift Participants were not able to nap whenworking day shifts due to current ICU behavioral norms Participants experiencedthe highest quality of sleep on free days, The mean quality of sleep score beforestarting a day shift or a night shift was significantly lower The lowest score forquality of sleep was for sleep after the night shift No significant differences in sleepquality between circadian clock were found Sleepiness and fatigue increasedsignificantly when working night shifts Performance indices showed no difference

in psychomotor vigilance, except for the 85th percentile of response times, whichwas higher during the night shift than during the day shift

Also, Moradi et al (2014) investigated the outbreak of shift work-related

disorders and the relationship between shift work and job satisfaction in a sectional study The Survey of Shift worker (SOS) questionnairewas used as themajor study tool The nurses’ demographic and work condition data were collectedusing a research-made questionnaire.Results indicated that the highest prevalence

cross-rate was related to emotional and mental problems (96.4%), social life (84.5%),and digestive problems (81%), respectively Sleep disorders were more prevalent

in the staff working at night or on shifts than those working a regular day-timeschedule

Descriptive study to examining nurses' sleep quality, job satisfaction, and the

relationship between them done by Karagozoglu,Bingo (2008) Pittsburgh Sleep

Quality Index (PSQI) and Short Form Minnesota Satisfaction Questionnaire (MSQ),were used for data collection According to the findings nurses' total sleep qualityscore mean was 7.28 ± 3.56 and job satisfaction score mean was 48.05 ± 11.77 Asthe nurses' sleep quality increased their job satisfaction increased In general, theresults obtained from research show that nurses' sleep quality is low and their jobsatisfaction is at a moderate level In similar with this, as the nurses' sleep qualitydecreases their job satisfaction also decreases

Also,Oyane et al.( 2013)investigated various aspects of shift work and other

working conditions among Norwegian nurses The questionnaire included itemscovering demographic factors and working conditions, question on current shiftschedule and a question about having current or had previous night worksociodemographicvariables Nurses with no night work experience were less oftenmarried and had less often children living at home than nurses reporting currentnight work Among nurses with at least 3 years of night work experience, age wasnegatively associated with sleepiness Being married was negatively associated withfatigue in women, while having children was negatively associated with sleepiness

in subjects with less than 3 years of night work experience

Also, Yu-San etal.conducted a study in (2013), explored changes in cognitive

functions, sleep propensity, and sleep-related hormones in the daytime of nurses

working on fast rotating shifts Twenty nurses who worked two consecutive nightshifts and 23 off-duty nurses were recruited from an acute psychiatric ward Theresult of study revealed that the subjects in the off-duty group were more able tomaintain wakefulness than those in the night-shift group and the subjects in thenight-shift group had poorer performances on visual attentive tasks and higher levels

of TSH than those in the off-duty group, and this resulted in a lack of a learningeffect on the tasks that required a high attentive load

Also, Peter et al (2013) conducted a study to explore the mechanisms

through which nurse practice environment dimensions are associated with joboutcomes and nurse-assessed quality of care The study population was registered

acute care nurses (N =1201 ) in two independent hospitals and one hospital group

with six hospitals in Belgium tested with structural equation model designed withvalid measurement instruments The result of study revealed that nurse practiceenvironment dimensions predicted job outcome variables and nurse ratings ofquality of care Analyses were consistent with features of nurses’ workcharacteristics including perceived workload, decision latitude, and social capital, aswell as three dimension of burnout playing mediating roles between nurse practiceenvironment and outcomes A revised model adjusted using various fit measuresexplained 52% and 47% of job outcomes and nurse-assessed quality of care,respectively

Danielle andSeanconducted a study in( 2010) to study the relationship

between registered nurses' extended work duration with adverse events and errors,including needlestick injuries, work-related injuries, patient falls with injury,nosocomial infections, and medication errors to do this A11,516 registered nursesexamined they characteristics, work hours, and adverse events and errors with usingbivariate and multivariate logistic regression The results of study appeared that all

of the adverse event and error variables were significantly related to working morethan 40 hours in the average week Medication errors and needle injuries had thestrongest and most consistent relationships with the work hour and voluntaryovertime variables.

Another study discussed the impact of a week of simulated night work on

sleep, circadian phase, and performance, by Lamond et al (2003) the aim was to

investigate factors that may contribute to performance adaptation during permanentnight work The method was used fifteen healthy subjects participated in anadaptation and baseline night sleep, directly followed by seven simulated eight-hournight shifts At the end of each shift they were taken outside and exposed to naturallight for 20 minutes They then slept from approximately 8 hours until they naturallyawoke A result was significant increase in mean performance on a visualpsychomotor vigilance task across the week Daytime sleep quality and quantitywere not negatively affected Total sleep time (TST) for each of the daytime sleepswas reduced, resulting in an average cumulative sleep debt of 3.53 hours prior to thefinal night shift TST for each of the daytime sleep periods did not significantlydiffer from the baseline night, nor did TST significantly vary across the week Therewas a significant decrease in wake time after sleep onset and sleep onset latencyacross the week; sleep efficiency showed a trend towards greater efficiency acrossthe consecutive daytime sleeps Hours of wakefulness prior to each simulated nightshift significantly varied across the week The melatonin profile significantly shiftedacross the week

Stimpfel, Sloane, Aiken (2012)investigated the relationship between hospital

nurses’ shift length and three nurse outcomes: burnout, job dissatisfaction, andintention to leave the job.cross-sectional data was use, sample of 22,275 registerednurses from the Multi-State Nursing Care and Patient Safety Study The nurses

worked in 577 hospitals in California, New Jersey, Pennsylvania, and Florida shiftlength was calculated as the difference between the start and end time of the mostrecent shift that the nurse worked Shift length was grouped into four categories: 8–

9 hours, 10–11 hours, 12–13 hours, and more than 13 hours Result 65% of nursesworked shifts of 12–13 hours , 26% worked shifts of 8–9 hours, and the remainingnurses worked shifts of either 10–11 hours or more than 13 hours Nurses working

in intensive care units were also more likely than medical or surgical nurses to worklonger shifts Increases in shift length were associated with significant increases inthe odds of burnout, job dissatisfaction, and intention to leave the job

3.2 Problem statement.

Fatigue and sleeplessness has an effects on nursing performance and this maylead to negative effects on the patient safety, quality of care and the system of thecorporation to provide the service

3.3 Significant of study.

To make the nurses knowing what and how the performance affected asaresult of fatigue and sleeplessness Also , to help policy makers in the hospitals tofind out and investigate the causes that make the nurses feel fatigue andsleeplessness and conduct a study about this , so they may develop some policies

in the hospitals to solve this problem and take action such as prevent double shiftsand increases the number of nurses in each shift

3.4 Aims of this Study & Objective.

The aim of this study was to investigate the effects of fatigue and sleepiness

on nursing performance

Objective :

1 To identify effect of fatigue on nursing performance.

2 To identify effect of sleepiness on nursing performance

3.5 Research question are :

1 Dose fatigue has an effect on nursing performance?

2 Dose sleeplessness affect on nursing performance?

3.6 Hypothesis.

 There is significant relationship between fatigue and nursing performance

 There is significant relationship between sleeplessness and nursingperformance

Chapter Four Methodology