Relationship Between Quality of Sleep and Psychological Well-being Among Frontline Nurses During the COVID-19 Pandemic in Saudi Arabia

Abstract

Background:

The coronavirus 2019 (COVID-19) pandemic is a world health emergency crisis that challenges the global health system and healthcare providers, especially frontline nurses’ physical and mental well-being.

Objective:

The aim of the study was to examine the association between depression, anxiety, and sleep quality among nurses working in Saudi Arabian hospitals during the COVID-19 pandemic.

Methods:

This is an quantitative cross-sectional study. An online self-reported data was collected from 187 nurses who were on duty during COVID-19 pandemic.

Results:

About 87.2% of the nurses were female nurses; not surprising that 88% had poor sleep quality; 44.4% had moderate anxiety, and 44% of the studied nurses had mild to moderate depression. The study revealed that there was an association between level of anxiety and poor sleep quality. Poor sleep quality and emotional stability of nurses play a major role in quality of care and patients’ safety.

Conclusion:

We conclude that healthcare leaders should adopt an occupational wellbeing program for nurses that focuses on their psychological wellbeing and sleep quality.

1. BACKGROUND

For the past previous years, Coronavirus disease 2019 (COVID-19) has caused worldwide health emergencies with a makeup, high mortality, and morbidity, with more than 118,000 confirmed cases worldwide and 4292 deaths at the declaration (1). The COVID-19 pandemic is an extreme health burden that has significant implications for public health (1). According to Centers for Disease Control and Prevention (2), COVID-19 is described as “New coronaviruses are part of the coronavirus family, which includes common viruses that cause a variety of diseases, from colds to more severe conditions, such as severe acute respiratory syndrome (SARS) and the Middle East Respiratory Syndrome (MERS)" (1).

In Saudi Arabia, the Saudi Ministry of Health (MOH) announced the first confirmed coronavirus case on March 3, 2020 (2, 3). Healthcare systems worldwide were under great strain due to the COVID-19 pandemic, including in Saudi Arabia. There was an increase in COVID-19 cases in all countries, causing many healthcare organizations to cancel or stop elective procedures (4). On the other hand, the peak of infected cases results in dramatic recourses depletion at hospitals in many countries and a critical shortage of human recourses, personal protective equipment (PPE), and mechanical ventilators (4).

This pandemic affected the social life of individuals and societies as many schools, colleges, universities, restaurants, and places of worship have been closed; also many people lost their jobs and careers due to the economic burden in many countries (5). Moreover, the COVID-19 pandemic affects all age population groups, including people living in the poverty line, children, pregnant mothers, and older adults (5). With the focus on the transmission of COVID-19 across the globe, public attention may be diverted from other problems associated with the outbreaks, such as psychological effects (6). Several people were distressed because of COVID-19’s immediate health impacts with consequences of physical isolation and lockdown (5). Causing fears of infection, death, losing family members, and physical separation from friends and peers (5). Moreover, specific population groups showed high COVID-19-related psychological distress degrees; especially Health Care Workers (HCWs) were exposed to several work-related stressors as they were primary caregivers of COVID-19 patients (7). It could be argued that HCWs have a higher risk in comparison because they are the primary patient in contact with a highly contagious environment (8). Previous literature reported that HCWs were exhausted physically and psychologically due to overstretched health systems, shortage of personal protective equipment, and risk of infection (8-10). In the above-perceived exhaustion, multiple work-related stressors increase the risk of negative mental health outcomes. This work-related stress can overwhelm healthcare systems by increasing the urgent needs of patient care. Additionally, nurses are one of the Global HCWs that have felt unprecedented stress during the pandemic due to high patient workload and extended shifts, while having limited equipment recourses, and sleep interference due to poor work-life balance (9).

However, despite the studies that recently have studied the influence of COVID-19 on the mental health of nurses who engaged in direct patient care, very limited studies were reported focusing on the association between Quality of Sleep and Psychological Well-being among Nurses working in Saudi Arabia.

2. OBJECTIVE

To examine the association between sleep quality and the psychological well-being of Saudi Arabian frontline nurses during the COVID-19 pandemic.

3. MATERIAL AND METHODS

Design

A cross-sectional quantitative study design was conducted through an online survey between March-April 2021. The study included nurses working at Ministry of Health hospitals, Military hospitals, University hospital, and Private hospitals.

Ethical Approval

The ethical approval was obtained from ethical review IAU (IRB NO -PGS-2022-04-106). The online survey included a brief description of study, informed consent that explained the participants’ rights to withdrawn at any time, risks, and benefits of participation, ensuring data confidentiality. No personal name identification was required. The principle of confidentiality and anonymity were upheld.

Participants

The sample was determined using the G* power program version 3.1.25; effect size of 0.5 to achieve a power of 0.90 and statistical significance of 0.05 to decrease the probability of type I and type II errors (23). A total of 187 nurses who met the following criteria were enrolled in the study: Staff nurses provided direct care to COVID-19 patients during the COVID-19 pandemic (frontline nurses). Nurses who were not available during data collection, such as those on sick leave or maternity leave were excluded.

Data collection

Socio-demographic information comprises 18 items: age, gender, nationality, marital status, educational level, years number of professional experience, type of hospital sector, the name of the administrative region of employment in Saudi Arabia, the presence of any chronic disease, psychological condition, sleep condition, provided direct care to COVID-19 patients, hospitals area of work, their living status during the peak time of Covid-19 pandemic either living with their families or isolated from family, if they have been infected with Covid-19, the adequacy of personal protective equipment (PPE) while providing care to COVID-19 patients, if they were afraid of being infected with COVID-19 while delivering care to patients, and if there anxiety level differ after receiving three doses of COVID-19 vaccines.

The Pittsburgh Sleep Quality Index (PSQI) was used to measure nurses “sleep quality; the PSQI is a 19-item, self-rated questionnaire designed to measure sleep quality and disturbance over the past month. The 19 items are grouped into seven components, including (1) sleep duration, (2) sleep disturbance, (3) sleep latency, (4) daytime dysfunction due to sleepiness, (5) sleep efficiency, (6) overall sleep quality and (7) need of sleep medication [24]. Each sleep component yields a score ranging from 0 to 3, with 3 indicating the most significant dysfunction. The sleep component scores are summed to produce a total score ranging from 0 to 21, with the higher total score (referred to as the global score) indicating worse sleep quality (25).” A global PSQI score > 5 demonstrates a sensitivity of 89.6% and a specificity of 86.5% (25). PSQI scores have high test-retest reliability and validity for primary insomnia (26).

In this study, Cronbach alpha-PSQI was 0.917.

Anxiety was measured using the Beck Anxiety Inventory (BAI). The BAI is a widespread scale used to measure people’s subjective feelings about anxiety (27;28). According to Beck (27) the tool “consisting of 21 items, was used in assessing anxiety symptoms rated on a 4-point Likert-type scale. Scores obtaining from the BAI ranged from 0 to 63. Higher scores indicated higher levels of anxiety. The standard cut-off values are as follows: 0-7 indicates minimal anxiety, 8-15 indicates mild anxiety, 16-25 indicates moderate anxiety and 26-63 indicates severe anxiety.” Some studies report good, reliable and valid instruments based on existing empirical evidence (Cronbach’s alpha of 0.956 (29); Cronbach’s alpha of 0.89 (30).In this study Cronbach’s alpha was 0.831.

Meanwhile, depression will be measured by the Beck Depression Inventory (BDI), a standard used to screen for depressive symptoms (31). The BDI-II is scored by totaling the 21 items; the test can yield a score ranging from 0 to 63. Symptoms are rated from 0 to 3 on a 4-points scale. The standard severity range is 0-9, where a person is not depressed, 10-18 when they are mild or moderately depressed, 19-29 when they are moderate-severely depressed, and 30-53 when they are severely depressed (31). Based on studies that demonstrate that the BDI-II is a valid, reliable, and culturally relevant instrument for measuring depressive symptoms, excellent reliability coefficient of 0.92. (32). In this study the BDI was 0.869.

A pilot study was performed and conducted among 15 nurses, 10% of the required sample size. The pilot study conducted to test questions clarity, ensuring that items were understandable, and time estimation necessary to complete the survey. A minor adjustments in survey format was done based on participants feedback. All nurses involved in the pilot study were excluded from the sample. After the necessary permission was obtained, the survey was sent via email through hospitals administration. Nurses used their computers or smartphones to complete the survey at their convenience. The survey took about 17 minutes on average. A follow-up invitation was sent seven days after the first invitation.

Statistical analysis

The statistical analyses were conducted using SPSS version 20.0 (SPSS, Chicago, IL). Mean, standard deviation (SD), and percentage were used for determining the demographic profile. Categorical data were expressed in numbers and percentages. The Chi-square test was used for the association between quality of sleep and psychological well-being (depression and anxiety) The reliability (Internal Consistency) test for the questionnaires used in the study was calculated. Statistical significance was set at P <0.05.

4. RESULTS

Socio-demographic characteristics

A total of 187 nurses participated in the study; the majority were female (87.2%). One-third of them (31%) were single, and (61%) were married. The average age was 35 years (SD = 8.1). Two-thirds of the participants were Saudi nurses. More than two-thirds, (69%), had a bachelor’s degree, and only (17.1%) had a diploma. The average years of experience were 10.7 years (SD = 6.6) (Table 1).

Table 1. Socio-Demographics Characteristics of the Nurses (N=187).

Socio-Demographics Characteristics	N	%
Age (Years)
<25	12	6.4
25-35	101	54.0
>36	74	39.6
Mean± SD	34.6±8.1
Gender
Male	24	12.8
Female	163	87.2
Nationality
Saudi	111	59.4
Non-Saudi	76	40.6
Marital Status
Single	58	31
Married	114	61
Others	15	8
Educational Level
Diploma	32	17.1
Bachelor	129	69
Postgraduate Study	26	13.9
Experience (Years)
<10	83	44.4
>10	90	48.1
>20	14	7.5
Mean ± SD	10.7±6.6

Overall sleep quality, anxiety, and depression

Table 2 shows the overall sleep quality, anxiety, and depression (N=187). The result shows that the majority of nurses (88.8%) reported poor sleep quality, while (11.2%) had good sleep quality. In addition around (44 %) of the nurses reported mild anxiety levels, while (15% &17.1%) reported moderate to severe anxiety, respectively. On the other hands, around half (49.20%) of the nurses had normal mood, and (13.9%, 3.7% &12.8%) had mild mood disturbance, borderline depression, and moderate depression respectively. While (5.9%) nurses reported severe depression and (8%) of them reported extreme depression.

Table 2. Distribution of overall sleep quality, Anxiety, and Depression (N=187).

	N	%
Pittsburgh Sleep Quality Index (PSQI) PSQI level of sleep quality
Poor sleep quality	166	88.8
Good sleep quality	12	11.2
Anxiety level
Minimal level of Anxiety	83	44.4
Mild level of Anxiety	44	23.5
Moderate level of Anxiety	28	15
Sever level of Anxiety	32	17.1
Depression level
Ups and downs consider normal	92	49.20
Mild mood disturbance	26	13.90
Boarder clinical depression	7	3.74
Moderate depression	24	12.83
Severe depression	23	12.30
Extreme depression	15	8.02

Association between nurses sleep quality and nurses perceived depression and anxiety

Table 3 shows that there was a significant association between reported sleep quality and perceived anxiety (X²= 12.983, P= 0.005). Similar findings were observed when comparing sleep quality and perception of depression. There was a significant association between reported sleep quality and perceived depression (X²=12.707, P= 0.026).

Table 3. Association Between Nurses Sleep Quality, Perceived Depression and Perceived Anxiety. (N=187) **Statistically significant p<0.05.

	Good Sleep Quality		Poor Sleep Quality		Chi-Square
	N	%	N	%	X2	P
Anxiety Score/Minimal level of anxiety	16	76.2	67	40.4
Mild Anxiety	5	23.8	39	23.5
Moderate Anxiety	0	0.0	28	16.9
Severe Anxiety	0	0.0	32	19.3	12.983	0.005*
Depression Score
These ups and downs are considered normal	19	90.5	85	51.2
Mild mood disturbance	2	9.5	24	14.5
Borderline clinical depression	0	0.0	7	4.2
Moderate depression	0	0.0	24	14.5
Severe depression	0	0.0	11	6.6
Extreme depression	0	0.0	15	9.0	12.707	0.026*

Association between the depression and anxiety

Table 4 shows that there was a strong positive association between the nurses’ perceived depression and perceived anxiety (X2= 156.161, P<0.001).

Table 4. Association between Nurses Perceived Depression and Perceived Anxiety. **Statistically significant p<0.05.

	Minimal level of anxiety		Mild Anxiety		Moderate Anxiety		Severe Anxiety		Chi-Square
	N	%	N	%	n	%	N	%	X2	P
Depression Score
Ups and downs are considered normal	73	88.0	25	56.8	5	17.9	1	3.1
Mild mood disturbance	7	8.4	11	25.0	7	25.0	1	3.1
Borderline clinical depression	1	1.2	2	4.5	2	7.1	2	6.3
Moderate depression	2	2.4	6	13.6	9	32.1	7	21.9
Severe depression	0	0.0	0	0.0	4	14.3	7	21.9
Extreme depression	0	0.0	0	0.0	1	3.6	14	43.8	156.161	<0.001**

5. DISCUSSION

According to some research nurses’ physical and negative psychological well-being, (e.g., including insomnia, anxiety, stress, and depression) (9, 10) is becoming a significant concern in caring for COVID-19 patients (11-13) as a result of prolonged exposure to patients with COVID-19.

Meanwhile, studies have shown that poor quality of sleep was one of the common problems among nurses during the pandemic (11, 12). Good quality sleep is one good indicator of both positive mental health and physical health, while disrupted quality sleep increases negative psychological symptoms such as insomnia, anxiety, stress, and depression (14).

According to previous literature, poor sleep quality could impair nurses’ cognitive functioning and weaken clinical decision-making ability, thereby increasing the risk of medical errors and decreasing clinical work efficiency while performing nursing care during a pandemic (8, 15-17). A recent study showed that nurses reported high anxiety levels and depression levels during the pandemic (17-19) which increased psychological distress (14-16). In a study conducted by Al Ateeq and colleagues (2020) to examine the mental health of healthcare workers during the COVID-19 pandemic in Saudi Arabia, the study showed that nurses had significantly higher mean scores of anxiety than other health professionals (9). According to some previous literature work stressors from COVID-19 can increase mild to severe anxiety levels, depression and sleep deprivation (4, 6, 8, 20).

Negative mental health outcomes are a worldwide problem. For example, in one study conducted in Sub-Saharan Africa examining COVID-19 its effects on nurses’ mental well-being frontline nurses are higher likely to experience symptoms of mental disorders such as anxiety and depression and in addition to persistent lack of sleep which leads to burnout during the pandemic (19). Another study conducted in Turkey evaluating sleep quality and related factors among nurses during the pandemic found out nurses have two times perceived higher poor sleep quality in comparison to other health professionals, such as physicians and dentists who participated in the same study (21). Moreover, one study examining Kenyan nurses’ mental health during COVID-19 (19) showed that insomnia was one of the main factors affecting the mental well-being of frontline nurses. This is interesting to note that poor sleep quality perceived depression, and high anxiety levels have been linked to medical errors that endanger patient safety (22). Hence, there is an urgent need to address the nurse’s anxiety levels, depression, and sleep deprivation by protecting the sleep health, mental health, and well-being of healthcare workers. Thus, safeguarding nurses’ mental health and improving sleep quality is important. Although, despite some research about the effect of depression, anxiety, and sleep quality among nurses, only a few studies were conducted on nurses in Saudi about COVID-19. For example, in one study conducted by Al-Dossary et al (21), most nurses had excellent knowledge of COVID-19. Also, another study recent study conducted in Saudi showed that most nurses providing direct patient care during the pandemic were associated with poor mental well-being (22).

This study determined the association between sleep quality and psychological well-being of Saudi Arabian frontline nurses during the COVID-19 pandemic. Several findings were reported in this study. In this study, around 70% of participating frontline nurses proved the adequacy of personal protective equipment PPE during COVID-19 in their hospitals in Saudi Arabia. Only 29.9% of participants had inadequate PPE in their hospitals. This result is similar to one study conducted in Saudi Arabia, which proved PPE adequacy during the first year of the pandemic (22). However, in other studies there was a lack of PPE provision in other countries, which adversely impacted frontline healthcare providers as one of the most factors that influenced their physical and psychological well-being and provoked burnout, among them (34, 35, 36).

Furthermore, the statement about the perception of receiving the doses of the COVID-19 vaccine impacted their anxiety level reported that 61.5% perceived yes, whereas 38.5% did not feel any change regarding their anxiety level. This is worth noting since, before our data collection time, several healthcare providers have received the COVID-19 vaccine and the booster doses since 2021; in Saudi Arabia, at vaccination centers across the Kingdom, the Ministry of Health was able to vaccinate 98% of healthcare professionals in 202193). Thus, most healthcare providers are vaccinated and immunized against COVID-19 in Saudi Arabia. Healthcare providers in Saudi Arabia were among the first targeted groups, along with the elderly and those with chronic diseases, nominated to receive the vaccine earlier than other Saudi adult populations in 2021 (3). Due to the high awareness among health practitioners about the importance of receiving the vaccine to protect themselves and raise the community’s immunity, many have received three vaccine doses. Another important finding showed that there is an association between nurses’ perceived severe anxiety and severe depression to their poor sleeping patterns. This result is in agreement with other recent studies that reported that frontline healthcare workers (HCWs) were anxious and depressed about the COVID-19 pandemic and its consequences (21, 22). A recent Saudi survey conducted in 2021 showed that the majority of anxiety and depression were significantly high; 54.69% of frontline nurses reported depression, and 60.8% reported anxiety in addition to stress (37).

A recent study showed a relationship between the perception of stress with insomnia and a high level of anxiety, in which 42.5% of the participants reported sleeping less than eight hours per night (8). Similar results were also found that nurses had more severe symptoms of anxiety than physicians; moreover, a high prevalence of anxiety and depression (53.3% and 52.2%), respectively, which is higher than our study’s prevalence rate of anxiety and depression (38). Healthcare workers experienced obstacles in the healthcare sector before and during COVID-19. Such problems can be prevented by various interventions that need to be addressed to make healthcare personnel feel secure when providing medical services to patients. Since most of the issues are contributed by the shortage of health care staff, especially nurses, thus, employing more staff will limit or eliminate such psychological problems as depression and anxiety among the team - furthermore, the obstacles consequence impact patient safety and medical errors (22). However, caution should be used in interpreting the findings, as anxiety and depression were measured by a self-administered validated tool and are prone to social desirability and subjective bias. Nevertheless, it is safe to conclude that having good enough sleep could reduce anxiety and depression.

Finally, the results showed that there is an association between nurses’ perceived extreme depression and nurses’ perceived anxiety. This finding is in agreement with other studies conducted in Oman (17), and Nigeria (18) among nurses which reported that depression and anxiety were interrelated among nurses working in the hospital during the COVID-19 pandemic. This is worth noting since anxiety and depression among nurses have drastically risen with the added new stressor of the current pandemic of the novel coronavirus disease 2019 (COVID-19) (6, 20, 21). The current pandemic has caused many stressors and depression as our overwhelmed healthcare system struggles to stay afloat (9). The healthcare team, specifically nurses who spend the most time with patients who are fighting for their lives in hospitals, are suffering from anxiety which often leads to depression (22). Specific to COVID-019 this population of nurses is particularly vulnerable to stress and job burnout during this pandemic outbreak of an infectious disease (21). It is critical that nurses be equipped with the coping mechanism to deal with anxiety symptoms to prevent nurse depression. Addressing depression and anxiety is an ethical obligation for healthcare professionals and they must seek treatment immediately (16). Interventions such as mindfulness, and meditation are particularly effective in reducing stress, anxiety, and depression (16).

Study limitations

The study is based on self-reported measures and a cross-sectional design. A cross-sectional study did not allow for assessing sleep, depression, and anxiety over an extended period. Therefore, data from different stages of the pandemic are lacking. Furthermore, questionnaires did not consider potential confounders, such as caffeine and nicotine intake, diets, and shift work details, potentially affecting sleep quality and psychological well-being. Moreover, most of the respondents’ female gender have an insufficient sample size for statistical measurements; thereby, results cannot be generalized. This study centralizes on specifical nurses involved directly with the delivery of care to patients; however, other jobs may be indirectly exposed to COVID-19 patients, including administrators, communication, and regulation officers; thus, future studies must include these groups as well.

The current study was carried out to assess the sleep quality, anxiety, and depression among (Frontline) nurses in Saudi Arabia after two years of the COVID-19 pandemic, to examine the extent of this pandemic on their psychological well-being and set recommendations based on valid evidence to reduce the burden of the crisis among them. In addition, at the time of the global health crisis, the findings of this study are especially vulnerable; however, the outcome of the current research will be consistent with the growing body of literature demonstrating the psychological impact of COVID-19 on nurses worldwide. Furthermore, to achieve long-term goals, structures and strategies are needed to enable policymakers to enhance healthcare systems to be prepared for public health emergencies in the future. Other emerging infections are likely to follow COVID-19. Develop programs to help healthcare providers cope with work stress, offering insight into coping mechanisms, reducing workplace stress, provide a better work environment for nurses to enhance their psychological well-being. Moreover, a lack of healthcare creates a massive obstacle for healthcare personnel in providing service since they will be straining themselves and overworking, making others feel hopeless. Also, providing enough PPEs to healthcare will decrease the fear of conducting infectious illnesses like COVID-19; thus, anxiety and depression will be reduced. Allowing nurses to work on shifts as recommended will give such healthcare personnel enough time to sleep and reduce sleep disorders, resulting in a good performance in service provision. When all these measures are adhered to, the psychological well-being of healthcare will improve and make them work with no mental problems.

6. CONCLUSION

This study determined the association between nurses’ sleep quality and nurses’ perceived depression and anxiety. In this investigation, nurses perceived severe anxiety and severe depression were connected to poor sleeping patterns. Also, nurses perceived depression as connected to their anxiety.

Data availability statement:

The datasets used and analyzed during the current study are available from the corresponding author upon request.

Conflict of interest:

There is no financial or related conflict of interest.

Author’s contribution:

All authors participated in manuscript review and editing. Eman Abdulla Alabdullatif: Conceptualization (lead); Methodology (lead); writing – original draft (lead); formal analysis (lead); writing – review and editing (equal). Rana Ali Alameri: Conceptualization (supporting); Methodology (supporting); Software (lead); writing – review and editing (equal). Reem Nasser Al-Dossary: Conceptualization (supporting); Methodology (supporting); writing – review and editing (equal).