Tiredness Takes its Toll: An Integrative Review on Sleep and Occupational Outcomes for Long-Term Care Workers

Abstract

Poor sleep quality and duration among healthcare professionals has revealed negative impacts on worker safety, work readiness, and wellbeing. However, the consequences of impaired sleep among long-term care workers remain understudied. This integrative review sought to explore associations between sleep and occupational outcomes in long-term care workers. Multiple database searches yielded 1,543 articles; nine articles met inclusion criteria. Results synthesized from included articles revealed sleep-associated occupational outcomes across three themes: burnout/fatigue, mental and physical health, and wellbeing, which may all affect performance measures and predict injuries/ errors. Exploring the outcomes of poor sleep quality and duration among long-term care workers has highlighted the needs of this population and may inform future intervention development. Long-term care organizations should consider implementing strategies to better support the sleep quality of their workforce. In addition, further research is needed to explore how impaired sleep contributes to negative worker outcomes and patient care quality.

Problem Identification

Sleep is essential for maintaining good health and quality of life by preventing chronic illnesses and infections (Office of Disease Prevention and Health Promotion [ODPHP], 2022a). Despite the importance of sleep health and its impact on various other health outcomes, it remains understudied and underrecognized as a public health opportunity (Harvey, 2022; Hale et al., 2020). While sleep health was added as a priority topic to the 2020 Health People Initiative, little progress has been made on sleep health promotion and increasing community understanding of sleep’s importance, as Healthy People 2030 sleep objectives remain virtually the same after 10 years (ODPHP, 2022b; ODPHP, n.d.). However, evidence continues to emerge and sleep can be impacted by stress from work, where more stress leads to shorter sleep duration and worse sleep quality (Charles et al., 2011). Poor or insufficient sleep has been linked to health issues including obesity, depression, heart disease, stroke, certain cancers, and diabetes (Cappuccio & Miller, 2017; International Agency for Research on Cancer, 2020). Further research has highlighted the effects of poor sleep quality and duration among nurses as decreasing their own safety (Zhang et al., 2018), likely as a result of decreased cognition related to extended periods of wakefulness (Van Dongen, 2003). Other evidence suggests a lack of quality sleep and adequate duration may impair nurses’ psychosocial functioning, or wellbeing (Caruso et al., 2017). Diminished wellbeing and psychosocial functioning may affect their work readiness and ability to engage in or complete tasks over their working lives - a concept often considered ‘work ability’ (Ilmarinen, 2009).

Healthcare workers require skills in multi-tasking and quick problem solving while demonstrating empathy and administering high quality care. However, research among nurses suggests sleep deficiencies are associated with a decrease in safe and quality patient care (Stimpfel et al., 2020). Specifically, fatigue, a sequelae of sleep loss and/or physical and mental exertion (Lerman et al., 2012), has been found to directly impact decision making (Castro & de Almondes, 2018), and is associated with a lack of concentration (Jaradat et al., 2020). Sleep concerns are not restricted to nurses. Nursing aides have also been found to report poor sleep quality (23%) and duration (46%) in one study - reporting less than six hours of sleep per night on average (Zhang et al., 2016). With an estimated number of 920,655 licensed practical nurses/licensed vocational nurses (LPN/LVNs) in the United States (2020NurseandMidwife, 2021), there is scant evidence surrounding their sleep health. However, their shift scheduling is similar to registered nurses and aides, putting them at risk for poor sleep and fatigue as well.

Despite the known consequences of poor sleep, the impact of poor sleep on occupational outcomes for long-term care workers has not been comprehensively explored previously. Long-term care workers include nurses and others involved in providing direct care (i.e., registered nurses, licensed practical nurses/ licensed vocational nurses, social workers, and nursing assistants). Long-term care workers generally work outside of the hospital setting in post-acute facilities such as nursing or care homes, rehabilitation centers, extended care facilities, assisted living, or skilled nursing facilities (Organisation for Economic Cooperation and Development [OECD], 2015). Long-term care nursing roles involve both indirect care tasks (i.e., liaison for administration, completing documentation, chart reviews, managing inventories and supply stock, placing orders, and scheduling) and direct care tasks (i.e., providing treatment, completing procedures, and administering medication) (Montayre & Montayre, 2017). Long-term social workers provide psychosocial support and address the emotional and social needs of the residents (i.e., empowering residents, offering coping mechanisms, and advocating for resident rights) (Roberts et al., 2021). These different roles may work long hours with high volume patient assignments (Harrington et al., 2016).

To explore what is known about long-term care workers and their sleep health, this integrative review aimed to answer the question: among post-acute/retirement center/long-term care workers, is worker insufficient sleep duration and/or poor sleep quality associated with increased occupational injuries, incidents, errors, and/or other performance measures (e.g., absenteeism, presenteeism, intent to leave)? This integrative review was guided by Whittemore & Knafl’s (2005) five stage methodology which includes problem identification, literature search, data evaluation, data analysis, and data presentation. Results may help to mitigate sleep challenges faced by long-term care workers, so that efforts can be considered to improve their health and the health of their patients. This review did not seek Institutional Review Board approval because it did not include human subject participation.

Review Methods

Literature Search

A health sciences research librarian was consulted on the search strategy. Online databases of PubMed, CINHAL, Scopus, and NIOSH-tic were reviewed for articles to answer the guiding question in July 2021. Keywords of sleep, nursing homes, and nurses with different phrasing depending on database requirements were used (refer to Table 1 in the Appendix for database search variations). Limits were placed on the search to exclude articles published before 2010 to remove articles over 10 years old and include more current evidence for consideration. Inclusion criteria were outlined as follows: a work setting of post-acute care facilities (e.g., nursing homes, rehabilitation centers, assisted living, skilled nursing facility); workers consisting of nursing assistants (or equivalent practice), licensed practical nurses, or registered nurses; study conducted in a high-income country (where results may be comparable to the U.S. long-term care health system) as defined by the World Bank designation; and articles written in English. Exclusion criteria involved study settings for outpatient care, review articles, and grey literature. A total of 1,543 articles were identified in the literature search. After 14 duplicates were removed, 1,529 article abstracts were screened for initial eligibility. Then the full text of 144 articles were read to determine which met the review inclusion criteria. Figure 1 in the Appendix displays the Preferred Reporting Items for Systematic Reviews (PRISMA) flowchart for the search, screening, and inclusion process of articles (Moher et al., 2009). Included articles were critiqued based on the Johns Hopkins’ Evidence Level and Quality Guide (Dang & Dearholt, 2018). This method assigns a level from I-V based on the type of study design used (i.e., I= experimental; II= quasi-experimental; III= non-experimental studies; IV= opinion pieces; and V= experiential or non-research evidence) and a grade of A (high quality), B (good quality), and C (low quality) to indicate overall quality.

Two authors (EK and BH) were involved in screening articles and determining eligibility. Debated articles were reviewed by the third author (CS) to make a final eligibility determination. The two authors then independently reviewed the articles to rate their quality and discussed any discrepancies in quality ratings until agreement was met. Using the Whittemore and Knafl framework (2005), the data were extracted, ordered, and categorized by two of the researchers (EK and BH) who grouped similar data together through qualitative data analysis (Miles et al., 2014). Patterns were iteratively compared and discussed to generate themes. Themes were triangulated by the third researcher (CS).

Review Results

Nine articles met eligibility criteria and were included in this review. Studies were completed in the U.S. (n=4), Sweden (n=2), Austria (n=2), and Norway (n=1). All articles were rated as Level III due to their quantitative non-experimental study designs. The long-term care workers of the included studies were registered nurses, social workers, certified nursing assistants or apprentices, and licensed practical nurses. One study included healthcare workers in the long-term care setting with ‘others’ who did not have direct patient care (i.e., administrative roles) (Buxton et al., 2018). Sample sizes ranged from 24-650, with reported study response rates ranging from 69.9% to 87%. Three studies explicitly reported Cronbach alphas for reliability of their instruments. Sleep duration reported by long-term care workers varied across studies from 5.8 hours before the first workday (Goffeng et al., 2018) to an average of approximately 6.5 hours each night (DePasquale et al., 2019). More detailed article characteristics can be found in Table 2 in the Appendix.

Data Analysis and Presentation

The quality of evidence ranged from high to low with one article rated A (high quality), five rated as B (good quality), and three rated as C (lower quality). Results revealed occupational outcomes across three themes: burnout/fatigue, mental and physical health, and wellbeing. As a part of the data analysis process according to Whittemore and Knafl (2005), the extracted data was converted into a matrix display, to visually represent the patterns across studies for data presentation. This matrix can be found in Table 3 of the Appendix.

Burnout/ Fatigue

Four of the nine studies specifically addressed the relationship of sleep with outcomes of burnout or fatigue among their study participants. Results of one study that sampled certified nursing assistants employed in long-term care suggested a significant inverse relationship between decreased sleep duration and greater depersonalization - a component of burnout (Bamonti et al., 2019). Another study that sampled long-term care workers with additional nonwork caregiving roles supported that sleep quality can predict fatigue occurrence, as those with better reported sleep quality on average had a 74% lower odds of reporting fatigue (Depasquale et al., 2019). Josefsson (2012) found that 37% of the registered nurses working in care homes for older adults had feelings of fatigue or unhappiness related to their work; however, rest days seemed to improve fatigue and sleep quality for nurses working in nursing homes (Blasche et al., 2017).

Mental and Physical Health

Poor sleep quality was found to impact both physical and mental health. Healthcare workers working in one nursing home (including registered nurses, social workers, and nursing assistants) reported experiencing sleeping issues such as needing 30 minutes or more to fall asleep, spending 30 minutes or more awake in between sleep, and awakening 30 minutes early or before they wanted (Goffeng et al., 2018). The same study exposed the physical impact of having higher variability in heart rate with less sleep duration before the first workday across four workdays, suggestive of higher levels of cardiovascular stress (Goffeng et al., 2018). Another study reported on the ability of sleep health (evaluated through self-reported measures of sleep apnea and sleep sufficiency, along with objective methods of actigraphy assessed sleep timing and nap frequency and duration) to predict the risk for cardiovascular conditions, including Type 2 Diabetes and obesity (e.g., cardiometabolic risk) (Buxton et al., 2018; Brunzell et al., 2008). More specifically, greater sleep sufficiency, shorter time of wake after sleep onset, and fewer or no daytime napping, were linked to a decreased cardiometabolic risk in the sample of extended care workers, which included registered nurses, licensed practical nurses, certified nursing assistants, and others (Buxton et al., 2018).

Along with physical impacts, poor sleep quality from work resulted in spill-over effects for mental health. Among nursing assistants working in nursing homes, a statistically significant association was detected between poor sleep quality and lower mental health scores (β = −5.22, p<0.01) (Zhang et al., 2017). Poor sleep also mediated the relationship of work-family conflict and mental health in this population (Zhang et al., 2017). Further, most registered nurse participants working in care homes for older adults reported at times feeling physically (51%) and psychologically (52%) exhausted after work (Josefsson, 2012). Demanding work situations, categorized as time pressures (rho 0.275, p<0.01) and emotional pressures (rho 0.187, p<0.01), were significantly correlated to sleep disorders.

Wellbeing

Included studies found the negative relationship of sleep deprivation on wellbeing. Declines in wellbeing for nurses working in nursing homes were reported to be greater during subsequent days of working 12-hour shifts as compared to non-working days (Blasche, et al., 2017), and a lack of sleep was reported most before working days (Goffeng et al., 2018). Registered nurses working in care homes also expressed difficulty leaving behind thoughts from their workday daily (16%), suggestive of intrusive or repetitive thoughts about work events (Josefsson, 2012). Moreover, a significant association was found between work-family conflict and poor sleep quality (PR= 1.53, p<0.01) in nursing assistants working in nursing homes (Zhang et al., 2017). Haluza et al. (2019) argued that nurses employed in the long-term care setting work in a physically and psychologically demanding work environment, where inadequate recovery would lead to sleep deprivation and diminished performance, undoubtedly affecting wellbeing. Conversely, the sustainable work ability (e.g., lower sickness absence) of assistant nurses working on elderly care units was associated with sleeping well and feeling recuperated (Hagglund et al., 2011).

Discussion

The long term and downstream effects of poor sleep on wellbeing, mental and physical health, and burnout/ fatigue can impact performance measures along with occupational errors and injuries among long-term care workers. Burnout specifically has been correlated with turnover intention in a study of care workers in long-term care hospitals (Youn et al., 2016). In the same study by Youn et al. (2016), elements of mental health, including emotional labor and job stress, were also correlated with the care workers’ intention to leave. More job stress and strain related to less manager support has further been found to increase long-term care workers’ risk for cardiovascular disease and decrease their sleep duration per day (Berkman et al., 2010). Yet, improved physical health with increased physical activity has been found to lower sickness absences generally (Amlani & Munir, 2014). Finally, wellbeing has been linked to job satisfaction in general, which is related to commitment and turnover (Brunetto et al., 2012).

The lack of sleep found among long-term care workers in this integrative review (from 5.8 to 6.5 hours each night) suggests poor sleep is related to negative effects on worker mental and emotional health, leading to burnout and fatigue, and diminishing wellbeing levels (Goffeng et al., 20018; DePasquale et al., 2019). Sleeping less than the recommended amount of 7-8 hours per night for adults (National Heart, Lung, and Blood Institute, n.d.), places long-term care workers at increased risk for adverse health outcomes. Moreover, poor sleep health decreases productivity, increases costs for worker health (Buxton et al., 2018), and as a result, may increase risk for poor patient outcomes (Stimpfel et al., 2020).

Nurses in various specialties have similarly reported fatigue from a lack of sleep and heavy occupational workloads as a result of mandatory overtime, long work hours, and consecutive working shifts (Sagherian et al., 2017). While long-term care workers face similar work hours contributing to fatigue and sleep deficits, research suggests there are some individual and organizational contributors that may be unique to this worker population as compared to health workers in acute care settings. Specifically, combined workloads of off-duty caregiving among long-term care workers can contribute to poor sleep quality and fatigue (Depasquale et al., 2019). Van Houtven et al. (2020) reported from their study of 958 long-term care workers that approximately 61% had double or triple unpaid child or other relative caregiving roles. In the same study by Van Houtven et al. (2020), 1 in 6 long-term care workers reported having a second job. Not only may long-term care workers be engaged in unpaid caregiving, but many also hold second and third jobs due to suppressed hourly wages. This additional workload not only impacts long-term care workers’ time for social and family obligations, but also affects their ability to adequately recover from work or ensure necessary sleep quality and duration is achieved. Moreover, when work-family conflict or work-life balance is affected (Zhang et al., 2017), wellbeing is also impacted (Kossek et al., 2014).

As this review found results of fatigue across the studies of long-term care workers, there is a need to reduce fatigue and its occupational consequences such as burnout in this population. To do so, long-term care organizations should implement specific protective workplace policies that support workers, such as ensuring appropriate staffing and scheduling so employees can take breaks during their shifts (Gurubhagavatula et al., 2021; Lerman et al., 2012; Wong et al., 2019). Organizations can also consider providing education regarding how to engage in recovery and promote quality sleep, included in annual retraining programs for staff (Lerman et al., 2012; Wong et al., 2019). Additionally, organizations may implement fatigue-detection devices that provide alerts when a worker is fatigued, to both them and their managers (Wong et al., 2019; Lerman et al., 2012).

To mitigate the mental and physical health impacts of short sleep duration and poor sleep quality on workers in the long-term care environment, resources can be made available that support healthy lifestyles and sleep health promotion. Also offering peer support groups may help workers manage and discuss shared experiences regarding sleep and overall health effects. Implementing peer support groups may be an effective strategy in supporting the psychological health among workers and provide them the space to talk about how they are dealing with their jobs and other caregiving roles and workloads (Pereira et al., 2021). Organizations could also provide subscriptions to mobile meditation applications to promote positive mental health and quality sleep. Using relaxation techniques from applications such as Calm or Headspace are useful and convenient ways to help workers prepare for healthy sleep (U.S. Department of Health and Human Services, 2011).

To promote wellbeing in the workplace, efforts from both long-term care workers and management can be made to create a culture of health. This may include management providing incentives or stipends for workers who engage in wellness activities, including tracking healthy sleep-promoting habits or participating in regular screening for sleep disorders with tools like the Global Sleep Assessment Questionnaire [GSAQ] (Roth et al., 2002). Wellness stipends are becoming more popular among companies as a means for supporting employees in a more holistic manner, addressing their unique health needs (Compt, n.d.). Prioritizing employee health and sleep may lead to positive impacts for worker wellbeing and the workplace itself, indirectly improving patient care and organizational outcomes.

Limitations

There are several limitations of note in this review. First, the literature search was limited to articles that were published online and searchable by the databases, risking the omission of relevant research. Second, there was the inclusion of studies completed in various countries to fulfill the research question. However, this inclusion may reduce the generalizability of results to other long-term care settings. Third, studies used differing scales to assess variables of interest (e.g., sleep, fatigue, burnout, coping, insomnia), and could not be combined or compared for deeper understanding.

Despite these limitations, the countries where the studies were conducted are all high-income countries, so results are translatable to the U.S. Furthermore, some studies used validated measures with acceptable reliability to gather data resulting in credible results. As the included studies were all non-experimental quantitative designs and most were cross-sectional, future studies using a quantitative longitudinal approach or a qualitative design may aid in a richer understanding of the needs of long-term care workers.

Conclusion

Findings from this integrative review suggest that poor sleep health among long-term care workers can impact occupational injuries, errors, and performance measures by affecting worker health and safety outcomes of wellbeing, mental and physical health, and burnout/fatigue. Continued exploration for ways that long-term care organizations can better support their unique workforce is needed, while considering their other workloads and caregiving roles. Understanding how the workplace impacts sleep and leads to negative health outcomes for long-term care workers may support the urgency for these organizations to adopt additional strategies that promote the overall health of their workers through improved sleep. Potential considerations include providing sleep education programs and ensuring appropriate staffing to reduce fatigue and burnout; offering peer support groups at work and free relaxation mobile applications to support positive mental and physical health; and offering wellness stipends for engaging in healthy sleep promoting behaviors to enhance overall employee wellbeing. Making organizational changes to mitigate risks associated with poor sleep quality and duration may further support the sustained work ability of long-term care workers and improve patient outcomes.

Appendix

Table 1.

Database Variations

Database	Search String
PubMed	: ((("Sleep"[Mesh]) OR "Sleep Deprivation"[Mesh] OR "Sleep Wake Disorders"[Mesh] OR "Sleep Hygiene"[Mesh] OR sleep*[tiab]) AND ("Nursing Homes"[Mesh] OR "Rehabilitation Centers"[Mesh] OR "Assisted Living Facilities"[Mesh] OR "nursing home*"[tiab] OR rehabilitation center*[tiab] OR assisted living[tiab] OR "Long-Term Care"[Mesh] OR "long-term care"[tiab] OR "Subacute Care"[Mesh] OR "subacute care"[tiab] OR "post-acute care"[tiab] OR "retirement center*"[tiab] OR "Housing for the Elderly"[Mesh] OR "housing for the elderly"[tiab]) AND ("Nurses"[Mesh] OR "Nursing Assistants"[Mesh] OR "Licensed Practical Nurses"[Mesh] OR nurse*[tiab] OR “nursing assistant*”[tiab] OR "licensed practical nurs*"[tiab] OR LPN[tiab] OR “licensed vocational nurs*” OR LVN OR “registered nurs*” OR RN))
Scopus	TITLE-ABS-KEY (("Sleep") OR ("sleep quality") OR ("sleep duration") OR ("sleep disorder") OR ("sleep-wake disorder") OR ("sleep deprivation") OR ("sleep hygiene")) AND (("extended care") OR ("nursing home")) AND (("nursing aide") OR ("nursing assistant") OR ("nurse") OR ("licensed practical nurse") OR ("licensed vocational nurse") OR ("registered nurse")). The search returned 869 documents, which were then limited to articles published after 2010
CINHAL	(MH "Sleep Disorders, Circadian Rhythm") OR (MH "Sleep Disorders") OR (MH "Sleep") (MH "Sleep Deprivation") OR (MH "Sleep-Wake Transition Disorders") OR (MH "Sleep Hygiene") AND (MH "Nursing Homes") OR (MH "Assisted Living") OR (MH "Rehabilitation Centers") OR (MH "Senior Centers") OR (MH "Housing for the Elderly") OR (MH "Long Term Care") OR (MH "American Long Term and Sub Acute Nurses Association") AND (MH "Nurses") OR (MH "Practical Nurses") OR (MH "Nursing Assistants") OR (MH "Registered Nurses").
NIOSH-tic	Sleep OR sleep quality OR sleep duration OR sleep disorders OR sleep-wake disorders OR sleep deprivation OR sleep hygiene AND extended care OR nursing home AND nursing aides OR nursing assistants OR nurse OR licensed practical nurse OR licensed vocational nurse OR registered nurse

Figure 1.

PRISMA

Table 2.

Article Characteristics

Author & Date	Purpose & Design	Sample & Setting	Results	Strengths & Limitations	Evidence Level, Quality
Bamonti et al., 2019	To examine if coping and cognitive emotion regulation strategies can predict burnout while controlling for age and sleep duration Quantitative non-experimental cross-sectional design	56 direct certified nursing assistants (CNAs) employed in long-term care (LTC) 4 skilled nursing facilities in the U.S.	Shorter sleep duration was significantly associated with greater depersonalization as an aspect of burnout (β = −.27, p = .01) On average, participants slept 6 hours of per night on work nights	Cronbach alphas were reported for each scale; valid and reliable tools were used Limitations were acknowledged Relatively small sample size and no power analysis reported Sample lacked racial, ethnic, and shift time diversity Survey response rate not included	Level III B
Blasche et al., 2017	To assess recovery time (through measures of fatigue, vigor, distress, and sleep quality) across two consecutive 12-hours day shifts and three rest days Quantitative non-experimental design	48 day shift registered nurses 3 public Austrian nursing homes	At least three rest days are needed for full recovery (e.g., adequate time for rest to prevent against prolonged fatigue) after working two consecutive 12-hours day shifts Compared to working days, participants have lower perceptions of fatigue and higher well-being on rest days Sleep quality was significantly worse on the two workdays, as compared to the reference (second rest day)	Sample size was smaller, but reported as adequate based on a power analysis and effect size Methods described clearly and limitations were acknowledged The demographic and sleep diary questionnaires were adapted from pilot testing, revised with participant remarks, but was not based on theory or valid/ reliable tools Fatigue, distress, vigor, and sleep were measured with standardized tools with supported reliability (listed Cronbach alphas) but validity was not mentioned Self-reported data could introduce bias No controls reported to decrease confounders	Level III C
Buxton et al., 2018	To explore if indicators of sleep health can predict 10-year estimates for cardiometabolic risk scores (CRS) among extended care workers vs. information technology (IT) workers Quantitative nonexperimental cross-sectional design	Workers in extended care (n = 1,275) including registered nurses and licensed practical nurses (29%), certified nursing assistants (65%), and other positions including administrators, educators, and food service aides (6%) From 30 distinct worksites located in the northeastern U.S.	On average, extended care workers worked 40.53 hours per week (SD = 10.59). The average Body Mass Index (BMI) of extended care workers was: 29.43 kg/m2 (SD = 6.94), so most (61%) fell below the obese range (BMI < 30 kg/m2) Extended care workers were more likely to have less sleep sufficiency, more WASO, longer sleep duration, later and more variable sleep midpoint times, and take any naps, more naps and longer naps compared to IT workers Higher perceptions of sleep sufficiency, fewer minutes of wake after sleep onset, and fewer or no daytime napping was associated with lower cardiometabolic disease risks among extended care workers	85% participation rate noted among eligible employees and 87% participation rate among eligible managers Limitations were acknowledged Extended care employees were compared to IT employees Reliability and validity not discussed for all measurements SATED scale used not fully validated yet Interviews were complet ed at the worksite, increasing risk for bias and coercion Self-reported measures decrease objectivity of data	Level III B
Depasquale et al., 2019	To examine sleep duration and sleep quality reduce fatigue among long-term care employees with nonwork caregiving roles. Quantitative nonexperimental micro-longitudinal design	166 women with nonwork caregiving roles for dependent children or adult relatives 30 nursing homes across 6 U.S. states	Sleep duration, sleep quality, and fatigue occurrence significantly changed on nights before a workday compared to nights before a non-workday Tonight’s sleep duration and quality predicts tomorrow’s fatigue Double duty caregiver roles moderated the relationship between participant sleep duration and fatigue	85% response rate reported Limitations acknowledged Study was conceptually informed by the theoretical Work, Nonwork, and Sleep (WNS) framework Reliability and validity of measurements not addressed, as each sleep and fatigue construct was measured with a single self-reported item	Level III B
Goffeng et al., 2018	To investigate fluctuations in heart rate and the psychological and physical strain experienced during sleep and work among health care workers over four consecutive 14 hours work shifts Quantitative nonexperimental cross-shift/cross-week design	24 health care workers (nurses, social workers, assistants/apprentices) One nursing home in Norway	There was a higher level of cardiovascular stress during the first workday compared with the fourth workday 21 % of participants (n=5) reported having general sleep problems the night before the first workday whereas 17% (n=4) reported sleep problems before the fourth workday The night before the first workday, participants slept an average of 5.8 hours. The night before the fourth workday, participants slept an average of 6.5 hours. Differences in stress from Day 1 to Day 4 were not statistically significant.	Sample size adequacy not reported; sample size is smaller Validation of tools reported but not described Director of nursing home encouraged participation increasing risk for bias Participants served as their own controls	. Level III B
Hagglund et al., 2011	To explore aspects of sustainable work ability in female nursing assistants caring for older persons Quantitative nonexperimental cross-sectional nested case–control design	366 female assistant nurses 12 units within elderly care in a Swedish municipality	Sustainable work ability was associated with participants’ ability to sleep well	Sample size and power analysis not explicitly discussed, but response rate of 73% and sample attributes were reported to support generalizabilit y of results to those caring for elderly persons in Sweden Participants were recruited and surveys were completed at their place of work, increasing the risk for bias Data collected as self-reports increases the risk for bias The study did not control for potential confounding variables	Level III C
Haluza et al., 2019	To explore recovery processes among nurses who work successive night shifts during their off-duty periods Quantitative non-experimental design	53 night shift nurses 2 public nursing homes in Austria	Findings of recovery suggest that well- being was impaired on days following working a night shift, while it improved following rest days (RDs) Three rest days, one sleeping day (12 hours) and two full days off- duty (48 hours), are needed to support recovery (where occupational physical and phycological fatigue has improved following shifts and during off days)	Cronbach alphas reported for fatigue, vigor, and distress measures, supporting good internal consistency reliability but validity not reported 69.6% response rate reported The small number of male study participants limits generalizability of results to both genders Self-reported questionnaire used and non-random sample increases risk for bias Power of sample size not mentioned No controls reported to decrease confounders	Level III C
Josefsson, 2012	To describe work-related health problems, sickness presence and absence, along with perceptions of time, competence, and pressure at work, among nurses who work in community care of older people Quantitative nonexperimental descriptive design	213 registered nurses 60 residential care homes in a large community in Sweden	Most nurse participants (52%) felt psychologically exhausted at times after work, whereas 12% reported often, 28% rather often, and 8% never Most nurse participants (51%) felt physically exhausted after work at times, whereas 15% reported often, 21% rather often, and 13% never Time pressures (rho 0.275, p < 0.01) and emotional pressures (rho 0.187, p <0.01) were significantly correlated to sleep disorders	62% of target population participated supporting a high response rate Limitations acknowledged No control group noted Only one author risks adding bias to results	Level III B
Zhang et al., 2017	To explore the relationship between work-family conflict and the mediating effect of sleep quality and duration on the mental health of nursing assistants Quantitative non-experimental cross-sectional design	650 nursing assistants 15 non-unionized nursing home facilities located in Maryland and New England, U.S.	Poor sleep quality mediated the association between work- family conflict and mental health More work-family conflict was correlated with lower mental health scores (Rho = −0.16, p < .01)	Participants given the option to complete the surveys at home for privacy 73% response rate Reliability and validity were reported although not described for all measurement tools Selection bias may exist due to differences in work characteristics between the participants included	Level III A

Table 3.

Result Presentation

Occupational Outcomes
Burnout/ Fatigue	Mental and Physical Health	Wellbeing
Bamonti et al., 2019 Sleep duration was significantly and negatively associated with the burnout subscale of depersonalization (p=−0.34) As sleep duration increases depersonalization decreases, and when sleep duration decreases, deper sonalization increases	Zhang et al., 2017 After adjusting for sociodemographic and working conditions, there was a significant association found between mental health and poor sleep quality (R2 = 13.8%, β = −5.87, p<0.01)	Haluza et al., 2019 Average wellbeing was considerably worse on the first two days following working night shift, when compared to the first rest day
Blasche et al., 2017 The average level of perceived fatigue, vigor, distress, and sleep during Work Days 1–2 differed significantly from that of Rest Day 2. On working days, participants were more fatigued, less vigorous, more distressed, and had a lower quality of sleep than on Rest Day 2	Goffeng et al., 2018 LF/ HR ratio was significantly higher on the first compared to the fourth workday- and a high LF/HF ratio indicates high cardiovascular strain The night before the first work day, most participants (65%, n=15) reported a sleep pattern of one or more of the following characteristics: 30 minutes or more falling asleep, 30 minutes or more awake in between sleep, and awakening 30 minutes or before wanted	Hagglund et al., 2011 31.5% (n=42) of participants had good sleep ability and sustainable work ability Nurses with reported good sleep ability are estimated to be 0.69 (CI: 0.43, 1.1) more likely to have sustainable work ability
Haluza et al., 2019 The average level of fatigue, vigour and distress during Post Night Shift Day 1 and 2 differed significantly from that of Rest Day 1	Josefsson, 2012 Nurse participants reported work-related health problems including work-related neck or back disorders, dry skin, muscles or joint disorders, sleep disorders, and headache, along with high time pressure at work Sleep disorders were significantly related to time pressure (0.275, p<0.01) and emotional pressure (0.187, p<0.01)	Zhang et al., 2017 A significant association was found between work-family conflict and poor sleep quality (P R=1.53, p<0.01)
DePasquale et al., 2019 Fatigue occurred on 359 of 1,221 days (29%) The average fatigue severity score was 5.61 (SD = 2.08) The odds of reporting fatigue more than doubled (OR = 2.48, p<0.001) on workdays compared with nonwork days	Buxton et al., 2018 More sleep apnea symptoms (r=.14, p <0.001), more perceived sleep sufficiency (r = .08, p=.0005), and more numbers of naps (r =.14, p<0.001) were associated with higher cardiometabolic risks (CRS) One unit increase in sleep apnea symptoms was associated with 0.44% higher CRS	Josefsson, 2012 37% of the RNs had episodes of fatigue/unhappiness/sadness because of their work and found difficulties overcoming these feelings Nurses (n=213) stated these episodes occurred several times a year (51%), sometimes (37%), and rarely (12%). These episodes lasted either always (8%), some months (4%), some weeks (31%) or some days (57%)