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Relationship between Circadian Rhythm Amplitude and Stability with Sleep

Quality and Sleepiness among Shift Nurses and Health Care Workers

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DOI: 10.1080/10803548.2015.1081770

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 International Journal of Occupational Safety and
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ISSN: 1080-3548 (Print) 2376-9130 (Online) Journal homepage: http://www.tandfonline.com/loi/tose20

Relationship between circadian rhythm amplitude

and stability with sleep quality and sleepiness
among shift nurses and health care workers

Akram Jafari Roodbandi, Alireza Choobineh & Somayeh Daneshvar

To cite this article: Akram Jafari Roodbandi, Alireza Choobineh & Somayeh Daneshvar
(2015) Relationship between circadian rhythm amplitude and stability with sleep quality and
sleepiness among shift nurses and health care workers, International Journal of Occupational
Safety and Ergonomics, 21:3, 312-317, DOI: 10.1080/10803548.2015.1081770

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 International Journal of Occupational Safety and Ergonomics (JOSE), 2015
Vol. 21, No. 3, 312–317, http://dx.doi.org/10.1080/10803548.2015.1081770

Relationship between circadian rhythm amplitude and stability with sleep quality and sleepiness
among shift nurses and health care workers
Akram Jafari Roodbandia , Alireza Choobinehb and Somayeh Daneshvarc∗
a School of Health, Kerman University of Medical Sciences, Kerman, Iran; b Research Center for Health Sciences, Shiraz University of
Medical Sciences, Shiraz, Iran; c School of Medical Sciences, Tarbiat Modares University, Tehran, Iran

Introduction: Sleep is affected by the circadian cycle and its features. Amplitude and stability of circadian rhythm are
important parameters of the circadian cycle. This study aims to examine the relationship between amplitude and stability
of circadian rhythm with sleep quality and sleepiness. Method: In this cross-sectional research, 315 shift nurses and health
care workers from educational hospitals of Kerman University of Medical Sciences (KUMS), Iran, were selected using
Downloaded by [somayeh daneshvar] at 21:14 13 December 2015

a random sampling method. The Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS) and Circadian
Type Inventory (CTI) were used to collect the required data. Results: In this study, 83.2% suffered from poor sleep and
one-half had moderate and excessive sleepiness. The results showed that flexibility in circadian rhythm stability, job stress
and sleepiness are among the factors affecting quality sleep in shift workers. Discussion: Those whose circadian rhythm
amplitude was languid suffered more from sleepiness and those whose circadian stability was flexible had a better sleep.
Variables including circadian rhythm stability (flexible/rigid) and amplitude (languid/vigorous) can act as predictive indices
in order to employ people in a shift work system so that sleepiness and a drop in quality of sleep are prevented.
Keywords: circadian rhythm; sleep quality; sleepiness; nurses; shift work

1. Introduction types of individuals in order to obtain a score to enter uni-

Some people are more alert, energetic and capable in some
special hours of the day and night and this varies from
one person to another.[1] These characteristics are regu-
larly repeated every 24 h and are called circadian rhythms,
adjusted by the body’s biological clock.[2] Circadian refers
to variations in behavioral activities and metabolism of liv-
ing things.[3] Circadian rhythm is a sine-like wave with
phase, amplitude and stability [4] (Figure 1).
The circadian phase can be defined as a circadian
variable (e.g., body temperature) reaching a particular
condition.[5] In addition to the circadian phase, other
factors such as circadian rhythm amplitude and stabil-
ity are of high importance in circadian cycle features.[6]
Circadian rhythm stability and amplitude are determined
as flexible/rigid (FR) and languid/vigorous (LV), respec-
tively. Those whose circadian rhythm stability is flexible
(F) type show flexibility toward sudden changes in internal
rhythm (like staying up for a night shift). In contrast, those
whose circadian rhythm stability is rigid (R) type resist
against sudden changes. Those whose circadian rhythm
amplitude is languid (L) type find it more difficult to over-
come sleepiness and lethargy as a result of lack of sleep.
On the contrary, those who are vigorous (V) type can resist
against sleepiness and remain vigorous.[6] In a study con-
ducted by Besoluk [7] to determine the effect of circadian
versity, out of 235 high school students participating in
the study 19.1%, 68.1%, 11.9% and 9% had almost mod-
erately morning type, neither type, moderately evening
type and completely evening type, respectively. Morning-
oriented students had a better performance in the morning
examinations. The results of a study by Nag and Nag [8]
on circadian type showed that languidness in sleep habits
was affected by a shift-work schedule so that there was a
significant difference in a night shift and a rotating shift.
However, such a difference was not observed among those
whose circadian rhythm stability was flexible. In research
conducted by Natvik et al. [9] on personality factors related
to tolerating shift work in nurses, it was found that three-
shift nurses who had flexibility suffered less from insomnia
and were able to work and sleep at any time of day. But
this was not true for two-shift nurses. Moreover, nurses
who were languid (in both groups of two shifts and three
shifts) showed a higher level of sleepiness, anxiety and
depression.[9] Mokarami et al. [10] carried out research on
shift workers of SIPA Press and observed that 57.1% of
regular day workers and 47.1% of shift workers had poor
sleep quality.
Sleepiness is a state of fatigue in a person who
is inclined toward sleeping easily.[11] Sleep quality is
defined as satisfaction from sleep in which dimensions

*Corresponding author. Email: s.danesh89@gmail.com

© 2015 Central Institute for Labour Protection – National Research Institute (CIOP-PIB)
 International Journal of Occupational Safety and Ergonomics (JOSE) 313

Figure 1. A circadian rhythm can be entrained by external stimuli (e.g., light/dark or temperature cycles) and will maintain that
Downloaded by [somayeh daneshvar] at 21:14 13 December 2015

rhythm when placed in constant conditions. Features of the curve that are commonly measured are the period (the duration between the
occurrence of a relative position on the curve, usually peaks or troughs), the amplitude (the level of expression measured from the
midline to either the peak or trough) and the phase (the relative positioning of the curve in reference to a specific time point, such as the
time placed in constant light). Negative values denote time during light/dark cycles that entrain the clock. Positive values denote time in
constant light.

such as the beginning of sleep, maintaining sleep, sleep
quantity and how refreshed one is when waking up are
included.[12] According to Rutenfranz et al. cited in
LaDou,[13] those working during the day, shift-work peo-
ple without a night shift, night-shift workers and fixed
night-shift workers suffer from sleep disorders in 15–20%,
5%, 10–80% and 60% of cases, respectively. The rate of
sleepiness increases toward the end of a night shift in terms
of mental features and physiological variables.[14] Sleepi-
ness or poor sleep may be owing to the fact that their
amplitude and circadian rhythm do not correspond with
shift work.[6]
The body’s biological clock or the human circadian
system regulates many regular activities of different body
organs. The sleep–wake cycle is no exception, which is
adjusted by the biological clock as well as natural and
artificial light, ambient sounds, work and social activities.
Sleep is one of the most important human biological pro-
cesses which have deep effects on mental and physical
health.[15]
In Iran, 80% of those employed in the health and treat-
ment system are nurses.[16] Studies have indicated that
night-shift nurses suffer from sleepiness and making errors
twice as much as day-shift nurses.[17,18] Given that nurs-
ing is a serious and important job and the workers’ ability
corresponding with employment in shift work has a notable
effect on nursing services, and since sleep quality and
sleepiness of people are affected by their amplitude and
circadian rhythm, this study aimed to examine the rela-
tionship between flexibility/rigidity of circadian rhythm
stability and languidness/vigorousness of circadian rhythm
amplitude with sleep quality and sleepiness among shift
nurses and health care workers from educational hospitals
of Kerman University of Medical Sciences (KUMS),
Iran.
2. Method
In this cross-sectional research, the study population con-
sisted of 315 shift nurses and health care workers from
educational hospitals of KUMS, Iran. The subjects were
selected using a random sampling method. In this study, the
Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepi-
ness Scale (ESS) and Circadian Type Inventory (CTI) were
used as data-collecting tools.
The PSQI examines sleep quality over the past 4 weeks
and includes seven scores for the following scales: sub-
jective sleep quality; sleep latency; sleep duration; habit-
ual sleep efficiency (the proportion of time that one is
asleep over the total time spent in bed); sleep distur-
bances (defined as someone waking up at night); use of
sleep medication; and daytime dysfunction (defined as
troubles someone experiences during the day caused by
sleeplessness).[19] Total scores from 0 to 4 indicate ade-
quate sleep and scores of 5–21 show inadequate sleep.
Farrahi et al. [20] reported Cronbach’s α of the Persian
version of the PSQI to be 0.89.
The validity and reliability of this questionnaire has
been approved by Johns [21] and its Cronbach’s α has been
reported as 0.88. In Iran, Masoodzadeh et al. [22] used
this questionnaire and its reliability was shown to be more
than 70% through test–retest. Sleepiness is a score between
0 and 24 which is attributed to each variable after com-
pleting the Epworth questionnaire. Scores of 0–6, 7–8 and
more than 8 show adequate sleep, medium sleepiness and
inadequate sleep, respectively.
 314 A. Jafari Roodbandi et al.

The Persian version checklist of the CTI which has Table 1. Some demographic characteristics of the study
been examined and approved in terms of validity and reli- population (N = 315).
ability includes 11 questions covering two independent Variable Frequency %
variables.[23] The first variable is FR, showing circadian
rhythm stability, and those obtaining a high score from this Gender
variable are flexible and can be employed in a shift-work Male 136 43.2
Female 179 56.8
system with the ability of staying up during abnormal hours Marital status
of the day or night. The second variable is LV, showing cir- Single 84 26.6
cadian rhythm amplitude. Those who obtain a high score Married 231 73.3
from this variable are called languid, and find it more dif- Age (years)
ficult to overcome the feeling of sleepiness and lethargy as 20–30 104 33
31–40 121 38.4
a result of insomnia.[6]
>50 90 28.5
Those who obtain a score above 18.75 from five related Work experience (years)
questions in the first factor (FR) belong to the percentile <10 154 48.9
above 75 and therefore their circadian type is considered 10–20 121 38.4
flexible in terms of stability. These people are able to stay 21–30 40 12.7
Educational level
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awake during abnormal hours of the day or night. The peo-

Diploma 38 12.1
ple obtaining a score higher than 22.5 for the second factor Associate degree 23 7.3
(LV) by answering the six related questions are considered Bachelor of Science/Art 228 72.4
to belong to the percentile above 75 and therefore their cir- Master of Science/Art 26 8.3
cadian type is regarded as languid in terms of amplitude. Perceived job stress
Overcoming sleepiness is more difficult for this group of Very low and low 46 14.6
Moderate 131 41.6
people. High and very high 138 43.8
In addition to completing the PSQI, ESS and CTI, the
participants were asked to answer a 5-item questionnaire
about job stress they perceived at work. Table 2. Status of sleep quality, sleepiness and circadian
SPSS version 11 was drawn upon to analyze the data. rhythm and amplitude features of the study population
For this purpose, the t test was used to examine the mean (N = 315).
difference for diverse age groups in terms of circadian
rhythm amplitude and stability, and the χ 2 test was utilized Variable Status % Frequency
to investigate the frequency difference for both genders in Sleep quality Adequate 16.8 53
terms of circadian rhythm amplitude and stability and in Inadequate 83.2 262
order to compare the frequency difference of sleep quality Sleepiness Lack of sleepiness 50.8 160
and sleepiness in FR and LV variables. Logistic regression Medium sleepiness 19.0 60
analysis was used to determine the factors affecting sleep Excessive sleepiness 30.2 95
Circadian Percentile above 75 19 60
quality. rhythm (languid)
amplitude Percentile below 75 81 225
(LV) (vigorous)
Circadian Percentile above 75 8.9 28
3. Results rhythm (flexible)
In total, 315 shift nurses and health care workers partici- stability Percentile below 75 91.1 287
(FR) (rigid)
pated in this study with a mean age and mean job tenure
of 35.68 (SD = 8.2) and 12.21 (SD = 7.7) years, respec-
tively. Table 1 presents some demographic characteristics
of the study population. of circadian rhythm stability and 91.1% had a percentile
Table 2 presents the status of sleep quality, sleepiness below 75 (R type).
and circadian rhythm and amplitude features of the study Table 3 depicts the frequency of sleep status among the
population. As shown, 16.8% of the participants had ade- subjects based on circadian rhythm amplitude and stability.
quate sleep; 50.8% of all participants had no sleepiness The results revealed that there is no significant difference
and 19% and 30.2% had medium and excessive sleepi- between adequate and inadequate sleep regarding their fre-
ness, respectively. The M (SD) hours of sleep for the quency in both the L and V groups (p > 0.05). Therefore,
subjects were 6.62 (1.6). In this study, 19% of the indi- circadian rhythm amplitude probably has no effect on sleep
viduals belonged to the percentile higher than 75 (L type) quality. However, this test showed that there is a signif-
in terms of circadian rhythm amplitude and 81% had a per- icant difference between adequate and inadequate sleep
centile lower than 75 (V type). The results indicated that regarding their frequency in the F and R groups (p < 0.05).
8.9% belonged to the percentile above 75 (F type) in terms Circadian rhythm stability therefore probably affects sleep
 International Journal of Occupational Safety and Ergonomics (JOSE) 315

Table 3. Frequency of sleep status among the study Table 5. Regression model indicating factors with the
population based on circadian rhythm amplitude and stability strongest influence on the study population (N = 315).
(N = 315).
Independent
Sleep quality factor retained
Circadian in the model β p OR 95% CI
variable Adequate Inadequate pa
Reported stress 0.601 .007 1.82 [1.17, 2.82]
Circadian L (n = 60) (7) 11.67% (53) 88.33% 0.16 Circadian rhythm 1.479 .001 4.39 [1.85, 10.37]
rhythm V (n = 255) (46) 18% (209) 82% stability
amplitude Sleepiness − 0.422 .037 0.66 [0.44, 0.97]
(LV)
Note: CI = confidence interval.
Circadian F (n = 28) (12) 42.9% (16) 56.1% 0.001
rhythm R (n = 287) (41) 14.3% (246) 85.7%
stability
(FR) 4. Discussion
Note: Data presented as (n) percentage. F = flexible; L =
In this study, 83.2% of the individuals had inadequate
languid; R = rigid; V = vigorous; a = χ 2 test between both sleep and half of them suffered from medium and exces-
groups. sive sleepiness, and their mean hours of sleep per day was
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6.62 (SD = 1.6). The quantity and quality of sleep often

quality such that flexible people have a better sleep than
rigid people in terms of quality.
Table 4 presents the frequency of sleepiness based on
circadian rhythm amplitude and stability. Based on the
results of the χ 2 test, the significant difference (p < 0.05)
between sleepiness frequencies in the L and V groups indi-
cates that circadian rhythm possibly affects sleepiness so
that the rate of sleepiness is higher in languid people than
in vigorous individuals. In contrast, results of the statis-
tical test showed that there was no significant difference
between the R and F groups as far as level of sleepiness
was concern (p > 0.05). Circadian rhythm stability there-
fore may have no effect on the status of sleepiness of the
study population.
To determine the factors affecting sleep quality of
the study nurses and health care workers, logistic regres-
sion analysis (backward stepwise conditional) was used
(Table 5). The variables of sleepiness, age, gender, mari-
tal status, educational level, perceived job stress, LV and
FR were included in the regression model. The results
show that circadian rhythm stability, rigidity (odds ratio
[OR] = 4.39), perceived higher stress levels (OR = 1.82)
and the degree of more excessive sleepiness (OR = 0.66)
influenced the quality of sleep.
decreases when the sleep schedule changes from night to
day. In a study by Menzel cited in LaDou,[13] the mean
sleep of a morning shift and that of an afternoon shift
was determined as 7.5 and 8.5 h, respectively, while night-
shift workers slept 4–6 h on average. Maurice, cited in
LaDou,[13] reported that 50% of day-shift nurses slept
7–8 h while only 15% of night-shift nurses slept equiva-
lent to this time. In this study, the mean amount of sleep
was 4.68 h among the night-shift nurses and its quality was
inadequate in 83%. However, it should be noted that hours
of sleep required for anyone varies according to lifestyle,
physical activity and age. Sleep disorders are mainly com-
mon among shift-work employees since the time of sleep
changes during a time which does not correspond with cir-
cadian rhythm and environmental conditions. In his study
of 9000 night-shift workers, Thiis-Evensen cited in LaDou
[13] showed that 20% of subjects suffered from sleep-
lessness and complained about sleep problems caused by
noise. Evidence therefore suggests that night-shift workers
face more sleep disorders than their daytime counterparts.
The findings of the current study revealed that those
with languid circadian amplitude probably have more
sleepiness and those with flexible circadian rhythm may
have better sleep quality.
Di Milia et al. [3] argued that languid people were
less alert during the day and after lunch while vigorous

Table 4. Frequency of sleepiness based on circadian rhythm amplitude and stability among the study
population (N = 315).

Lack of Medium Excessive

Circadian variable sleepiness sleepiness sleepiness pa

Circadian rhythm amplitude (LV) L (n = 60) (19) 31.7% (18) 30% (23) 38.3 0.003
V (n = 255) (141) 55.29% (42) 16.47% (72) 28.23%
Circadian rhythm stability (FR) F (n = 28) (16) 57.14% (4) 14.28% (8) 28.57% 0.72
R (n = 287) (144) 50.17% (56) 19.51% (87) 30.31%

Note: Data presented as (n) percentage. F = flexible; L = languid; R = rigid; V = vigorous; a = χ 2 test
between both groups.
 316 A. Jafari Roodbandi et al.
people were more alert during the day. Based on our find-
ings, languid people suffer more from sleepiness and those
with flexible circadian rhythm have better sleep quality.
Tonetti et al. [24] determined circadian preference and
mental quality of the sleep–wake cycle in secondary school
students. They found that evening-oriented people’s awak-
ening quality was significantly lower than that of morning-
oriented ones and sleeplessness, fatigue, headache and
fatigue persistence without any particular reason during
the daily awakening was more common among evening-
oriented people.[24] The current study results were also
similar to those of Tonetti et al. in that those with flexible
circadian rhythm had better sleep quality.
A study carried out by Ognianova et al. [25] to examine
stress states experienced by a group of operators working
in a 12 h shift system reported that individual differences,
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related to circadian rhythms, have a notable role in stress
states. The findings of this study imply that languid peo-
ple perceive more stress in the night shift and the subjects
with flexible circadian rhythm perceive less stress.[25] In
the current study, the reported stress acted as a meaningful
index in languid people, which is similar to the results of
Ognianova et al.’s study.[25]
Nag and Nag [8] carried out a study on female VDT-
cum-telephone operators to investigate the effects of per-
manent and rotating shifts on the behavioral responses and
health disturbances. The results showed that languidness of
sleep habits was affected by the shift-work schedule. How-
ever, this was not true for flexibility. This part of Nag and
Nag’s findings is in line with the current study results so
that shift-work participants in this study suffered more from
sleepiness with languid type but no significant relation-
ship was found between languidness of circadian rhythm
amplitude and sleep quality.
It is important to note that variability or adjustability of
circadian rhythm is also probable, i.e., one with morning-
oriented characteristics may incline toward night orienta-
tion or vice versa. With increasing age,[26] along with
weakness in temporal symptoms and having a weak circa-
dian system (in terms of change in temporal situation and
return to the earlier mood), one’s inclination toward morn-
ing orientation increases. This case corroborates the mood
that one is languid and flexible in terms of circadian rhythm
amplitude and stability, respectively.[27] Ageing reduces
amplitude and leads to a morning-orientation habit. That is,
one sleeps earlier and gets up earlier as well.[28] Kramer
et al. [29] studied individual differences in sleep and awak-
ening behavior under natural conditions among young
and old subjects. They found that old subjects had more
regular sleep pattern than young individuals in addition to
midnight awakenings. In the present study, there was no
significant relationship between age and sleep quality. This
can be owing to lower variance of age of the subjects as
compared with Kramer et al.’s study.
To examine the relationship between personal features
and shift-work tolerance in the New Zealand police force,
Tamagawa et al. [30] compared two groups of fixed night-
shift and rotating shift workers. Their results revealed that
there was no significant relationship between flexibility
or need to sleep and personality and mental, emotional
variables.
Logistic regression results showed that sleep quality
is affected by perceived stress, circadian rhythm stabil-
ity, rigidity and severity of sleepiness. Accordingly, sleep
quality in subjects with high perceived stress (OR = 1.82)
was lower than in those with lower levels of perceived
stress. Knudsen et al. [31] demonstrated that some occu-
pational stressors are significantly related to sleep quality
and extreme workload. Chan [32] conducted a study in
order to determine factors related to nurses’ sleep qual-
ity in rotating shifts and stated that 70% of nurses suffered
from lack of sleep and also had a high level of stress. A
logistic regression model was used for this purpose and the
results indicated that older age (OR = 0.9), gastrointestinal
disorders (OR = 7.4), impaired sleep status (OR = 1.8)
and high scores on the strain and symptoms questionnaire
(SSQ index) (OR = 0.3) are related to inadequate sleep in
nurses.[32] Findings from the current study were consis-
tent with those of Knudsen et al and Chan in the terms of
the relationship between perceived stress and sleep quality.
In addition, inflexible people with OR = 4.39 had
worse sleep quality than flexible people. Di Milia et al.
[3] performed a study for validation of the CTI instru-
ment with mine shift workers and university day workers.
V-type individuals were more conscious than L-type sub-
jects according to the circadian rhythm domain and a
significant difference was observed between F and L types
from 16:00 to 22:00. F-type individuals were reported to
be less affected by circadian and awakening factors in this
period of time. Furthermore, F-type individuals reported
less needed sleep in comparison with R types. In Di Milia
et al.’s study, those with V-type circadian domain and with
stable F-type circadian rhythm were the most suitable peo-
ple for shift work, and also in this study F-type people had
better sleep quality than R-type in the terms of circadian
rhythm stability, and thus were suggested suitable for shift
working.[3]
Based on regression analysis, sleepiness with an OR
less than one (OR = 0.66) was effective in improving
sleep quality and thus had a protective role in this area.
It meant that sleep quality was better in people with
higher sleepiness. Yazdi et al. [33] conducted a study to
compare sleep disturbances in shift workers and people
working in a fixed shift schedule, and concluded that shift
workers had poorer sleep quality than fixed-shift workers
(OR = 2.2) and also had higher extreme daily sleepiness
than fixed-shift workers (OR = 1.3). In many studies, it
has been observed that poor sleep quality and sleepiness
occurred at a higher rate in shift workers. In the current
study evaluating the relationship between sleep quality and
sleepiness, we found that sleepiness of subjects had a pro-
tective role in sleep quality. This can be attributed to this
 International Journal of Occupational Safety and Ergonomics (JOSE)
fact that sleepiness of people is owing to their lack of sleep
and need to sleep. If suitable conditions are provided for
sleeping, the sleep would have a better quality.
5. Conclusion
According to the findings of this study, it can be concluded
that the prevalence of sleepiness was higher in languid
individuals. In flexible subjects, sleep quality was higher.
The factors affecting sleep quality in the study population
include perceived job stress level, circadian rhythm sta-
bility and sleepiness level. Circadian rhythm stability and
amplitude (LV and FR) variables could act as predictive
indices in order to select and employ individuals in a shift-
work system so that sleepiness and a drop in the quality of
sleep might be prevented.
Downloaded by [somayeh daneshvar] at 21:14 13 December 2015
Acknowledgements
The authors’ thanks go to the participating nurses.
Disclosure statement
No potential conflict of interest was reported by the authors.
There is no conflict of interest in this article.
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