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The Effect of Sleep Hygiene and Sleep Deterioration on Quality of Life in

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DOI: 10.29399/npa.24827

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 Arch Neuropsychiatry 2021;58:11−15
RESEARCH ARTICLE https://doi.org/10.29399/npa.24827

The Effect of Sleep Hygiene and Sleep Deterioration on Quality of Life in

Shiftworking Healthcare Professionals
Didem GÖRGÜN HATTATOĞLU1 , Şenay AYDIN2 , Cihan AYDIN1 , Birsen Pınar YILDIZ1
Department of Pulmonology, University of Health Sciences, Yedikule Thoracic Disease and Surgery Training and Research Hospital, İstanbul, Turkey
1

Department of Neurology, University of Health Sciences, Yedikule Thoracic Disease and Surgery Training and Research Hospital, İstanbul, Turkey
2

ABSTRACT

Introduction: Deterioration in sleep quality and sleep hygiene may result
in impairments on mental and physical health leading to deterioration of
quality of life (QoL) in healthcare shift workers. We aimed to determine
the presence of sleep deterioration as well as poor sleep hygiene, and if
any, the effects of these on health-related outcomes.
Methods: This study prospectively included healthcare professionals
who did and did not work shifts (n=90 and n=66, respectively). The
participants completed the Pittsburgh Sleep Quality Index (PSQI), Sleep
Hygiene Index (SHI), Epworth Daytime Sleepiness Scale (EDSS), Short
Form-36 quality of life scale (SF-36), and the Beck depression (BD) and
Beck anxiety (BA) scales.
Results: Although the total PSQI scores showed a tendency to increase
in shift workers, no significant differences were observed in total scores
as well as subdivisions, except for an increase in sleep latency. Increased
SHI total score in shift workers were represent more deteriorated sleep
hygiene behavior (p=0.002). Increased needs of daytime nap, variability of
both go and get out of bed and stay in bed longer than usual were recorded
respectively (p: 0.001, p: 0.001, p: 0.001, p: 0.001, p: 0.001). SHI had
prominent effects on QoL parameters such as vitality (r=-0.284, p=0.007),
social function (r=-0.323, p=0.002), mental health (r=-0.274, p=0.009), and
calculated mental component total score (r=-0.302, p=0.004).
Conclusion: In our study, we clearly detected prolonged sleep latency
and poor sleep hygiene in shift workers which should be responsible for
the deterioration of QoL.
Keywords: Shiftworking, sleep hygiene, quality of life

Cite this article as: Görgün-Hattatoğlu D, Aydın Ş, Aydın C, Yıldız BP. The Effect of Sleep Hygiene and Sleep Deterioration on Quality of Life in Shiftworking Healthcare
Professionals. Arch Neuropsychiatry 2021; 58:11-15.

INTRODUCTION
Shift work has the potential to disrupt family and social life, and poor
sleep quality leads to the deterioration of quality of life (QoL) parameters
(1). The association between shift work and health problems has been
shown in several studies, most probably related with chronic changes
in the endogenous circadian timing system triggered by behavioral
alterations, including the sleep/wake and fasting/feeding cycles (2, 3).
Sleep hygiene which is important for improving sleep quality, includes
behavioral practices that facilitate sleep (e.g. regular exercise) and avoid
interfering with sleep (e.g. smoking, evening alcohol, evening caffeine,
daytime napping) (4). Associations between poor sleep hygiene practices
and poor sleep quality in adults have been shown in previous studies
(5, 6). Limited data are available to show associations between sleep
hygiene and functional outcomes such as QoL, daytime sleepiness, as
well as depressive symptoms and anxiety (7, 8). Although sleep hygiene
is expected to deteriorate in shift workers, limited data are available
in literature to determine poor sleep hygiene behaviors in healthcare
professionals or healthcare shift workers. Therefore it needs to show
deterioration of sleep hygiene if any in this group of professionals could
be effect on QoL or quality of work ability.
The primary aim of our study was to determine the presence of poor
sleep hygiene behaviors in healthcare professionals who worked as shift-
based schedules. Secondarily, to determine whether there were any
associations between sleep hygiene and functional outcomes such as
daytime sleepiness, mood, sleep quality, and QoL.
METHODS
Subjects
A prospective cross-sectional study was conducted between January
2018 and June 2018 in a tertiary care hospital. A total of 90 shift workers,
nurses (n=58), technicians (n=25), physicians (n=7), and 66 regular
workers were included in the study. The participants worked 40 hours
per week according to a pre-determined work schedule.
The work schedules followed a 24-hour rotation system divided into three
periods; the morning shift (08:00 AM to 04:00 PM), night shift (04:00 PM
to 08:00 AM), and 24-hour shifts (08:00 AM to 08:00 AM). Shift days were
scheduled according to hospital rules by workers request considered.
The exclusion criteria included age <18 years, history of sleep disorder,
current use of anti-depressive and hypnotic drugs, major systemic illness,
malignancy, and pregnancy. Our study was approved by the local ethics

Correspondence Address: Şenay Aydın, Department of Neurology, University of Health Sciences, Yedikule Thoracic Disease and Surgery Training and Research Hospital, İstanbul, Turkey •
E-mail: aydin.senay@hotmail.com
Received: 10.08.2019, Accepted: 07.01.2020, Available Online Date: 24.04.2020
©Copyright 2020 by Turkish Association of Neuropsychiatry - Available online at www.noropskiyatriarsivi.com

11
Görgün-Hattatoğlu et al. Sleep in Shiftworking Healthcare Professionals
committee (Number: 1126) and all participants gave written informed
consent. The participants were asked to complete the questionnaires
on their duty day. They completed a background questionnaire that
included demographic information such as age, job, body mass index
(BMI), education time, smoking status, pack/year of smoking, alcohol use,
and comorbidities; the latter was scored using the Charlson Comorbidity
Index (CI).
Sleep Hygiene Index
The Sleep Hygiene Index (SHI) is a 13-item self-administered index. The
SHI is used to evaluate environmental of behavioral variables that affect
sleep hygiene (9). The participants were asked to indicate how frequently
they repeat in specific behaviors (always=5, frequently=4, sometimes=3,
rarely=2, never=1). Item scores were summed to provide a global
assessment of sleep hygiene. The total possible score ranges between
13 and 65, with higher scores indicating poorer sleep hygiene status.
Poor sleep hygiene behavior was defined according to the participants’
responses of “always” or “frequently” to each item.
Sleep Quality
Sleep quality was measured using the Pittsburgh Sleep Quality Index
(PSQI). This questionnaire consists of 19 self-administered questions,
divided into seven components: (PS1) subjective sleep quality; (PS2)
sleep latency; (PS3) sleep duration as the ratio between time slept and
time in bed, not necessarily sleeping; (PS4) habitual sleep efficiency; (PS5)
sleep disturbances (presence of situations that compromise hours of
sleep); (PS6) use of sleep medication; and (PS7) daytime dysfunction. The
total score is determined by the sum of the scores obtained from the 7
separate scores. Each component is scored from 0 to 3. The global score
(TS) ranges from 0 to 21 ( ≤5: good sleep quality; >5: poor sleep quality;
≥15: important sleep impairment (10).
Epworth Sleepiness Scale
The Epworth Sleepiness Scale (ESS), which represents daytime sleepiness,
consists of 8 items that are each rated on a 4-point scale. ESS <10
corresponds to the absence of sleepiness, ESS 11–15 suggests excessive
daytime sleepiness, and ESS >16 indicates severe sleepiness (11).
Beck Depression Inventory
We used the Beck Depression Inventory (BDI) to evaluate depressive
symptoms. The BDI consists of 21 items rated on a 4-point scale. BDI <9
shows the absence of depression or minimal depressive symptoms, 10–
18 indicates slight-to-moderate depression, 19–29 illustrates moderate-
to-severe depression, and 30–63 indicates severe depression (12).
Beck Anxiety Inventory
The Beck Anxiety Inventory (BAI) measures the intensity of anxiety
symptoms in patients with depression. This questionnaire consists of 21
items that reflect typical anxiety symptoms somatically, emotionally, and
cognitively, rated on a 4-point scale from 0 to 3. The total score may vary
from 0 to 63. BAI <10 shows the absence of anxiety or minimal anxiety
symptoms, 11–19 indicates slight-to-moderate anxiety, 20–30 reveals
moderate-to-severe anxiety, and 31–63 indicates severe anxiety (13).
Quality of Life (QoL)
A generic questionnaire for the assessment of QoL (SF-36) was used
in this study. The SF-36 is composed of 36 items, which measure eight
health-related QoL domains; physical functioning (PF), social functioning
(SF), role limitation due to physical problems (RP), role limitation due to
emotional problems (RE), mental health (MH), energy and vitality (VT),
bodily pain (BP), and general perception of health (GH). For each QoL
domain tested, item scores were coded, summed, and transformed into
a scale from 0 (worst) to 100 (best) using the standard SF-36 scoring
algorithms. Besides that, Physical and Mental Summary Component
12
Arch Neuropsychiatry 2021;58:11−15
Scale (PCS and MCS, respectively) scores were also calculated using the
algorithm described by the developers (14).
Statistical Analysis
Statistical analyses were performed using the SPSS 24.0 software (SPSS
Inc., Chicago IL). The clinical and demographic characteristics of patients
are presented as mean ± standard deviation (SD) or the absolute number
of subjects. Correlations between numeric variables were investigated
using the Pearson’s correlation analysis. All continuous variables were
analyzed for normality using the Shapiro-Wilk test. Parametric variables
were compared between the groups using Student’s t-test depending on
the number of groups. Non-parametric variables were analyzed using
the Mann-Whitney U or Kruskal-Wallis test depending on the number of
groups. Significance was set at p<0.05.
RESULTS
Subjects
A total of 90 shift workers (50 females, 40 males; mean age 31.84±9.03
years) and 66 regular workers without any shift (42 females, 24
males; mean age 33.25±6.21 years) were included in our study. The
study cohort was stratified into three occupational categories; nurses
(n=58, 64%), technicians (n=25, 28%), and physicians (n=7, 8%). The
participants worked 40 hours per week according to a pre-determined
work schedule.
Ninety-seven percent of the participants had received more than 5 years’
education. There were no differences between the groups in terms of age,
sex, BMI, smoking status and pack/years if they were smokers, alcohol
use, education period, and comorbidities. The demographic variables are
shown in Table 1.
Sleep Hygiene Index, Sleep Quality and Sleepiness Analyses
The difference between the mean SHI score in shift workers (29.7±6.7) and
in regular workers (26.3±6.8) was statistically significant (p=0.002). Items 1,
2, 3, and 5 scores in the SHI had significantly higher in shift workers (Table
2). In our shift worker group, the SHI was associated with ESS (r=0.37;
p<0.0001) and PSQI total score (r=0.363; p<0.0001), as well as PSQI
components such as PS1 (r=0.345, p=0.001) and PS2 (r=0.319, p=0.002).
The SHI also correlated on quality of life parameters such as vitality
(r=-0.284, p=0.007), social function (r=-0.323, p=0.002), mental health
(r=-0.274, p=0.009), and calculated MCS (r=-0.302, p=0.004) (Figure 1).
Sixty of the 90 (67%) shift workers and 37 of the 66 (57%) regular workers
had global PSQI scores >5. Although PSQI total scores were not statistically
different between the shift workers and regular workers, the component
2 score was higher among shift workers. The total PSQI scores among
shift workers tended to be higher than in regular workers (6.17±3.29 vs.
5.45±2.88), but no significant difference was found.
The ESS score was >10 in 20/90 (22%) in shift workers and 7/66 (10%) in
regular workers. Although daytime sleepiness scores and risk of excessive
daytime sleepiness tended to be worse among the shift workers, no
statistically significant differences were detected (p=0.058).
Results of Quality of Life
The comparison of mean ( ± SD) values of the SF-36 domains between
the study groups is presented in Table 3. Regarding the eight domains
of SF-36 QoL profiles, the mean scores of physical role limitations
(p=0.047), social role functioning (p=0.003), and emotional role
functioning (p=0.046) were significantly lower among shift workers than
in regular workers. The other domains were not significantly different
between the study groups. The calculated MCS and PCS scores were
analyzed subsequently. Although MCS scores were lower (p=0.017) in
shift workers, there were no statistically significant differences in PCS
Arch Neuropsychiatry 2021;58:11−15 Görgün-Hattatoğlu et al. Sleep in Shiftworking Healthcare Professionals

Table 1. Demographic features of study groups

Shift Workers Regular Workers

(n=90) (n=66) p*
Age 31.84 ± 9.03 33.25 ± 6.21 0.249
Sex
Female, n (%) 50 (55.5) 42 (63.6)
0.311
Male, n (%) 40 (44.5) 24 (36.3)
Height 1.67 ± 0.08 1.68 ± 0.09 0.453
Weight 67.24 ± 13.11 69.74 ± 15.64 0.294
BMI 23.81 ± 3.60 24.25 ± 3.68 0.452
Smoking status
Yes, n (%) 34 (37.7) 19 (28.7)
0.241
No, n (%) 56 (62.3) 47 (71.3)
Smoking (pack/year) 13.62 ± 14.19 11.57 ± 8.32 0.563
Alcohol use
Yes, n (%) 17 (18.8) 18 (27.3)
0,282
No, n (%) 73 (81.2) 48 (72.7)
Education period 13.68 ± 2.87 14.13 ± 2.73 0.329
Charlson Comorbity Index 0.078 ± 0.374 0.015 ± 0.123 0.141
Modified Comorbidity Index 0.200 ± 0.656 0.152 ± 0.401 0.596
BMI: Body mass index=weight (kg)/height (m)2, Data are expressed as mean ± SD or median (range)., *T-test or chi square test

Table 2. SHI, PSQI and ESS results in study groups

Mental Summary Component

Shift Workers Regular Workers
Social Function

(n=90) (n=66) p
SHI
Total 29.71 ± 6.66 26.27 ± 6.75 0.002
SHI-1 2.28 ± 0.95 1.68 ± 0.86 0.001
SHI-2 3.41 ± 1.25 2.65 ± 1.11 0.001 Sleep Hygiene Index Sleep Hygiene Index
SHI-3 3,12 ± 1.27 2.15 ± 0.86 0.001
SHI-4 1.24 ± 0.50 1.24 ± 0.58 0.982
SHI-5 2.48 ± 1.15 1.87 ± 0.86 0.001
Beck Anxiety Score
Beck Depression

SHI-6 2.32 ± 1.54 2.07 ± 1.39 0.306

SHI-7 2.56 ± 1.43 2.72 ± 1.40 0.487
SHI-8 1.92 ± 0.96 1.87 ± 0.90 0.775
SHI-9 2.54 ± 1.40 2.28 ± 1.43 0.266
SHI-10 1.47 ± 0.82 1.34 ± 0.73 0.312
SHI-11 1.33 ± 0.61 1.40 ± 0.85 0.523
Sleep Hygiene Index Sleep Hygiene Index
SHI-12 2.13 ± 1.15 1.89 ± 0.99 0.177
SHI-13 2.86 ± 1.24 3.00 ± 1.26 0.513 Figure 1. Scatter plots showing the correlation between Sleep Hygiene Index and
A) Social Function, B) Mental Summary Component, C) Beck Depression and D) Beck
ESS
Anxiety Score. SHI had a strong effect on quality of life parameters such as social
≤ 10, n (%) 70 (77.7) 59 (89.3) function (r=-0.323, p=0.002), and calculated MCS (r=-0.302, p=0.004). Both anxiety and
0.058 depression scores were correlated with SHI (r=0.397, p<0.0001, r=0.256, p=0.015)
> 10, n (%) 20 (22.3) 7 (10.7)
PSQI
scores (p=0.409) between the groups (Table 3). The calculated PCS
<5, n (%) 30 (33.3) 29 (43.9) scores showed significant associations with BDI and BAI scores (r=-0.274,
0.177
≥ 5, n (%) 60 (66.7) 37 (56.1) p=0.009 and r=-0.345, p=0.001, respectively). The calculated MCS had a
Total 6.17 ± 3.29 5.45 ± 2.88 0.156 significant association between BDI (r=-0.595, p<0.0001), BAI (r=-0.491,
PSQI-1 1.26 ± 0.77 1.13 ± 0.52 0.213 p<0.0001), ESS (r=-0.328, p=0.002), total Pittsburgh score (r=-0.313,
PSQI-2 1.50 ± 1.16 1.03 ± 1.02 0.010 p=0.003) and also PS1 (r=-0.238, p=0.025), PS6 (r=-0.351, p=0.001), and
PSQI-3 0.84 ± 0.86 0.95± 0.87 0.432 PS7 (r=-0.352, p=0.001).
PSQI-4 0.24 ± 0.62 0.24 ± 0.72 0.985
PSQI-5 1.16 ± 0.54 1.18 ± 0.55 0.865
PSQI-6 0.14 ±0.55 0.12 ± 0.48 0.784
Mood and Shift Work
PSQI-7 1.00 ± 1.06 0.78 ± 0.88 0.188 Scores of the BAI and BDI statistically significantly increased in shift
workers compare to regular workers (p=0.026, p=0.008, respectively). In
SHI: Sleep Hygiene Index, ESS: Epworth Sleepiness Scale, PSQI: Pittsburgh Sleep addition, both anxiety and depression scores were positively correlated
Quality Index., *T-test or chi square test
with SHI (r=0.397, p<0.0001; r=0.256, p=0.015) (Figure 1).

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Görgün-Hattatoğlu et al. Sleep in Shiftworking Healthcare Professionals Arch Neuropsychiatry 2021;58:11−15

risk of shift work disorder (25). In population-based studies it was shown

Table 3. Comparison between the groups for average ranks of SF-36 quality of life
scores that sleep hygiene practice is associated with poor sleep quality and
functional outcomes including QoL (7, 26). Increased needs of daytime
Shif Workers Regular Workers p* nap, variability of both go and get out of bed and stay in bed longer than
Physical Functioning 85.50 ± 15.65 92.12 ± 10.15 0.207 usual were determined in shift workers which might have a critical role
on QoL. In our shift worker group, the SHI was associated with quality of
Physical Limitation 76.11 ± 34.12 85.98 ± 27.43 0.047 sleep and daytime sleepiness. We also showed increased sleep latency as
mentioned in previous studies, which would be the result of poor sleep
Emotional Limitation 71.55 ± 38.38 83.30 ± 32.34 0.046
hygiene (19–21). Furthermore, it would be important to show the effect
General Health 67.83 ± 1828 69.09 ± 19.03 0.677 of sleep hygiene on health-related outcomes (e.g. QoL, mood, daytime
sleepiness, and cognitive functions).
Perceptions Vitality 55.55 ± 21.27 60.75 ± 21.75 0.137

Social Functioning 70.53 ± 26.44 81.57 ± 18.45 0.003
Pain 74.78 ± 22.50 77.47 ± 22.13 0.460
Mental health 64.40 ± 19.05 69.93 ± 15.59 0.048
Physical component 52.88 ± 7.32 53.86 ± 7.00 0.409
Mental component 35.07 ± 16.94 41.26 ± 13.62 0.017
* T-test.
DISCUSSION
Evaluation of Sleep Quality and Sleep Hygiene in Shift Workers
Although daytime sleepiness and sleep quality, except sleep latency
period, did not affect the shift workers in our cohort, the SHI was
significantly increased, which indicates more maladaptive sleep hygiene
practices. Several studies have suggested the relationship between shift
work and impaired sleep characteristics such as decreased quantity
and quality of sleep and sleep deprivation in healthcare workers (15–
17). Sleep quality can be assessed using scales such as the PSQI, which
includes quantitative measures such as a sleep duration, sleep latency,
and number of awakenings. Our study showed that the presence of poor
sleep quality among healthcare workers was tended to higher (67% in shift
workers and 57% in regular workers had PSQI scores >5), as consistent
with the previous reports that showed that sleep impairment was
generally common among healthcare workers (18). Although the total
PSQI scores in shift workers tended to be higher than in regular workers,
no significant difference was found as a similar to a previous study (19). In
addition, the component 2 score, which reflects sleep latency was higher
among shift workers, which might be the result of poor sleep hygiene
has been shown in our study as a first report in the English literature. It
seems that quality of sleep, as assessed using the PSQI in our study, was
not excessively affected in shift workers except sleep latency period. This
result is consistent with previous reports showed difficulty in falling sleep
was one of the most common health-related effects of shift work (19–21).
ESS, which is used in the assessment of daytime sleepiness, is positively
correlated with poor sleep quality, and this result was confirmed in our
study (22). ESS is one of the main indicators showing the detrimental effects
of poor sleep (11, 23). We showed that both shift workers and regular
workers in healthcare had an increased prevalence of abnormal sleepiness.
However, no significant differences were detected between the groups.
It can be concluded that shift work by healthcare professionals does not
affect daytime sleepiness, consistent with findings of previous reports (24).
Quality of Life in Shift Workers and Items Associated with Sleep
Impaired sleep has a critical role for QoL constructed by psychological,
physical, and social health. Conflicting results available between shift work
and health problems. This is because there are a lack of comprehensive
data addressing whether there are any detrimental effects of shift work
due to the consequences of various functional outcomes such as daytime
sleepiness, mood, sleep quality, and quality of life. Our findings are
consistent with previous studies showing that shift work is associated
with severely impaired QoL (27, 28), with the social (24, 28) and
emotional components (21) being affected most. In the present study,
both anxiety and depression scores were higher among shift workers
than in regular workers, and had an association with all QoL parameters
including summary scores of mental and physical components. Although
the considerable literature supports the relationship between shift work
and QoL, conflicting results have been reported until now (29, 30).
In our study, physical role limitations, social role functioning, and
emotional role functioning were affected significantly in shift workers. In
addition, the calculated MCS was affected more seriously than PCS in this
group. Difficulties related with sleep latency, arousal, early awakening,
and others can lead to poorer sleep quality and shorter sleep duration,
which conclude with harmful effects in personal and social life as well
as cognitive function needs for occupational safety. Various problems
such as deprived sleep and poor sleep hygiene could be responsible
for the detrimental effect of QoL parameters in shift workers. Although
associations between QoL and sleep quality (31), as well as sleep quality
and sleep hygiene (5, 9) have been shown in previous studies, no data
have been available regarding the effect of sleep hygiene on QoL in
healthcare professionals who work shifts. Limited study that evaluated
the relationship between sleep hygiene and QoL in people with epilepsy
or sleep apnea, they concluded that sleep hygiene disturbances has been
associated with lower QoL (7, 8). Our study is very important to show
sleep hygiene effects to QoL in a different population which would be
responsible for the workplace safety.
The most important limitation of our study is that polysomnography,
which is known as the gold standard diagnostic method for sleep
disorders, was not used. In addition, possible sleep disorders such as
obstructive sleep apnea syndrome and restless leg syndrome were
evaluated clinically using questionnaires developed for these disorders,
and participants with any sleep disorder were excluded from the study.
We also included people who worked in the same institute which might
be important for the exclude the effects of environmental factors but also
can effect to the results due to related with the special difficulties of the
institution.

We found poorer sleep hygiene behaviors in shift-working healthcare
professionals compared with regular workers. Although sleep hygiene
practice can be affected in shift workers, limited data are available in the
English literature to determine poor sleep hygiene behaviors in either
healthcare workers or shift workers in general. Recently, Booker LA et al.
has been shown close relationship between poor sleep hygiene and high
In our study, we aimed to show the effects of shift work, if any, on sleep
deterioration as well as other health outcomes. To our knowledge we
firstly showed possible relationship between sleep hygiene and QoL in
health-care workers related with the shift based schedule. Poor sleep
hygiene, as the reason for increased sleep latency, may have detrimental
effects in QoL but without affecting sleep quality among shift workers.

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Arch Neuropsychiatry 2021;58:11−15 Görgün-Hattatoğlu et al. Sleep in Shiftworking Healthcare Professionals

15. Gómez-García T, Ruzafa-Martínez M, Fuentelsaz-Gallego C, Madrid JA,

Ethics Committee Approval: Our study was approved by the local ethics committee Rol MA, Martínez-Madrid MJ, Moreno-Casbas T; SYCE and RETICEF Group
(Number: 1126). Nurses’ s sleep quality, work environment and quality of care in the Spanish
Informed Consent: All participants gave written informed consent. National Health System: Observational study among different shifts. BMJ
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Peer-review: Externally peer-reviewed. 16. Karhula K, Hakola T, Koskinen A, Ojajärvi A, Kivimäki M, Härmä M. Permanent
Author Contributions: Concept- DGH, ŞA; Design- DGH, ŞA; Supervision- DGH, ŞA,
night workers´ sleep and psychosocial factors in hospital work. A comparison
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ŞA, CA; Analysis and/or Interpretation- DGH, CA, ŞA, BPY; Literature Search- DGH, CA; 17. Pilcher JJ, Lambert BJ, Huffcutt AI. Differential effects of permanent and
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