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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 8  |  Issue : 2  |  Page : 106-109

Assessment of sleep quality among postgraduate residents of a tertiary care hospital in Kashmir: Using the Pittsburgh Sleep Quality Index


1 Directorate of Health Services Kashmir, Jammu and Kashmir, India
2 Department of Community Medicine, GMC, Srinagar, Jammu and Kashmir, India

Date of Submission05-Aug-2022
Date of Decision08-Oct-2022
Date of Acceptance10-Oct-2022
Date of Web Publication31-Dec-2022

Correspondence Address:
Dr. Tanzeela Bashir Qazi
Department of Community Medicine, GMC, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijcfm.ijcfm_53_22

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  Abstract 

Introduction: The Postgraduate medical training is long and emotionally taxing. These occupations are associated with stress and good workload along with night shifts which effects the sleep quality. Studies have documented that high levels of stress among medical residents have been associated with sleep problems. Our study aims to investigate sleep quality among the postgraduate residents of a tertiary care hospital using Pittsburgh Sleep Quality Index.
Material and Methods: It was a cross sectional study that was conducted from 1 November 2021 to 31 December 2021. Study participants included Postgraduate medical residents working at a tertiary care hospital in district Srinagar of Kashmir valley. A total of 400 participants took part in the study.
Results: The mean age of the participants was 33.4 years (S.D 4.9). Majority of the participants (54%) were females. The mean global Pittsburgh Sleep Quality Index score (±SD) for sleep quality was 8.46 (±4.5) with a median score of 6 and Inter Quartile Range of 6.5.
Conclusion: Poor sleep quality was reported in 75% of the residents. This highlights the need for awareness about this problem. There is a need for early interventions in order to introduce flexible working hours for medical residents and to provide shifts of manageable durations.

Keywords: Pittsburgh Sleep Quality Index, postgraduate residents, sleep quality


How to cite this article:
Yousuf AM, Qazi TB. Assessment of sleep quality among postgraduate residents of a tertiary care hospital in Kashmir: Using the Pittsburgh Sleep Quality Index. Indian J Community Fam Med 2022;8:106-9

How to cite this URL:
Yousuf AM, Qazi TB. Assessment of sleep quality among postgraduate residents of a tertiary care hospital in Kashmir: Using the Pittsburgh Sleep Quality Index. Indian J Community Fam Med [serial online] 2022 [cited 2023 Feb 2];8:106-9. Available from: https://www.ijcfm.org/text.asp?2022/8/2/106/366548


  Introduction Top


The postgraduate medical training is long and emotionally taxing. These occupations are associated with stress and good workload along with night shifts which affect sleep quality. Commonly encountered sleep disorders are insomnia, parasomnia, and hypersomnia. Studies have reported a sleep disorder of 10% among individuals who have night and rotating shift work.[1] Both undergraduate and postgraduate medical students are subjected to a stressful daily routine. Conventionally, medical residency programs in India are known for working long hours. In the 1990s, residents of surgery used to work for more than 100 h per week.[2] Nowadays, the Accreditation Council of Graduate Medical Education (ACGME)-mandated resident work hours to 80 h weekly for surgical residents.[3] All this leads to the symptoms of anxiety, fatigue, daytime sleepiness, and burnout among postgraduate residents.[4] The poor sleep quality and daytime sleepiness among medical residents have profound implications on their health and can indirectly affect the health-care system also.

The ongoing COVID-19 pandemic has also added to the stressful conditions of medical residents. The daily rising in the number of cases, unpreparedness, lack of vital resources, excessive workload, and the inability to contain the spread has caused fear and anxiety among the public, especially the physicians, residents, fellows, and health-care workers. The medical residents are at the front line of the COVID-19 outbreak response and as such are exposed to hazards that put them at risk of infection and thereby increasing workload and burnout among them. This also has profound implications on sleep quality of medical residents. Studies have documented that high levels of stress among medical residents have been associated with sleep problems.[5] Prolonged working hours usually lead to sleep deprivation and can have adverse health events. Our study aims to investigate sleep quality among the postgraduate residents of a tertiary care hospital using the PSQI.


  Materials and Methods Top


This was a cross-sectional study conducted from November 1, 2021, to December 31, 2021 at a tertiary care hospital in the district of Srinagar of Kashmir valley. Postgraduate medical residents working at the hospital have participated in the study. The inclusion criteria for participants are as:

  1. Medical residents pursuing postgraduation in clinical branches of a tertiary care hospital
  2. Those willing to participate.


It was an online survey designed to assess sleep quality among postgraduate medical residents. Data were collected using an online questionnaire through Google Forms and it was disseminated through WhatsApp application. A structured questionnaire – PSQI was used that was pretested in a pilot phase on 10 participants' study and the necessary changes in language, style, and responses were done. In the initial part of the form, the participants were informed about the conduct of the research. Information regarding the purpose of the study and research objectives was provided to the participants. All the survey responses were anonymized using unique random generated codes. Consent was obtained from all the study participants.

A sample size of 372 was obtained taking the prevalence of 63% and an error of 5%.[6] Hence, a total of 400 participants were recruited for the study.

The PSQI was used to assess the sleep quality among medical residents. It is a validated and frequently used scale to assess sleep quality. It contains 19 self-rated questions. These are then combined to form seven component scores. The components are subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disorders, use of sleep medication, and daytime dysfunction. The seven components are then added to yield one global score ranging from 0 to 21 points with “0” indicating no difficulty and “21” indicating severe difficulty in all areas.[6] Scores ≥5 indicated poor sleep quality and <5 were considered good sleep quality. A PSQI global score >5 resulted has a sensitivity of 98.7 and specificity of 84.4 as a marker for sleep disturbances.[7]

Statistical analysis

Data were entered into a Microsoft Excel spreadsheet and analyzed using SPSS 23 version. Categorical variables were expressed as frequencies and percentages, and continuous variables were expressed as mean ± standard deviation (SD). Pearson's Chi-square test/Fischer's exact test was used to determine the association between categorical variables. Backward stepwise elimination was used to remove nonsignificant variables until only statistically significant variables remained in the final model. Adjusted odds ratio (OR) and the corresponding 95% confidence interval were calculated using multivariable logistic regression analysis. P < 0.05 was considered statistically significant.

The study had no ethical issues related to animal or human experimentation. The study was approved by the Institutional Ethical Committee of Government Medical College, Srinagar vide ref. no. 133/ETH/GMC.


  Results Top


A total of 400 participants were enrolled in the study. The mean age of the participants was 33.4 (± 4.9) years. The majority of the participants (54%) were females. The type of specialty was categorized as medical and surgical. Most of the participants (62.5%) belonged to the medical specialty. Sixteen percent of the participants were residing in a hostel, whereas the remaining were residing at their home. The postgraduate training is a 3-year training. Most of our participants (41%) were in the 2nd year of training [Table 1].
Table 1: Sociodemographic characteristics of study participants

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Mean and median values of scores of the Pittsburgh Sleep Quality Index categories are depicted in [Table 2]. The mean global PSQI score for sleep quality was 8.46 (SD = 4.5) with a median score of 6 and interquartile range of 6.5. [Figure 1] illustrates a box and whisker plot showing median of various domains of PSQI score. The mean PSQI score for medical speciality was 8.8 ± 4.6 and for surgical speciality was 8.4 ± 4.5 [Table 3]. Poor sleep quality was reported in 75% of the participants [Table 4]. Poor sleep quality was more commonly reported among 3rd-year residents. A statistically significant association was derived between the quality of sleep and type of specialty. Sleep quality was poorer among residents of medical branches as compared to surgical branches (P = 0.002). Quality of sleep also differs significantly across different years of residency (P < 0.001) [Table 5].
Table 2: Mean and median values of scores of the Pittsburgh Sleep Quality Index categories among postgraduate residents

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Figure 1: Box and whisker plot showing various domains of PSQI score. PSQI: Pittsburgh Sleep Quality Index

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Table 3: The mean values for the Pittsburgh Sleep Quality Index score as per specialty

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Table 4: Distribution of participants as per their sleep quality based on the Pittsburgh Sleep Quality Index score

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Table 5: Association between sleep quality with clinical specialty and year of residency

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[Table 6] depicts the multivariable logistic regression analysis of sleep quality among postgraduate residents shows that after controlling for all the other variables in the table, males were almost 60% less likely to have good sleep quality than females. Those with surgical specialty had 1.8 higher odds of good sleep quality than medical residents. Statistically, positive association was also found for the place of residence and year of residency in full as well as the final model.
Table 6: Multivariable logistic regression analysis of sleep quality among postgraduate residents

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  Discussion Top


In our study, we assessed the sleep quality among medical residents using the PSQI A total of 400 residents were enrolled in the study. Our results showed three-fourth of the participants had poor sleep quality which is higher than the study conducted by Esen et al. among medical residents which reported that 54% of the residents had poor sleep quality.[1] The poor sleep quality among medical residents can attributed to multiple factors. First, the increased workload which results in exhaustive work schedule and long and tiring night shifts. Second, the ongoing COVID-19 pandemic had added to the already present stress and burnout.

Global PSQI scores were higher among medical residents as compared to surgical residents. We also derived a significant association between the type of specialty and quality of sleep. These results are contrary to the findings of a study where poor sleep quality was reported more among surgical residents.[1] Based on PSQI component scores, it was seen that subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, and sleep disturbances were reported as more severe as compared to the other component scores. These results are similar to other studies.[8],[9] This can be attributed to the fact that extreme work stress and being overburdened with work interferes with the ability of residents to fall asleep and this has greater impact on the subjective assessment of their sleep quality.

We also derived a significant association between the year of residency and quality of sleep (P < 0.001). Sleep quality was poorer among 3rd-year residents as compared to 1st and 2nd years. This may be attributed to the fact that 3rd-year residents are examination going and are subjected to more stress than 1st and 2nd years as they have to submit their thesis and prepare for examinations also, in addition to their existing workload. All these highlight the need for awareness of this problem. The poor sleep quality among residents is likely to affect their well-being and health. There is a need for early interventions to introduce flexible working hours for medical residents and to provide shifts of manageable durations. Education regarding the practice of sleep hygiene among medical residents can also play a role. Such interventions will ensure a productive resident which in turn will lead to good patient care. The productive residents will then lead to quality care for patients and thereby improve the health status of the country.

There are a few strengths of the study. First, it was the first cross-sectional study to assess the sleep quality (using PSQI) among medical residents of a tertiary care hospital in Srinagar. Second, a validated questionnaire was used to assess sleep quality. Finally, the study had a good sample size. One of the limitation of the study is the nature of the questionnaire which was self-administered. Second, no adjustment was done for any potential confounders which could lead to bias. Finally, the study was limited to a small duration of 1 month, which may have diminished our ability to fully represent the sleep quality of medical residents.


  Conclusion Top


Poor sleep quality was reported in more than half of the residents. Sleep quality was poorer among medical residents than surgical residents. This in turn can adversely affect the physical health as well as the cognitive performance of the medical residents. It is also associated with low clinical performance. These sleep disturbances among medical residents are mainly attributed to excessive working hours and increased number of night duties.

Recommendations

More attention to this problem is needed, taking into consideration that sleep disorders can affect one's quality of life and predispose a person to some medical conditions such as metabolic syndrome, and can also be associated with poor work performance. A need for early interventions to have flexible working hours for medical residents and to provide them with shifts with manageable durations is recommended. Few more studies in other geographic regions are suggested to compare the results and to do the necessary interventions to have a balanced work schedule.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Esen AD, Mercan GN, Kacar E, Toprak D. Sleep quality and related factors in medical residents. TJFMPC 2017;11:271-7.  Back to cited text no. 1
    
2.
Ulmer C, Wolman DM, Johns ME. Resident Duty Hours: Enhancing Sleep, Supervision and Safety. Washington (DC): National Academies Press; 2009.  Back to cited text no. 2
    
3.
Hutter MM, Kellogg KC, Ferguson CM, Abbott WM, Warshaw AL. The impact of the 80-hour resident workweek on surgical residents and attending surgeons. Ann Surg 2006;243:864-71.  Back to cited text no. 3
    
4.
Carvalho Aguiar Melo M, das Chagas Medeiros F, Meireles Sales de Bruin V, Pinheiro Santana JA, Bastos Lima A, De Francesco Daher E. Sleep quality among psychiatry residents. Can J Psychiatry 2016;61:44-9.  Back to cited text no. 4
    
5.
Alsaggaf MA, Wali SO, Merdad RA, Merdad LA. Sleep quantity, quality, and insomnia symptoms of medical students during clinical years. Relationship with stress and academic performance. Saudi Med J 2016;37:173-82.  Back to cited text no. 5
    
6.
Murthy VS, Nayak AS. Assessment of sleep quality in post-graduate residents in a tertiary hospital and teaching institute. Ind Psychiatry J 2014;23:23-6.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Pittsburgh Sleep Quality Index Questionnaire. Available from: PSQI.pdf (opapc.com). [Last accessed on 2022 Feb 04].  Back to cited text no. 7
    
8.
Backhaus J, Junghanns K, Broocks A, Riemann D, Hohagen F. Test-retest reliability and validity of the Pittsburgh sleep quality Index in primary insomnia. J Psychosom Res 2002;53:737-40.  Back to cited text no. 8
    
9.
Cox SD, Benoit JS, Brohard CL, McIntyre TM. Evaluation of sleep quality among nursing faculty: Application of the Pittsburgh sleep quality index-A descriptive correlational study. Nurs Open 2022;9:339-48.  Back to cited text no. 9
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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