Skip to main content

Sleep disturbances among physicians during COVID-19 pandemic

Abstract

Objectives

To assess prevalence and related factors of sleep disturbances among Saudi physicians during COVID-19 pandemic. Data were collected through a questionnaire including items about demographic characters, knowledge about covid-19 and items to assess sleep quality that were extracted from Pittsburgh Sleep Quality Index (PSQI) scale.

Results

Prevalence of sleep disorders was 43.9%, doctors in the age group of 31–40 years, associate consultants had a significant higher prevalence of sleep disorders. Medical interns and laboratory/pathology/microbiology doctors had a significant more difficulty in fall asleep during COVID-19, and internists and surgeons had a significant higher percent of those who used sleeping pills. Resident doctors had a significant higher percent of having trouble in staying awake, and residents and consultants had a significant higher percent of those who suffered decreased sleep duration. Sleep quality during COVID-19 was very good, fair good and very bad in 23.4%, 60% and 3.5% of HCW respectively. The study observed a negative impact of COVID-19 pandemic on HCW sleep quality. Hospitals administrations should provide optimal working hours with enough break and employ more doctors during the pandemic. Doctors experiencing sleep problems should have mandatory leaves.

Introduction

COVID-19 appeared in Wuhan, China, in December 2019 and rapidly spread to become a global pandemic.[1,2,3,4]. Clinical manifestations include mainly fever (99%), fatigue (70%), dry cough (60%), myalgia (44%), and dyspnea at the onset of the disease [5, 6]. Treatment of COVID-19 is mostly supportive and no known effective specific treatment exists [7].

All people during COVID-19 pandemic have fears of getting infected or infecting others [8]. Health care workers face other stresses, such as absence of clear strategy to follow and an increased risk of exposure to aerosols [8].

Sleep disorders involve problems either in the quality, timing or amount of sleep [9, 10]. Studies from China identified that healthcare workers were at high risk for poor sleep quality during COVID-19 epidemic [11], and high prevalence of post-traumatic stress syndrome and poor sleep quality [12]. No published studies addressed the problem of sleep quality during COVID-19 epidemic in Saudi Arabia. The current study aimed to assess prevalence and related factors of sleep disturbances among Saudi physicians of the Western province of Kingdom of Saudi Arabia (KSA) during COVID-19 pandemic.

Main text

Methods

Study design and setting, and time frame: a cross-sectional survey was carried out in health care settings in the Western province of Saudi Arabia that included the Mecca, Jeddah, and Taif cities. The study was done during the period the period of May 2020 to August 2020.

Study participants: The study was carried out on Saudi doctors who were willing to participate in the survey. Physicians working in other regions of Saudi Arabia and non-Saudi doctors were excluded from our study.

Sample size and sampling method: a minimum sample size of 327 was calculated with 95% confidence level, 5% margin of error and power of study (β-error) at 80% considering the values derived from the pilot study. A mixture of cluster, convenience and snowball sampling was followed to acquire the minimum sample size.

Data collection: a pre-tested and validated questionnaire was used. Social media tools were used to broadcast the relevant link of the questionnaire.

The questionnaire included items to collect demographic data, and knowledge about COVID-19. Knowledge items were about (a) inhalation of droplets from sneezing, coughing, or talking of an infected person (b) contact with something contaminated by an infected person, (c) the incubation period of the virus, (d) contact with an asymptomatic person and possibility of infection, and (e) if there are already targeted drugs that could cure the disease. For all questions responses to items related to knowledge regarding COVID-19 were recorded and each correct response were given a score of ‘1’ and wrong answers were given score ‘0’ (11). Thus, the maximum score one could get is 6. The scores were then categorized based on the percentages into ‘Good’ (80–100%), Fair (60–79%) and Poor (< 59%).

For assessing the sleep quality, five items were extracted from Pittsburgh Sleep Quality Index (PSQI) scale [13], and these include: Subjective sleep quality, difficulty in starting sleep within 30 min, easy waking during sleep and early waking in the morning, use of sleep medication, and the sleep duration, within 1-month lasted. A very good quality sleep is defined when the subject experiences all of the five characteristics mentioned: (a) Sleeping more time while in bed (at least 85% of the total time in bed), (b) Falling asleep in 30 min or less, (c) Sleeping for more 7 h or more, (d) Falling back asleep within 20 min after getting up, and (e) Waking up—for five minutes or longer—no more than once a night. Subjects were asked to rate the quality of their sleep based on the above five points as ‘very good’, ‘fairly good’, ‘fairly bad’ and ‘very bad’. Single-item sleep measures have been used in previous studies [12, 14].

Validation of the Questionnaire: the questionnaire included items that covered knowledge regarding Covid 19 infection and measured the sleep quality. The items related to sleep quality was adopted from Pittsburgh Sleep Quality Index (PSQI) scale by Buysse et al. [13]. Validation of this questionnaire was done using focus group discussion, expert evaluation, pilot study, reliability and validity assessment etc. Three experts in the field of COVID 19 and one biostatistician were involved in the validation of our questionnaire. A pilot study was done on 15 participants and the data obtained was used for reliability and validity analysis. Content validity, face validity, and construct validity of the developed questionnaire were examined. Content validity and face validity were established by expert evaluation and focused group discussions.

Construct validity was established by exploratory factor analysis with varimax rotation to test the hypothesized domain structure and examine its substructure. Items with correlation coefficient > 0.7 were omitted. Internal consistency was examined, but test/retest reliability could not be performed because of paucity of time. The homogeneity of the question items in each domain was evaluated using Cronbach's α coefficient. A coefficient of 0.7 or higher is preferred for a questionnaire to be internally consistent.

Data analysis: data analysis done by the SPSS program version 23. Descriptive statistics in the form frequencies and percentages were used to describe the demographics; sleep characteristics and COVID-19 related knowledge among the study participants. Means and Standard deviations (mean ± SD) were used to represent continuous variable and Pearson’s Chi-Square test was used to test the association between categorical variables.

Results

Of the participants, 340 (73.6%) had an age ranging from 23–30 years, 235 (50.9%) were females, 202 (43.7%) were from Taif city, 256 (55.4%) were residents, and 18.6% had an internal medicine specialty. The mean knowledge score in our study was found to be 4.23 ± 1.06 thus showing ‘good’ scores by 78.1% (n = 361), 12.1% showed fair knowledge and 9.7% gave poor scores. When the relationship of the knowledge scores and difference sociodemographic characteristics were assessed, there was no statistically significant difference observed with the gender, age, position, specialty and region of practice of doctors (Table 1, Additional file 1: Figure S1).

Table 1 Relationship of Knowledge about COVID-19 with gender, age and designation of participants

The prevalence of sleep disorders in our study was found to be 43.9% during COVID-19 pandemic. When the relationship of sleep disorders with different sociodemographic and work-related characteristics was compared, there was significant association observed with age, position and specialty. Doctors who belonged to age group of 31–40 years showed more prevalence of sleep disorders (63%) compared to other age groups (p = 0.002). When the prevalence of sleep disorders with different position of doctors at hospitals was assessed, it was found that associate consultants and residents showed more sleep disorders than other groups with a highly statistically significant association. The prevalence of sleep disorders was found to be 53.1% and 49.6% in associate consultants and residents respectively (p < 0.001) (Table 2). When the prevalence of SD was examined based on different specialties, anesthetists, Laboratory/Pathology/Microbiology specialists and dentists had the highest prevalence (66.7%) compared to other specialties with a statistically significant association (p = 0.024) (Additional file 1: Figure S2).

Table 2 Prevalence of sleep disorders and its relationship with Age, gender and designation of participants

Assessment of different sleep characteristics during COVID-19 is given in Table 3. When the participants’ difficulty to fall asleep within 30 min was measured, it was found that 24.7% had the difficulty to fall asleep twice or more in a week during COVID-19, compared to 10.2% before the pandemic with a statistically significant difference (p < 0.001). Difficulty in fall asleep during COVID-19 showed a statistically significant association with specialty of the participants, where medical interns and doctors working in laboratory/pathology/microbiology department had significantly more difficulty (p = 0.002). The evaluation of usage of sleeping pills during COVID-19 showed that 3.9% and 10.2% used it three or more times a week and one or twice week respectively. This usage was more seen in internists (31.9%) and surgeons (19.1%) compared to other specialties with a statistically significant association (p = 0.028) (Table 3).

Table 3 Sleep characteristics and its relationship with Sociodemographic characters

The prevalence of trouble in staying awake while driving, eating meals or engaging in social activity was 6.1% and 13.9% in ≥ 3 times a week and once or twice week respectively. This was significantly more reported in resident doctors (≥ 3 times/week = 71.4% and once/twice = 68.8%) compared to other groups (p = 0.002). When sleep duration among doctors was measured, 38.1% reported sleeping for < 6 h/day during COVID-19 compared to 32.3% before COVID-19 with a statistically significant difference (p < 0.001). Residents (45.7%) and consultants (43.1%) showed a significant higher percent of those who suffered decreased sleep duration (< 6 h) during COVID-19 (p < 0.001).

The overall sleep quality during COVID-19 was observed to be very good and fair good in 23.4% and 60% of doctors respectively. Only 3.5% of the doctors were found to have ‘very bad’ sleep during this pandemic, and this was significantly more prevalent in female doctors (5.3%) compared to males (1.7%) (p = 0.027).

Discussion

COVID-19 pandemic is a severe challenge for healthcare physicians in the Kingdom of Saudi Arabia (KSA) [15]. Doctors are at risk of getting infected and are often under great stress thinking of the possible transmission of the infection to their family members, colleagues, and other patients [15]. Epidemiological studies done in the kingdom have reported a very high prevalence of poor sleep quality among the Saudi adult population [16, 17]. In addition to a poor sleep quality among physicians with a prevalence of 50% or more [18, 19]. COVID-19 has affected the mental wellbeing of health care workers that might have an impact on sleep quality [20].

The present study demonstrated that 78.1% of the doctors had good knowledge regarding COVID-19 irrespective of age, gender, position, and specialty. Another study demonstrated insufficient knowledge among doctors about this pandemic [21]. An excellent knowledge about COVID-19 is very essential among physicians when managing or treating patients [22].

The prevalence of sleep disorders among participants of this study was 43.9%. A study conducted in Iraq reported a prevalence of sleepless of 68.3% [23]. Good quality sleep is very much essential to boost the immunity that would help to fight against the viruses and disease [24], and to improve doctor-patient relationship [25].

In the present study physicians had more difficulty falling asleep during COVID-19. Impaired sleep due to high work demands, irregular break-times, and stress may cause clinical burnout in healthcare workers [26]. Sleep disorders were significantly more in physicians who had an age ranging from 31–40 years. This finding is consistent with another study [27]. Also, it was found that residents and the associate consultants had significantly more sleep disorders than others. Young physicians especially residents or associate consultants may be experiencing such a pandemic for the first time, this may force them to sleep in the hospital and lead to sleep deprivation.

The study findings also showed that the trouble staying awake while driving, eating meals, or engaging in social activity was found to be more in resident doctors. Previous studies reported that that physicians who had sleep deprivation are at increased risk of facing motor accidents while driving [28, 29].

The prevalence of sleep disorder during COVID-19 was high among physicians belong to emergency medicine, anesthesia, and Laboratory/Pathology/Microbiology. It is somehow clear that doctors working in laboratories have been working diligently during the last few months giving more priorities for the COVID-19 tests than other routine tests [30]. Sleep quality assessment showed that female physicians had poor sleep quality compared to males. A result revealed from a previous study [30]. Thus, risks of committing medical errors in physicians who have sleep deprivation are more due to cognitive and motor impairment [31, 32]. All these problems arise from a shortage of staff in the respective departments that force the doctors to work for prolonged hours than their actual work hours [33]. During a pandemic, the shortage of medical staff may become worse as some doctors may abstain from work due to fear of getting infected [33].

The hospital administrations should provide optimal work hours with enough break or leisure time, employing more doctors during this pandemic, monitor the doctor-patient ratio, educational and training programs to reduce stress among doctors.

Limitations

The study didn't check the influence of many factors as total working hours/week and substances abuse. The self-reporting questionnaire may have a recall bias.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

SARS:

Severe Acute Respiratory Syndrome

MERS-CoV:

Middle East Respiratory Syndrome Coronavirus

PSQI:

Pittsburgh Sleep Quality Index scale

SD:

Standard deviation

KSA:

Kingdom of Saudi Arabia

References

  1. 1.

    Ramadan N, Shaib H. Middle east respiratory syndrome coronavirus (MERS-CoV): a review. Germs. 2019;9(1):35–42.

    Article  Google Scholar 

  2. 2.

    Zhong NS, Zheng BJ, Li YM, Xie ZH, Chan KH, Li PH, Tan SY, Chang Q, Xie JP, Liu XQ, Xu J, Li DX, Yuen KY, Guan Y. Epidemiology and cause of severe acute respiratory syndrome (SARS) in Guangdong, People’s Republic of China, in February, 2003. Lancet. 2003;362(9393):1353–8.

    CAS  Article  Google Scholar 

  3. 3.

    Chatterjee P, Nagi N, Agarwal A, Agarwa A, Das B, Banerjee S, et al. The 2019 novel coronavirus disease (COVID-19) pandemic: a review of the current evidence. Indian J Med Res. 2020;151(2 & 3):147–59.

    CAS  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Lai THT, Tang EWH, Chau SKY, Fung KSC, Li KKW. Stepping up infection control measures in ophthalmology during the novel coronavirus outbreak: an experience from Hong Kong. Graefes Arch Clin Exp Ophthalmol. 2020;258(5):1049–55.

    CAS  Article  Google Scholar 

  5. 5.

    Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan China. JAMA. 2020;323(11):1061–9.

    CAS  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan China. Lancet. 2020;395(10223):497–506.

    CAS  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Shang Y, Pan C, Yang X, Zhong M, Shang X, Wu Z, et al. Management of critically ill patients with COVID-19 in ICU: statement from front-line intensive care experts in Wuhan, China. Ann Intensive Care. 2020;10(1):73–97.

    Article  Google Scholar 

  8. 8.

    Grover S, Dua D, Sahoo S, Mehra A, Nehra R, Chakrabarti S. Why all COVID-19 hospitals should have mental health professionals: the importance of mental health in a worldwide crisis! Asian J Psychiatr. 2020;51:102147.

    Article  Google Scholar 

  9. 9.

    Thorpy MJ. Classification of sleep disorders. Neurotherapeutics. 2012;9(4):687–701.

    Article  Google Scholar 

  10. 10.

    Maunder RG, Lancee WJ, Balderson KE, Bennett JB, Borgundvaag B, Evans S, et al. Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak. Emerg Infect Dis. 2006;12(12):1924–32.

    Article  Google Scholar 

  11. 11.

    Huang Y, Zhao N. Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: a web-based cross-sectional survey. Psychiatry Res. 2020;288:112954.

    CAS  Article  Google Scholar 

  12. 12.

    Liu N, Zhang F, Wei C, Jia Y, Shang Z, Sun L, et al. Prevalence and predictors of PTSS during COVID-19 outbreak in China hardest-hit areas: gender differences matter. Psychiatry Res. 2020;287:112921.

    CAS  Article  Google Scholar 

  13. 13.

    Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213.

    CAS  Article  Google Scholar 

  14. 14.

    Cappelleri JC, Bushmakin AG, McDermott AM, Sadosky AB, Petrie CD, Martin S. Psychometric properties of a single-item scale to assess sleep quality among individuals with fibromyalgia. Health Qual Life Outcomes. 2009;7:54–61.

    Article  Google Scholar 

  15. 15.

    Medic G, Wille M, Hemels ME. Short- and long-term health consequences of sleep disruption. Nat Sci Sleep. 2017;9:151–61.

    Article  Google Scholar 

  16. 16.

    Ahmed AE, Al-Jahdali F, AlALwan A, Abuabat F, Salih SA, Al-Harbi A, et al. Prevalence of sleep duration among Saudi adults. Saudi Med J. 2017;38(3):276–83.

    Article  Google Scholar 

  17. 17.

    Almojali AI, Almalki SA, Alothman AS, Masuadi EM, Alaqeel MK. The prevalence and association of stress with sleep quality among medical students. J Epidemiol Glob Health. 2017;7(3):169–74.

    Article  Google Scholar 

  18. 18.

    Al-Saif HI. Prevalence of and risk factors for poor sleep quality among residents in training in KSA. J Taibah Univ Med Sci. 2018;14(1):52–9.

    Google Scholar 

  19. 19.

    Zeng LN, Yang Y, Wang C, Li X, Xiang Y, Hall BJ, et al. Prevalence of poor sleep quality in nursing staff: a meta-analysis of observational studies. Behav Sleep Med. 2019;1:1–14.

    Google Scholar 

  20. 20.

    Preti E, Di Mattei V, Perego G, Ferrari F, Mazzetti M, Taranto P, et al. The psychological impact of epidemic and pandemic outbreaks on healthcare workers: rapid review of the evidence. Curr Psychiatry Rep. 2020;22(8):43–65.

    Article  Google Scholar 

  21. 21.

    Bhagavathula AS, Aldhaleei WA, Rahmani J, Mahabadi MA, Bandari DK. Knowledge and perceptions of COVID-19 among health care workers: cross-sectional study. JMIR Public Health Surveill. 2020;6(2):19160.

    Article  Google Scholar 

  22. 22.

    Liu Q, Luo D, Haase JE, Guo Q, Wang XQ, Liu S, et al. The experiences of health-care providers during the COVID-19 crisis in China: a qualitative study. Lancet Glob Health. 2020;8(6):e790–8.

    Article  Google Scholar 

  23. 23.

    Abdulah DM, Musa DH. Insomnia and stress of physicians during COVID-19 outbreak. Sleep Medicine: X. 2020;20:100017.

    Google Scholar 

  24. 24.

    Besedovsky L, Lange T, Born J. Sleep and immune function. Pflugers Arch. 2012;463(1):121–37.

    CAS  Article  Google Scholar 

  25. 25.

    Azzez SS, Abdulah DM, Piro RS, Miho Alhakem SS. Sleep severity and fatigue manifestations in relation to the doctor-patient relationship. Sleep Med. 2019;58:13–7.

    Article  Google Scholar 

  26. 26.

    Söderström M, Jeding K, Ekstedt M, Perski A, Akerstedt T. Insufficient sleep predicts clinical burnout. J Occup Health Psychol. 2012;17(2):175–83.

    Article  Google Scholar 

  27. 27.

    Yasin R, Muntham D, Chirakalwasan N. Uncovering the sleep disorders among young doctors. Sleep Breath. 2016;20(4):1137–44.

    Article  Google Scholar 

  28. 28.

    Comondore VR, Wenner JB, Ayas NT. The impact of sleep deprivation in resident physicians on physician and patient safety: is it time for a wake-up call? BCMJ. 2008;50:560–4.

    Google Scholar 

  29. 29.

    Barger LK, Cade BE, Ayas NT, Cronin JW, Rosner B, Speizer FE, et al. Extended work shifts and the risk of motor vehicle crashes among interns. N Engl J Med. 2005;352:125–34.

    CAS  Article  Google Scholar 

  30. 30.

    Boccabella A, Malouf J. How Do Sleep-Related Health Problems Affect Functional Status According to Sex? J Clin Sleep Med. 2017;13(05):685–92.

    Article  Google Scholar 

  31. 31.

    Fletcher KE, Underwood W 3rd, Davis SQ, Mangrulkar RS, McMahon LF Jr, Saint S, et al. Effects of work hour reduction on residents’ lives: a systematic review. JAMA. 2005;294:1088–100.

    CAS  Article  Google Scholar 

  32. 32.

    Smith JW, Denny WF, Witzke DB. Emotional impairment in internal medicine house staff. Results of a national survey. JAMA. 1986;255(9):1155–8.

    CAS  Article  Google Scholar 

  33. 33.

    Urooj U, Ansari A, Siraj A, Khan S, Tariq H. Expectations, fears and perceptions of doctors during Covid-19 pandemic. Pak J Med Sci. 2020;36:S37–42.

    Article  Google Scholar 

Download references

Acknowledgements

The authors gratefully acknowledge the cooperation of all participants.

Funding

None.

Author information

Affiliations

Authors

Contributions

YHA: designed the study, wrote the protocol and planed the study. He wrote the manuscript. He helped in statistical design, analysis, data entry and data collection. HAA: designed the study, wrote the manuscript, helped in statistical design and analysis, also helped in data collection. She will take the primary responsibility in responding to the reviewers’ comments. HAA and SHA: designed the study, wrote the manuscript, helped in statistical design and analysis, also helped in data collection. MMA and RHA: helped in study development. They helped in data collection, data entry, and the statistical design and analysis. RMA and MAA: helped in prepared and development of the study. They were supervisors from the center. RMA: Helped and assessed in the study development, progression and supervision. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Haneen A. Alshehri.

Ethics declarations

Consent for publication

All authors declare that the content of the manuscript has not been published, or submitted for publication elsewhere.

Competing interests

All authors declare that this manuscript is not submitted to any special issue.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Additional file 1: Figure S1.

Knowledge about COVID-19 among different specialities. Figure S2. Prevalence of sleep disorders according to specialties.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Alnofaiey, Y.H., Alshehri, H.A., Alosaimi, M.M. et al. Sleep disturbances among physicians during COVID-19 pandemic. BMC Res Notes 13, 493 (2020). https://doi.org/10.1186/s13104-020-05341-6

Download citation

Keywords

  • Sleep
  • Disturbances
  • Physicians
  • COVID-19
  • Pandemic
  • Saudi