Insomnia, Presenteeism, Put Patient Care at Risk: A Call to Prioritize Nurses' Sleep Quality, Well-Being

Implementing strategies to improve nurses’ sleep quality and well-being would improve their job performance, patient safety, and the overall care they provide. Proactively reducing sleep disturbances or insomnia in this profession would help decrease care left undone (CLU), which would not only benefit nurses’ well-being but that of their patients, as presenteeism would impact health care settings to a lesser degree. These conclusions are based on recent findings published in Journal of Advanced Nursing.¹

Proactive strategies that place more value on nurses' ability to get quality rest comprise an important part of being able to deliver quality patient care. | image credit: New Africa - stock.adobe.com

Presenteeism refers to situations where an individual continues to work despite feeling either physically or mentally unwell.

“The decision to come to work when ill is shaped by these perceived cultural norms, which are communicated to health care workers early in their training experiences and echoed throughout their interactions with colleagues,” wrote Julia Syzmczak, PhD, in her 2017 analysis of presenteeism and its detrimental effect on patient safety.² She found various studies indicating that presenteeism could proliferate due to logistical reasons, such as a health system not having the resources to make up for someone’s absence; sociocultural reasons, such as pressure to avoid creating additional work for colleagues or expectations to always be there for patients; or even reasons such as what is “too sick” to work. Although sickness can affect someone’s productivity on the job, Syzmczak also points out how bringing illness into a health care setting puts everyone at risk.

As the present authors outline, poor sleep quality and sleep issues contribute to presenteeism and bring about their own risks.¹ These associations are well known, the authors note, and have been shown to negatively impact work performance, lead to errors, and even delays in treatment. On the other hand, cognitive processes, such as decision-making, memory, and coordination, positively correlate with sleep.

CLU remains another prominent issue in the nursing field, referring to unfinished or deferred work, often for essential services, that results from time constraints, staffing shortages, or other factors. Over 50% of nurses—sometimes over 90%—report having experienced CLU, which is cause for alarm giving CLU’s direct relationship to patient experience, satisfaction, safety, and outcomes, the authors note. The consequences of poor sleep quality and presenteeism could logically impact CLU; however, although insomnia remains prevalent and well documented among nurses, there are not enough studies that investigate the relationship between sleeplessness and CLU outcomes.

Evaluating these associations remains “imperative,” the researchers write, given the crucial role nurses have for upholding the health care system and workforce, and their influence on patient outcomes. To explore this issue further, the researchers conducted a secondary data analysis on shift nurses in acute care hospital settings to determine whether presenteeism mediated the relationship between CLU and insomnia.

After recruiting participants through the use of a popular mobile application or an online survey, 1154 nurses were identified and included in this study. Data were then collected through online surveys in January 2023 and insomnia measures were evaluated according to the 7-item Insomnia Severity Index (ISI), where higher scores signify more intense insomnia. To extract information on presenteeism, participants were asked to respond “yes” or “no” to a single question: “Over the past 4 weeks, did you work when you were sick?” An additional questionnaire helped determine how much work was left unfinished throughout the study period.

Most participants were female (n = 1078) and worked in the surgical unit (n = 732), followed by the intensive care unit (n = 220), emergency department (n = 94), operating room (n = 66), and other units (n = 42). Over 90% (n = 1051) of participants reported not having regular breaks for rest (with the exception of a meal break), and just over 30% (n = 349) reported experiencing quick returns (less than 11 hours between shifts).

An ISI score of 15 or more indicated insomnia, and over 15% (n = 176) of participants met this insomnia threshold. Additionally, over 60% (n =735) responded “yes” to experiencing presenteeism. Survey results further revealed that nursing duties such as comforting or talking with patients (n = 731; 63.3%), educating patients and/or their family (n = 541; 46.9%), and documentation of nursing care (n = 430; 37.3%) were the most frequently reported CLU measures.

After conducting a Poisson regression analysis, the researchers also emphasized how insomnia (incidence rate ratio [IRR], 1.115; 95% CI, 1.021-1.218) and presenteeism experience (IRR, 1.154; 95% CI, 1.073-1.240) had positive correlations with CLU; insomnia was significantly associated with CLU (P = .01) and presenteeism (P < .001), while presenteeism had a significant impact on CLU (P < .001). Also, adequate rest breaks (P = .002) and experience of quick returns (P < .001) had significant influence on care.

Considering their findings, the authors concluded, “nurse managers and administrators must intensify their efforts to mitigate insomnia and presenteeism among nurses, as well as to reduce CLU.” To combat this issue, they advocate for proactive strategies to better support nurses with insomnia, the creation of a more open culture for nurses to talk about presenteeism, and a dedication to creating a healthy work environment and schedule that can allow for greater periods of rest without sacrificing the quality or availability of care.

References

1. Ji Y, Min A, Kang M, Park C. How shift nurses' presenteeism is related to insomnia and care left undone: a cross-sectional study using generalised structural equation modelling. J Adv Nurs. Published online September 24, 2024. doi:10.1111/jan.16483

2. Szymczak JE. Health care worker presenteeism: a challenge for patient safety. PSNet. Agency for Healthcare Research and Quality. October 1, 2017. Accessed September 25, 2024. https://psnet.ahrq.gov/perspective/health-care-worker-presenteeism-challenge-patient-safety