INTRODUCTION
Shift work, defined as working in changing periods of the day, is the basic form of functioning of the healthcare system, including the national Emergency Medical Services (EMS). Adopting this form of organizing the workload by Emergency Response Teams (ERTs) is dictated by the need to ensure those whose health or life is at risk have continuous access to health care.
In general terms, the work of a paramedic involves saving human life and health through undertaking medical emergency procedures which stabilize basic life functions, as well as preparing the patient for transport in case of a sudden threat to their life or health. The emergency procedures are carried out in varied conditions and circumstances, during the day and at night, which causes a physical and mental load being put on paramedics. Therefore, the people working as paramedics need not only possess the specialist medical knowledge required to perform their professional duties but also exhibit a high resilience to stress and possess a strong inner motivation and self-control related to undertaking risks and quick decisions. The work environment and its conditions, shift work hours, and its nature in and of itself, predispose paramedics to a range of various negative health complications, such as the risk of cardiovascular disease, infections, cancer, mental disorders, and sleep disturbance. Among healthcare professionals, paramedics are the group most often diagnosed with occupational illnesses every year [1–10].
It should be noted that the explosion of the COVID-19 pandemic significantly highlighted the daily issues of the ERT paramedic workday. It changed the perception of health prophylaxis and its importance in the healthcare system, exposing the issue of insufficient personnel, lack of self-protective equipment, ever-changing and forced-upon working conditions, and occupational overload. This situation negatively affected the health condition of healthcare workers, including their mental well-being and functioning in the workplace [5, 6, 10, 11].
Sleep issues constitute an increasing health problem worldwide. Research carried out so far shows that due to the differences in the application of diagnostic tools, the setting of the examination, and operational definitions used, the prevalence of sleep problems in the population varies greatly between studies, ranging anywhere from 6% to 50% [12].
A tendency towards overweight and obesity, higher cholesterol levels, cardiovascular and digestive system diseases, diabetes, cancers, and mood disorders has been noted in shift workers [13]. Due to epidemiological reasons and its potential health consequences, this phenomenon is no longer examined on an individual basis, becoming a societal concern of public health [14].
The aim of the following study was the evaluation the effect that shift work ERT paramedics engage in has on their quality of sleep. The reason for undertaking this research was the fact that such investigations into the relationship between shift work and sleep problems of ERT paramedics have not been carried out in the Polish context. The following paper fills this gap in knowledge and may serve as a starting point for the development of health promotion initiatives aimed at this professional group.
MATERIAL AND METHODS
The study was carried out as part of a joint project between the Health Department of the Mazovian Voivodeship Office in Warsaw and the Health and Social Policy Department of the Marshal’s Office for the Mazovian Voivodeship in Warsaw. It involved professionally active ERT paramedics in the Mazovian Voivodeship from 5 operational regions located in Warsaw, Płock, Ostrołęka, Siedlce, and Radom.
The sample choice was deliberately given that on the national scale, the Mazovian voivodeship has the highest number of mobile ERTs functioning. According to the data from Statistics Poland, there were 1577 (100%) mobile ERTs functioning in Poland in 2019 as part of the National Emergency Medical Services (369 specialist teams and 1208 basic teams). In this period, there were 200 mobile ERTs, constituting 12.7% of the entire pool (46 specialist teams and 154 basic teams) [15].
The study was carried out in compliance with the rules outlined in the Helsinki Declaration [16], as it was anonymous and voluntary in nature. All of the participants granted informed consent regarding their participation were informed about the aims of their study, as well as their ability to withdraw participation at any stage, and that their participation was voluntary. The questionnaires were filled out independently without the researcher present.
The data was collected in the period between May and September of 2019 on the basis of a self-developed, anonymous interview questionnaire created for the purpose of the study, as well as using the Athens Insomnia Scale.
The investigative tools were used to evaluate the sleep problems of paramedics employed in a shift work system. A self-developed, anonymous questionnaire consisted of 20 closed questions single and multiple choice. The questions investigated the following elements: sociodemographic data (age, gender, years of work experience, level of education) and the incidence of sleep disturbances, factors that disturb sleep as well as following sleep hygiene in the participant group. The questions were verifying in nature. The Athens Insomnia Scale (AIS) enabled a quantitative measure of insomnia symptoms. Obtaining up to 5 points on the scale is a sign of maintaining sleep norms, a score between 6 and 10 points suggests that sleep is above norms, while a score of 11 points or above is an indicator of insomnia [17].
For the qualitative variables, incidence (n) and frequency (%) were provided, for the quantitative variables like age and years of work experience, basic statistical measures describing the variables were provided (value of the mean, standard deviation, minimum and maximum values) and the non-parametric Mann-Whitney U test was applied. In order to assess sleeplessness, the Athens Insomnia Scale was used. To investigate the relationship between the incidence of sleep and sleep quality disturbances and the gender and level of education of the participants, the χ2 test of independence was used. The statistical analysis was conducted using the Statistica 13.1 PL statistical software. The study established a significance level of α = 0.05. Taking into account that the education norms for paramedics contemporary to the time of the research [18] involve completing an undergraduate degree, in the examination of the relationship between the level of education and the effect of shift work on the quality of sleep of the paramedics, the level of education was defined as secondary (including upper secondary) and higher (including a vocational or masters degree).
RESULTS
The final analysis included 238 participants (100%), of which 223 were male and 15 were female. The mean age of the participants was 39.03 ± 9.27 years for males, and 31.93 ± 7.76 years for females (Tab. 1).
|
Table 1. Age of the participants between genders |
||||||
|
Participant gender |
n |
M |
SD |
Min |
Max |
p-value |
|
Male |
223 |
39.03 |
9.27 |
23.00 |
65.00 |
0.003* |
|
Female |
15 |
31.93 |
7.76 |
23.00 |
50.00 |
|
The mean years of work experience of the paramedics differed significantly between genders (p = 0.000). Among males, it was 12.62 ± 9.41 years, while for females, it was 5.36 ± 7.04 years. In each of the participating groups, the shortest work experience was around half a year (Tab. 2).
|
Table 2. Years of work experience of the participants between genders |
||||||
|
Participant gender |
n |
M |
SD |
Min |
Max |
p-value |
|
Male |
223 |
12.62 |
9.41 |
0.50 |
41.00 |
0.000* |
|
Female |
15 |
5.36 |
7.04 |
0.50 |
28.00 |
|
The observed paramedics declared a higher vocational or master’s degree (189; 79.41%), as well as secondary/upper secondary education (49; 20.59%). The level of education was not related to the gender of the participants (p = 0.168).
In the participating paramedic group, the incidence of sleep disturbance and deficiencies in its quality were found. Over 76% of the participants wake up in the middle of the night (12; 80.0 % of females and 170; 76.23% of males), while 71.01 % (9; 60.00% of females and 160; 71.55% of males) report disturbed sleep, and almost 48% of the participants declared they had issues falling asleep (8; 53.33% of females and 106; 47.53% of males). Almost 70% go to sleep at different times every day (11; 73.33% of females and 152; 68.16% of males), and every second paramedic reported that the quantity of sleep does not exceed 5 hours (7; 46.67% of females and 105; 47.09% of males). This causes 63.64% of them to experience fatigue and sleepiness during the day (9; 60.00% of females and 142; 63.68% of males). This may be a result of shift work as well as the high number of shifts that the participating paramedics undertake. A statistically significant difference between genders was found as far as taking sleeping pills to help induce sleep (p = 0.001), as well as the feeling of breathlessness during sleep (p = 0.000), where for women this percentage incidence was higher than for men. The detailed results are presented in Table 3.
|
Table 3. Prevalence of disturbances in sleep and sleep quality of participants between genders among the participating paramedics |
|||||
|
Responses/gender |
Overall |
Female |
Male |
p-value* |
|
|
n (%) |
n (%) |
n (%) |
|||
|
238 (100.00) |
15 (100.00) |
223 (100.00) |
|||
|
I experience sleep induction issues |
Yes |
114 (47.90) |
8 (53.33) |
106 (47.53) |
0.663 |
|
No |
124 (52.10) |
7 (46.67) |
117 (52.47) |
||
|
I wake up in the middle of the night |
Yes |
182 (76.47) |
12 (80.00) |
170 (76.23) |
0.739 |
|
No |
56 (23.53) |
3 (20.00) |
53 (23.77) |
||
|
It is hard for me to fall back asleep after waking up |
Yes |
76 (31.93) |
4 (26.67) |
72 (32.29) |
0.651 |
|
No |
162 (68.06) |
11 (73.33) |
151 (67.71) |
||
|
When I wake up I feel tired |
Yes |
71 (29.83) |
6 (40.00) |
65 (29.15) |
0.374 |
|
No |
167 (70.17) |
9 (60.00) |
158 (70.85) |
||
|
I take sleeping pills in order to fall asleep |
Yes |
31 (13.03) |
7 (46.67) |
24 (10.76) |
0.001** |
|
No |
207 (86.97) |
8 (53.33) |
199 (89.24) |
||
|
I go to sleep at different times |
Yes |
163 (68.49) |
11 (73.33) |
152 (68.16) |
0.676 |
|
No |
75 (31.51) |
4 (26.67) |
71 (31.84) |
||
|
I sleep to make up for the lack of sleep |
Yes |
115 (48.32) |
6 (40.00) |
89 (39.91) |
0.994 |
|
No |
123 (51.68) |
9 (60.00) |
134 (60.09) |
||
|
I experience breathlessness while sleeping |
Yes |
17 (7.14) |
5 (33.33) |
12 (5.38) |
0.000** |
|
No |
221 (92.86) |
10 (66.67) |
211 (94.62) |
||
|
My hours of sleep vary and are irregular |
Yes |
140 (58.82) |
9 (60.00) |
131 (58.74) |
0.924 |
|
No |
98 (41.18) |
6 (40.00) |
92 (41.25) |
||
|
I experience fatigue and sleepiness during the day |
Yes |
151 (63.45) |
9 (60.00) |
142 (63.68) |
0.775 |
|
No |
87 (36.55) |
6 (40.00) |
81 (36.32) |
||
|
Hours of sleep in a day |
< 5 hours |
112 (47.06) |
7 (46.67) |
105 (47.09) |
0.975 |
|
> 5 hours |
126 (52.94) |
8 (53.33) |
118 (52.91) |
||
|
Disturbed sleep (I dream of distressing or unpleasant things) |
Rarely |
169 (71.01) |
9 (60.00) |
160 (71.55) |
0.311 |
|
No |
69 (28.57) |
6 (40.00) |
63 (28.25) |
||
|
I wake up at night with a feeling of anxiety |
A few times a month |
147 (61.76) |
9 (60.00) |
107 (47.98) |
0.742 |
|
A few times a year |
91 (38.24) |
6 (40.00) |
85 (38.121) |
||
While analyzing the phenomena in discussion in regards to the level of education of the paramedics, significant differences were found in issues such as waking up in the middle of the night (p = 0.000), going to sleep at different times every day (p = 0.000) and the hours of sleep in the group that slept less than 5 hours (p = 0.001), where the frequency of such issues is higher among participants with a higher vocational or masters degree (Tab. 4).
|
Table 4. Prevalence of disturbances in sleep and sleep quality of participants between levels of education among the participating paramedics |
|||||
|
Responses/gender |
Overall n (%) 238 (100.00) |
Secondary/Upper secondary n (%) 49 (100.00) |
Higher vocational/masters n (%) 189 (100.00) |
p-value |
|
|
114 (47.90) |
29 (59.18) |
85 (44.97) |
0.076 |
||
|
124 (52.10) |
20 (40.82) |
104 (55.03) |
|||
|
I experience sleep induction issues |
Yes |
182 (76.47) |
18 (36.73) |
164 (86.77) |
0.000* |
|
No |
56 (23.53) |
21 (42.86) |
35 (18.52) |
||
|
I wake up in the middle of the night |
Yes |
76 (31.93) |
32 (65.31) |
44 (23.28) |
0.000* |
|
No |
162 (68.06) |
17 (34.69) |
145 (76.72) |
||
|
It is hard for me to fall back asleep after waking up |
Yes |
71 (29.83) |
23 (46.94) |
48 (25.40) |
0.003* |
|
No |
167 (70.17) |
26 (53.06) |
141 (74.60) |
||
|
When I wake up, I feel tired |
Yes |
31 (13.03) |
9 (18.37) |
22 (11.64) |
0.212 |
|
No |
207 (86.97) |
40 (81.63) |
167 (88.36) |
||
|
I take sleeping pills in order to fall asleep |
Yes |
163 (68.49) |
19 (38.78) |
144 (76.19) |
0.000* |
|
No |
75 (31.51) |
30 (61.22) |
45 (23.81) |
||
|
I go to sleep at different times |
Yes |
115 (48.32) |
21 (42.86) |
94 (49.74) |
0.391 |
|
No |
123 (51.68) |
28 (57.14) |
95 (50.26) |
||
|
I sleep to make up for the lack of sleep |
Yes |
17 (7.14) |
4 (8.16) |
13 (6.88) |
0.756 |
|
No |
221 (92.86) |
45 (92.84) |
176 (93.12) |
||
|
I experience breathlessness while sleeping |
Yes |
140 (58.82) |
27 (55.10) |
113 (59.79) |
0.552 |
|
No |
98 (41.18) |
22 (44.90) |
76 (40.21) |
||
|
My hours of sleep vary and are irregular |
Yes |
151 (63.45) |
32 (65.31) |
119 (62.96) |
0.761 |
|
No |
87 (36.55) |
17 (34.69) |
70 (37.04) |
||
|
I experience fatigue and sleepiness during the day |
< 5 hours |
112 (47.06) |
11 (22.45) |
101 (53.44) |
0.001* |
|
> 5 hours |
126 (52.94) |
38 (77.55) |
88 (46.56) |
||
|
Hours of sleep in a day |
No |
169 (71.01) |
35 (71.43) |
134 (70.90) |
0.942 |
|
A few times a month |
69 (28.99) |
14 (28.57) |
55 (29.10) |
||
|
Disturbed sleep (I dream of distressing or unpleasant things) |
A few times a year |
147 (61.76) |
32 (65.31) |
115 (60.85) |
0.567 |
|
No |
91 (38.24) |
17 (34.69) |
74 (30.15) |
||
In the group of paramedics with secondary or upper-secondary education, participants more often reported issues with falling asleep after waking up (p = 0.000) and the feeling of tiredness after waking up (p = 0.003) (Tab. 4).
It can be observed that insomnia is reported most often by participants aged 45–54 years (29; 12.18%) and those who are above 55 years old (23; 9.66%). People who were above the norms were most often aged 45–54 years (53; 22.26%) and in the 35–44 years age bracket (29; 12.18%). The analysis of the general results yielded the conclusion that the participating paramedics are most often in the above norm group (112; 47.05%) or the insomnia group (77; 32.35%) as per the Athens Insomnia Scale (Tab. 5, Fig. 1).
|
Table 5. Athens Insomnia Scale results between age groups |
||||||
|
Result interpretation |
Overall n (%) 238 (100.00) |
Age brackets |
||||
|
≤ 24 years n (%) |
25–34 years n (%) |
35–44 years n (%) |
45–54 years n (%) |
> 55 years n (%) |
||
|
≤ 5 points — norm |
49 (20.58) |
4 (1.68) |
23 (9.66) |
15 (6.30) |
7 (2.94) |
– |
|
6–10 points — above the norm |
112 (47.05) |
3 (1.26) |
12 (5.04) |
29 (12.18) |
53 (22.26) |
15 (6.30) |
|
> 10 points — insomnia |
77 (32.35) |
– |
7 (2.94) |
18 (7.56) |
29 (12.18) |
23 (9.66) |
The participants most frequently reported that their falling asleep after going to bed and turning off the light was markedly (87; 36.55%) or slightly delayed (71; 29.83%). During sleep, awakenings in the middle of the night were a minor (86; 36.13%) or considerable (79; 33.19%) problem. Only every fifth participating paramedic reported a sufficient quantity of sleep (51; 21.42%), while participants most often reported a slightly insufficient number of hours of sleep (123; 51.58%). The overall quantity of sleep undoubtedly has an effect on its quality, where every fifth participant reported it to be satisfactory (43;18.06%) or slightly unsatisfactory (131; 55.04%). Their well-being the following day could be slightly decreased (93; 39.07%), normal (74; 31.09%), or very decreased (52; 21.84%). Sleep determined both physical and mental abilities on the following day, which has been reported most often by participants as normal (91; 38.23%), slightly decreased (85; 35.71%), or very decreased in every fifth paramedic (46; 19.32%). Participants most often reported mild sleepiness experienced the following day (93; 39.07%) or its complete lack (87; 36.55%).
On the basis of the undertaken data analysis, it can be observed that the participating paramedics exhibit sleep problems. The cause of this state of affairs may be shift work, overload, or issues related to stress (Tab. 6).
|
Table 6. Subjective evaluation of the sleep problems experienced by the participants according to the Athens Insomnia Scale |
||
|
Symptom |
Possible answers |
Obtained answers n (%) |
|
Sleep induction |
No problem |
53 (22.26) |
|
Slightly delayed |
71 (29.83) |
|
|
Markedly delayed |
87 (36.55) |
|
|
Very delayed or did not sleep at all |
27 (11.34) |
|
|
Awakenings during the night |
No problem |
56 (23.52) |
|
Minor problem |
86 (36.13) |
|
|
Considerable problem |
79 (33.19) |
|
|
Serious problem or did not sleep at all |
17 (7.14) |
|
|
Final awakening |
Not earlier |
67 (28.15) |
|
A little earlier |
93 (39.07) |
|
|
Markedly earlier |
59 (24.78) |
|
|
Much earlier or did not sleep at all |
14 (5.88) |
|
|
Total hours of sleep |
Sufficient |
51 (21.42) |
|
Slightly insufficient |
123 (51.68) |
|
|
Markedly insufficient |
49 (20.58) |
|
|
Very unsatisfactory, or did not sleep at all |
15 (6.30) |
|
|
Quality of sleep (regardless of its quantity) |
Satisfactory |
43 (18.06) |
|
Slightly unsatisfactory |
131 (55.04) |
|
|
Markedly unsatisfactory |
39 (16.38) |
|
|
Very unsatisfactory |
25 (10.50) |
|
|
Well-being during that day |
Normal |
74 (31.09) |
|
Slightly decreased |
93 (39.07) |
|
|
Markedly decreased |
52 (21.84) |
|
|
Very decreased |
19 (7.98) |
|
|
Physical and mental capacity during the day |
Normal |
91 (38.23) |
|
Slightly decreased |
85 (35.71) |
|
|
Markedly decreased |
46 (19.32) |
|
|
Very decreased |
16 (6.72) |
|
|
Sleepiness during the day |
None |
87 (36.55) |
|
Mild |
93 (39.07) |
|
|
Considerable |
39 (16.38) |
|
|
Intense |
19 (7.98) |
|
DISCUSSION
While conducting research into sleep disturbances, a significant challenge is setting objective and reliable parameters, such as e.g. its quality. The study constitutes an attempt at evaluating the effect of undertaking professional duties by ERT paramedics in a shift system on their quality of sleep. The present research showed that shift work significantly affects the quality of sleep of ERT paramedics. It also proved that shift work aids in the development of improper hygiene behaviors impacting the quality of sleep, such as falling asleep at different times every day, irregular and varied hours of sleep, and taking sleeping pills.
Research shows that shift works, as well as the number of night shifts undertaken in a month, contribute to disturbances in the circadian sleep cycle, consequently leading to a multitude of negative health consequences, which may intensify with time and continuing to pursue shift work, affecting the functioning of the human body. Shift work increases the risk of cardiovascular and digestive system disorders, sleep disturbances, neuropsychiatric disorders, and chronic pain, and is related to a higher incidence of accidents at work and lower work satisfaction among employees. In the context of paramedics undertaking shift work, there is a limited number of health consequences documented [19–27].
In their research which aimed to investigate the available literature regarding the effect of paramedics’ work on their health condition, Hegg-Deloye et al. [26] showed that sleep disturbances were widespread among paramedics, and they themselves were unable to control their health conditions. Additionally, they found that the impact of work in dangerous conditions, including shift work, has not been well documented and summarized in the professional group that paramedics constitute. The results regarding the sleep disturbances among paramedics obtained by the authors of the study are concurrent with those in the present study.
Between the 21st of December, 2018, and the 18th of January, 2019, Shriane et al. conducted a study that aimed to assess knowledge and understanding of sleep hygiene among paramedics working in a shift system, as well as its perceived impact on sleep, and to examine the engagement paramedics exhibited in sleep hygiene practices. The study was carried out among Queensland Ambulance Service paramedics in Australia (final participants sample n = 172) working in a shift system. More than half of the participants (53.8%) reported experiencing sleep difficulties “often” or “always”, while 26.3% reported “poor” or “very poor” sleep quality. Naps were “never” or “rarely” taken during the day by over half of the participants (58.2%). The study found that paramedics exhibited a limited understanding of the concept of sleep hygiene and they varied in their knowledge regarding the impact of specific sleep hygiene factors. Moreover, paramedics varied in their involvement in individual sleep hygiene practices. The findings of the authors are consistent with the present study’s results in this area [27].
In the cross-sectional study carried out by Brahim et al. among 158 paramedics working for the Mongi Slim La Marsa University Hospital Center in Tunis, sleep disorders were detected in 40.5% of the subjects [28]. The present study’s findings are consistent with those of the authors as far as people suffering from insomnia are concerned.
136 Australian paramedics participating in a cross-sectional study that aimed, among other things, to examine the prevalence of sleep problems, conducted by Khan et al. [29] reported significantly higher severity of insomnia symptoms and significantly poorer sleep quality. The authors’ findings are concurrent with the results of the present study.
According to a study, whose aim was the investigation into the relationship between rotational shift schedules, sleep, fatigue, and sleepiness among 15 paramedics working in the state of Victoria in Australia, it was shown that shift work is related to limited sleep, fatigue, and sleepiness, which combined can be harmful to the health of the employees. Paramedics reported significantly higher levels of sleepiness and fatigue during, immediately after, and the entire day after a night shift, in comparison with the state before the shift and after two days [30].
In their study, Wanstall et al. [31] showed that sleep loss and fatigue negatively affect the behavior and attitude of paramedics. Study participants know that sleep problems affect their well-being. Paramedics have limited knowledge of how to identify and manage sleep disorders. Education about sleep disorders is recommended, and information must be provided by an expert and trusted voice.
The findings of a study by Samunev-Zhelyabov et al. [32] among 468 employees of emergency medical centers in Bulgaria indicating that sleep disorders and fatigue are common among emergency healthcare workers, are consistent with our own research.
The impact of sleep disorders among paramedics and their effect on mental health has been described in a study by Straud et al. [33]. The sleep disorders shown there are consistent with those shown in our own study.
CONCLUSIONS
- Research indicates a lack of sufficient knowledge regarding the concept of sleep hygiene and consequently varied levels of engagement in hygiene sleep practices in this occupational group.
- In order to ensure safe and hygienic working conditions for paramedics and to identify all of the factors constituting potential threats, it is advised to pursue further research with the use of standardized diagnostic tools.
- It seems advisable for obligatory screening consultations to be implemented for paramedics with more years of work experience (e.g., 10 years) as part of occupational medicine prophylactic testing which would allow for early identification of sleep disorders.
- In order to minimize the possible health complications resulting from a shift system work schedule among paramedics, it seems reasonable to employ health education measures aimed at these issues in the paramedic training process. Health education aimed at minimizing health consequences resulting from the nature of the undertaken job ought to be provided as part of both formal and informal education.
Conflict of interest
All authors declare no conflict of interest.