Factors associated with sleep quality among nurse managers during regular prevention and control of the COVID-19 in China: a cross-sectional study

The novel coronavirus disease 2019 (COVID-19) spread rapidly throughout China and elsewhere, becoming a major public health event [1]. COVID-19 outbreak has constituted a massive challenge to already strained health systems worldwide [2]. Hospitals have remained on the frontline of prevention and control since the COVID-19 outbreak, and all medical staff have been under great pressure [3]. Since April 2020, the pandemic in China has been well controlled, and China has moved into the stage of regular pandemic prevention and control [4]. Even so, there are still new sporadic instances of local and imported cases in China, and the overall situation of the current global pandemic is still severe, which places demands on nurse managers.

As one of the most important administrative members of the healthcare team, nurse managers must allocate scarce resources effectively, create supportive work environments for nurses, and deal with rapidly changing guidelines related to COVID-19 [5]. In addition, they have 24-h responsibilities for their units every day and are always on-call [6, 7]. A heavy workload and complex duties expose nurse managers to huge stress and can further lead to the sleep disorders, such as insomnia, somnolence and short sleep duration [8]. Sleep disorders may result in serious health consequences of nurse managers and further the poor work performance and unsatisfactory decision-making [9], while it may have been a neglected issue.

Before the COVID-19 outbreak, several studies explored nurse managers’ sleep problems. For example, Sigursteinsdóttir et al. (2020) conducted an online survey in Iceland and found that 44% of 110 nurse managers experienced short sleep duration and 12% of them rarely had adequate sleep [10]. A study with 126 Chinese nurse managers found that the prevalence of poor sleep quality was 42.9% [11]. In addition, a qualitative study in America also showed that nurse managers reported sleep problems generally [7]. However, there is a paucity of research on nurse managers’ sleep quality in the context of COVID-19. In China, regular epidemic prevention and control has added much management stress to nurse managers, such as organizing nucleic acid testing for personnel and patients regularly, performing regular training, inspection and assessment related to the epidemic, and implementing strict channel management in the ward [3]. Thus, the sleep disorders of nurse managers during this period are expected to be exacerbated, compared to normal times. It has been reported that sleep disorders were associated with considerable diseases and functional impairment [7]. For nurse managers, sleep disorders were associated with chronic fatigue, anxiety and depression, and in the long term, they can adversely affect their quality of life, work efficiency and job satisfaction [12‐14]. Therefore, it is extremely important to evaluate, prevent and address nurse managers’ sleep disorders to promote their physical and mental health and ensure the quality of work.

Previous studies have shown that personal factors (e.g., age, gender, marital status and lifestyle), environmental conditions, psychological diseases and other factors can influence individuals’ sleep quality [15, 16]. In recent years, there is increasing evidence that coping style might be an independent and important predictor of sleep quality [17‐20]. Coping refers to stable cognitive and behavioral strategies adopted by individuals in response to external and internal challenges or stressors, which can be divided into two styles: active coping and passive coping [21]. Active coping style is manifested by the adaptive responses, such as considering ways to solve problems, express emotions to friends or families and seek support from others, while passive coping style refers to dealing with stress and problems by neglecting, avoidance and denial [22]. The COVID-19 pandemic has put additional tremendous stress and challenges on nurse managers who have been inevitably accompanied by the process of coping. However, the studies that explored the effect of coping style on sleep quality are still limited and there is a lack of research on this relationship among nurse managers. Therefore, understanding the relationship between coping style and sleep quality in nurse managers may provide the foundation for the formulation of strategies to improve their sleep quality.

This study was designed to investigate the prevalence of sleep disorders and identify factors predicting sleep quality among nurse managers in China during regular prevention and control of the COVID-19.

As far as we know, this study is the first to investigate the sleep quality of Chinese nurse managers during COVID-19 regular prevention and control and identify its influencing factors. Coping style, age and frequency of exercise were found as significant predictors of sleep quality among nurse managers.

In this study, 43.7% of participants suffered from sleep disorders. This finding was consistent with the result of 42.9% reported by Yang et al. (2012) [11], but higher than the result of 30% reported by Sun et al. (2019) [13] during a non-epidemic period in China. It is possibly due to higher role stress and duties of nurse managers in the context of COVID-19 regular prevention and control. During the COVID-19 pandemic, sleep disorders among frontline nurses have been widely reported in studies. For example, a study of 100 frontline nurses fighting against COVID-19 in Wuhan found that 60% of participants had sleep disorders, which was higher than the prevalence of nurse managers’ in this study [30]. This is partly because the study mentioned above was conducted in February 2020 when the COVID-19 pandemic was at its peak in China and there was a shortage of nurses. Conscripted frontline nurses were under huge workloads and prolonged working hours and were at risk of being infected. Under such circumstances, nurses were more vulnerable to sleep disorders. But it should not be ignored that there still was a fairly high incidence rate of sleep disorders of nurse managers in our study, which is expected to persist in the future. Our result highlights the importance and necessity of recognizing and putting efforts to solve their sleep problems. Besides, the score of each dimension of PSQI for nurse managers differed greatly, with much lower means for sleep medication and sleep efficiency dimensions than the others, which was in line with the result of Jahrami et al. (2021)’s study on medical staff [31]. Nurse managers, acting as professional healthcare workers, were proficient in the drug side effects and dependence, which may explain their less use of sleep pills. For sleep efficiency, which was defined as the ratio of total sleep time to time in bed and can be affected by various factors, such as physical and mental health and cultural or environmental factors [32]. Further studies are required to investigate the causes affecting the sleep efficiency of nurse managers.

We revealed that coping style was an important influencing factor of sleep quality among nurse managers. Specifically, active coping was adversely associated with poor sleep quality, whereas negative coping was positively related to it. Similar results were also found in previous studies [17, 33]. The underlying mechanism might be that passive coping leads to the decline of mood states and further the sleep disorders [34]. Sadeh et al. (2004) also thought that individuals with a passive response to stress tend to reduce emotional regulation and increase negative appraisal of stress, leading to hyper-arousal at bedtime that is associated with compromised sleep [35]. It follows that further studies could be conducted to investigate the interactions among stress, coping style, sleep quality and mental health of nurse managers. And healthcare administrators could provide nurse managers with professional psychological assistance like implementing the positive reappraisal coping intervention to promote their emotional regulation when experiencing stress [36], so as to promote nurse managers’ sleep quality.

As expected, our study also showed that nurse managers with older age (≥ 41 years old) were more susceptible to sleep disorders. A survey including 2007 general population in Sao Paulo found similar evidence that individuals aged 35 or above seemed to experience a higher level of sleep disorders [37]. Among nurses, older age was also found to be a risk factor for sleep disorders [9]. Generally, sleep problems have already been the well-established normal alterations in sleep physiology with age [38]. Especially for older (≥ 41 years old) female nurse managers, most of whom were either in menopausal transition or menopausal when rapid changes in estrogen levels, vasomotor instability and psychological symptoms were observed [39]. And it has been reported that these above changes can lead to the prevalence of women’s insomnia of 51–77% [39]. Hence, the mechanism of neurobiological changes may explain poor sleep quality of older nurse managers. Compared to their younger counterparts, middle-aged and old nurse managers have more family responsibilities and financial burdens and are also more prone to suffer from negative life events, such as divorces and chronic physical diseases [9, 40]. In this light, older nurse managers may experience worse sleep quality. Therefore, hospital administrators could provide older nurse managers more break time with fewer times on-call, equip them with assistants to take some responsibilities if possible, and reduce their workloads through optimizing work processes to alleviate age-related sleep disorders.

Finally, our result indicated that a higher frequency of exercise (≥ 1/week) had a positive impact on nurse managers’ sleep quality, which was consistent with the results of previous studies focusing on nurse managers [13] and nurses [41]. In addition, two meta-analyses also concluded that exercise could significantly reduce sleep latency and medication use of adults aged over 40 and improve sleep quality of middle-aged women [42, 43]. This is possibly because increased energy consumption, endorphin secretion and body temperature brought by exercise facilitate nurse managers’ sleep for recuperation of their bodies [42, 43]. And another study suggested that exercise as a means of active coping could potentially reduce stress levels and therefore has a positive effect on sleep quality [20]. Therefore, appropriate exercise training should be encouraged in nurse managers.

This study has several limitations. Firstly, the causal relationships between identified influencing factors and sleep quality cannot be drawn due to a cross-sectional design. Further longitudinal research is thus required to verify our findings. Secondly, the COVID-19 pandemic is continuing and changing, and studies investigating nurse managers’ sleep quality over longer periods are now needed. Thirdly, other factors that were not included in this study could also potentially affect sleep quality of nurse managers, such as bed capacity and occupancy rate in the ward, the number of staff they are managing, and the distance from the workplace to the accommodation. Therefore, further studies assessing the associations between sleep quality and these potential factors could provide additional information. Lastly, we conducted this study in 14 hospitals, but they were both located in Xiangyang City and the generalization of study results may be limited. Thus, research with a multi-regional sample will be required in the future.

This study indicated that there was a fairly high percentage of nurse managers suffered from sleep disorders during regular prevention and control of the COVID-19, which may become chronic and long-lasting in the future and should be paid enough attention. Coping style, age and frequency of exercise were significant influencing factors of sleep quality in this study. In view of this, nurse managers should be encouraged to adopt active coping strategies against stress and take appropriate exercise. In addition, hospital superior administrators should provide nurse managers with professional psychological assistance facilitating coping and create reasonable human resources allocation and role configuration to improve their sleep quality and well-being, thereby contributing to desirable management and quality patient care.