Factors influencing sleep quality among nurses in tertiary hospitals in Kelantan, Malaysia: a cross-sectional study

The average age of nurses was 38.86 ± 7.63 years, similar to recent research in Canada, Iran (34.5 ± 9.0 years), and China (35.3 ± 6.8 years) [15, 20, 21]. This suggests that most nurses were young adults, which aligns with the typical recruitment age for government servants. In this study, 95.5% of nurses were women, reflecting a female-dominated nursing profession in Kelantan. A study done in Melaka also found that Malaysian nurses are mostly women, which is consistent with international research, revealing that women dominate the nursing profession [11, 22].

Most nurses (89.1%) in this study were married, consistent with research showing that marriage rates tend to rise with age and professional stability in the nursing profession [9, 18]. Marriage is often cited as providing emotional support, which is crucial in demanding careers such as nursing. Recent studies have demonstrated that marital support is linked to lower levels of job-related stress, improved coping mechanisms, and enhanced mental health among healthcare professionals [23]. For example, marital support has been found to act as a buffer against burnout, which is prevalent among nurses due to the emotional and physical demands of their work [24]. Furthermore, research has shown that nurses who report stronger emotional support from their spouses tend to have better job performance and higher levels of job satisfaction [25]. Thus, the high proportion of married nurses in this study may contribute to their ability to manage the challenges of their profession more effectively, potentially improving patient care outcomes [26]. Nursing is a demanding career that requires both mental and physical support, and marriage may provide the emotional support needed to cope with these job challenges [27].

Regarding education, the majority of nurses (68.9%) in this study held a certificate or diploma, followed by 26.8% with post-basic diplomas, and 4.3% with degrees or master’s qualifications. These educational levels have a significant impact on patient care quality, workforce planning, and healthcare delivery efficiency [10, 28]. Higher education levels are associated with improved patient outcomes, better critical thinking skills, and the ability to take on leadership roles in healthcare settings.

In addition to formal qualifications, continuous professional development (CPD) plays a crucial role in ensuring that nurses remain competent and up-to-date with the latest developments in healthcare. CPD programs and ongoing education are essential for maintaining clinical competence, particularly as healthcare environments become more complex due to advances in technology and evolving treatment modalities [29]. Research shows that nurses who engage in CPD are better equipped to handle the challenges of modern healthcare, leading to higher levels of job satisfaction and improved patient care [30].

Moreover, ongoing education contributes to career progression, enabling nurses to take on specialized roles that require advanced skills, such as nurse educators, clinical nurse specialists, and nurse managers [31]. In the Malaysian context, efforts to promote CPD and lifelong learning among nurses are critical to addressing the growing demand for skilled healthcare professionals, especially in light of the global nursing shortage projected to reach 12.9 million by 2035 [32].

Thus, our findings align with broader workforce trends, where higher educational attainment and CPD are crucial for both individual career development and improving the overall quality of healthcare delivery. Encouraging nurses to pursue further education and professional development can enhance workforce flexibility, reduce the likelihood of errors, and improve patient outcomes in tertiary care settings.

Regarding sleep, a study by Farah et al. (2019) found that nurses in Malaysia averaged 5.81 ± 0.96 h of sleep per day, which is below the World Health Organization’s (WHO) recommended 7 h of sleep for adults [6]. This deficit in sleep duration is particularly concerning given that nurses often work rotational or night shifts, which can disrupt circadian rhythms [33]. Similar studies show that nurses working night shifts or rotating schedules frequently experience shift work-related insomnia and fragmented sleep, making it difficult to achieve the recommended amount of sleep [11]. This highlights the ongoing struggle nurses face in balancing their professional responsibilities with adequate sleep, contributing to long-term health risks.

The nurses in this study had an average of 15.16 ± 7.39 years of work experience. This extensive experience fosters clinical knowledge, competence, and practical skills among nurses. Experienced nurses are better equipped to anticipate problems, implement solutions efficiently, and ultimately enhance patient care quality. The fact that 60.9% of nurses had been working in their respective departments for over five years underscores the importance of familiarity with departmental protocols. Nurses with long-term experience in a particular department tend to develop stronger communication, teamwork, and coordination with other healthcare providers, which is essential for patient safety and seamless healthcare delivery [34].

Only 19.9% of nurses reported working more than 48 h per week, with the majority (80.9%) working less. This finding is consistent with the National Health Interview Survey (NHIS), which reported that over 12% of U.S. women worked more than 48 h per week in 2010 [35]. The relatively lower percentage of nurses working extended hours in this study suggests a more manageable work schedule, which can significantly enhance productivity, efficiency, and overall performance. Long working hours are associated with burnout and reduced job satisfaction, so maintaining a balanced work schedule is crucial for sustaining healthcare professionals’ well-being. This balance can positively impact both nurses’ health and the quality of care provided to patients [36].

To improve nurses’ sleep quality, hospitals and healthcare providers can adopt several evidence-based strategies. First, adjusting shift patterns, such as minimizing night shifts or implementing forward-rotating shifts, can help reduce the disruption to nurses’ circadian rhythms, thereby improving sleep quality [37]. Consistent scheduling and allowing more time between shifts are particularly helpful in promoting better rest. Additionally, wellness programs that include education on sleep hygiene and stress management can empower nurses with practical techniques to improve their sleep, such as relaxation exercises and creating a sleep-conducive environment [38]. Providing mental health resources can further support nurses in managing work-related stress, a key contributor to poor sleep. Flexible scheduling, where nurses have more control over their work hours, and ensuring regular rest breaks during shifts can also reduce fatigue and enhance sleep [39]. Finally, hospitals can create sleep-friendly workplace environments by offering quiet spaces or nap rooms where nurses can rest during long shifts, especially at night [40]. These interventions collectively contribute to improved nurse well-being, better job performance, and ultimately enhanced patient safety.

This study revealed that 69.8% of nurses at a tertiary hospital in Kelantan experienced poor sleep quality, a significant increase from the 57.8% reported in a 2008 study in Melaka [22]. This rise may be due to the increasing complexity of healthcare, driven by advances in medical technology, changing patient demographics, and stricter healthcare regulations. Nurses are now managing more critically ill patients with heavier workloads and more intricate treatment plans, increasing stress and negatively impacting sleep quality [41]. Additionally, the global nursing shortage, projected to reach 12.9 million by 2035 [10, 42], exacerbates this issue. Despite recent growth in Malaysia’s nursing workforce, with 117,116 nurses in 2022, the nurse-to-population ratio remains low at 1:279 [43]. This shortage leads to extended shifts, overtime, and heightened job expectations, contributing to sleep disturbances, job dissatisfaction, and burnout [41]. Furthermore, modern nurses face increased administrative tasks, such as documentation, compliance with regulatory standards, and the use of electronic health records (EHRs), which reduce time for direct patient care and add to their stress [43]. While technology has improved patient care, it has also blurred the lines between work and personal life for nurses.

Although this study was conducted after the peak of the COVID-19 pandemic, it is crucial to acknowledge the long-lasting effects that the pandemic has had on healthcare systems and frontline workers, particularly nurses. During the pandemic, nurses faced increased workloads, higher patient acuity, and the emotional toll of managing critically ill patients while also fearing infection and spreading the virus to their families [44]. These factors have led to heightened stress levels and increased instances of burnout, both of which are closely linked to poor sleep quality. Research shows that during the pandemic, nurses reported significantly higher levels of stress, anxiety, and depression, all of which can exacerbate sleep disturbances [45].

Pre-pandemic studies on nurse sleep quality highlighted issues such as shift work and work-related stress as primary factors contributing to sleep disruption [46]. However, the pandemic has intensified these challenges. Comparatively, post-pandemic studies indicate a marked decline in sleep quality among nurses, with many reporting chronic insomnia and frequent disruptions in their sleep patterns [47]. The long-term psychological effects of dealing with high mortality rates, personal protective equipment (PPE) shortages, and the constant risk of infection have left many nurses with lingering post-traumatic stress symptoms, which further deteriorate sleep quality.

The ongoing impacts of the pandemic, such as dealing with understaffed units and managing patient backlogs, continue to affect nurses’ ability to rest adequately. Addressing these issues is essential for mitigating the long-term effects of the pandemic on nurses’ well-being. Strategies such as providing mental health support, reducing shift hours, and creating opportunities for rest in the workplace are critical in helping nurses recover from the residual effects of the pandemic on their sleep quality [48].

Our study demonstrated that increasing sleep duration by one hour is linked to a significant reduction in the likelihood of poor sleep quality among nurses. Specifically, we found that each additional hour of sleep is associated with a 70.9% reduction in the odds of experiencing poor sleep quality, as indicated by an adjusted odd ratio (aOR) of 0.291, 95% confidence interval (CI): 0.215–0.393, p < 0.001. This emphasizes the importance of adequate sleep for maintaining good sleep quality. Sleep consists of cycles with stages such as light sleep, deep sleep, and rapid eye movement (REM) sleep. REM sleep is particularly crucial for cognitive functions like memory consolidation and emotional regulation. Insufficient sleep disrupts these stages, leading to fragmented sleep and lower sleep quality [42]. Additionally, sleep influences hormone regulation, which is important for tissue repair and managing stress.

Cognitive functions, such as focus, memory, and decision-making, are significantly impacted by poor sleep. When sleep is disrupted, these cognitive processes are impaired, leading to decreased mental performance and overall lower sleep quality [42]. This can have serious implications for nurses, who rely on their cognitive abilities to provide safe and effective patient care.

Experienced nurses often develop informal coping strategies to manage work-related stress and improve their well-being. Common approaches include effective time management, where nurses prioritize tasks to reduce stress, and peer support, which provides emotional and practical assistance from colleagues [49]. Some nurses also practice mindfulness techniques, such as deep breathing or brief meditation, to help them relax during breaks [50]. These strategies can help nurses better manage their stress, which in turn may improve sleep quality and overall job satisfaction.

While coping mechanisms were not a direct focus of this study, it is worth noting that formal training in stress management and resilience-building could enhance nurses’ ability to deal with the demands of their profession. Programs focusing on resilience have been shown to reduce burnout and improve both mental health and job performance [51]. Implementing such programs as part of continuous professional development could help nurses better manage the effects of stress and poor sleep, ultimately benefiting both their well-being and the quality of patient care [52].

This study identified that nurses with a history of commuting injuries have an 86.9% higher likelihood of poor sleep quality. Physical injuries from road accidents, such as fractures or chronic pain, can disrupt sleep by causing discomfort and making it difficult to find a comfortable position [34]. Emotional distress from the accident, including anxiety or post-traumatic stress syndrome (PTSD), may lead to flashbacks, nightmares, and intrusive thoughts, further disturbing sleep [43]. Fear of driving, or vehophobia, can also cause significant anxiety, especially during commutes, worsening sleep quality [35]. Additionally, the psychological impact of the accident can lead to cognitive disturbances, such as difficulty concentrating and racing thoughts, making restful sleep harder to achieve.

This research discovered that nurses with a history of medication errors are nearly three times more likely to experience poor sleep quality compared to those without such a history, with an adjusted odds ratio (aOR) of 2.669, 95% CI: 1.413–5.041, p = 0.002. Medication administration errors (MAEs) are a serious patient safety issue, often resulting in unnecessary harm or even death [53]. Nurses who have made these errors may suffer from increased stress and anxiety about their job performance and the potential for future mistakes, making it difficult to relax and sleep. Feelings of guilt and shame, especially if the errors caused harm, can also weigh heavily on their minds, disrupting sleep [42]. Fear of repercussions, such as disciplinary action or damage to their reputation, may lead to rumination and worry, further interfering with sleep. Additionally, past medication errors can cause a state of hyperarousal, making it challenging to relax and fall asleep [43].

This study has several limitations. First, the self-reported nature of the questionnaire, which assessed sleep quality over the past month, may have introduced recall and response biases, as nurses may not always accurately recall or report their sleep patterns. A more accurate approach would have focused specifically on assessing sleep quality during the period of data collection. Second, the study was conducted in only two tertiary hospitals in Kelantan, limiting the generalizability of the findings to other healthcare settings. Future research should expand the sample to include nurses from a broader range of hospitals across different regions in Malaysia to gain more comprehensive insights into the factors influencing sleep quality. Third, while we used the validated Malay version of the Pittsburgh Sleep Quality Index (PSQI), its specific validity among nurses has not been tested. Future studies should aim to validate this tool within the nursing population to ensure its reliability in this context. Lastly, the data collection period, which occurred from December to February, coincided with seasonal changes and festive or holiday periods that may have influenced sleep patterns. Future research should consider extending data collection across different seasons to account for potential variations in sleep behavior caused by external factors.