Sleep disorder experienced by healthcare nurses after terminating Zero-COVID-19 policy

The global spread of corona virus disease 2019 (COVID-19) has become a major public health event [1]. The COVID-19 pandemic resulted in an unprecedented challenge for society, especially in the healthcare sector [2]. This situation has entailed great responsibility for health workers, translating into both physical and psychological high pressure due to their exposure to the disease with a fear of contamination and the extra effort required to adapt their usual work routine to the new hospital conditions caused by the pandemic, such as wearing personal protective equipment, attending extremely ill patients, working irregular hours [3]. On 2022 November, the Chinese government optimized the epidemic prevention and control policy, and ending ‘Zero-COVID-19’ policy and mandatory quarantine measures [4]. This new strategy caused a swift and extensive outbreak of the Omicron variant in China after a sudden exit from the Zero-COVID-19 policy [5]. A surge in the number of patients visiting healthcare facilities introduced additional pressure on healthcare workers in an already strained healthcare system [6]. After terminating the policy, hospitals in China faced a sudden increase in patients presenting with fever and/or respiratory diseases in a short period of time. Healthcare staff dealt with the situation by converting regular care beds to severe care beds in a timely manner, and suffered great pressure [7].

Multiple studies reported that psychological and physical stressors among nurses were common during the pandemic [8]. Psychological and physical stress can cause long-term sleep deprivation leading to severe fatigue, memory loss, slow response, irritability, depression, suicidal ideation and occupational accidents [9]. Therefore, improving sleep quality is crucial, especially among healthcare workers, to improve their mental health, job satisfaction and ultimately delivering the best patient care possible [10].

A systematic review and meta-analysis showed that about one-third of nurses during the COVID-19 pandemic had psychological symptoms such as stress, anxiety, depression, and sleep disorders. The incidence of sleep disorders is 43% [11]. Another meta-analysis reported that the prevalence of sleep disorders among healthcare workers during the COVID-19 pandemic was 38.27% [12]. Although these meta-analyses highlight the poor sleep quality of nurses or healthcare workers during the pandemic, to date, there is currently very little research on the sleep quality of nurses in China after the end of the Zero COVID-19 policy. Therefore, the aim of this study was to evaluate the sleep disorder of nurses after China terminated Zero-COVID-19 policy.

The present study showed that sleep disorder was prevalent among nurses after the Zero-COVID-19 policy adjustment. Additionally, we found a higher risk of sleep difficulty among older age nurses and a lower risk of sleep disturbances among those with lower education levels. More importantly, our study indicated that sleep disorders are more common in nurses working on the front-line. As revealed in this study, 96.44% of participants had sleep difficulty, which demonstrates that sleep disorder is quite common among nurses after the Zero-COVID-19 policy adjustment. This finding was higher than the result of 42.9% reported by Yang [15] and the result of 30% reported by Sun [16] during a non-pandemic period in China. This may be related to the greater anxiety and depression experienced by nurses as they were under heavy workload, and they were at risk of being infected after the government’s adjusting the Zero-COVID-19 policy and mandatory quarantine measures. Besides, a meta-analysis  [12]  showed that the prevalence of sleep disorders among healthcare workers during the COVID-19 pandemic was 38.27% and in another study, the prevalence was 11.3% [17]. There are differences in the summarized prevalence rates among different studies, which can be explained by the diversity of assessment scales, healthcare systems, demographic characteristics, and lifestyles. In addition, another meta-analysis consisting of 93 cross-sectional studies involving a total of 93,112 nurses assessed for the first time that the overall prevalence of sleep disorders among nurses during the COVID-19 pandemic was 43% [11]. It is obvious that after the termination of the Zero-COVID-19 policy, the incidence of sleep disorders among nurses has significantly increased, whether compared with the non-epidemic period or during the COVID-19 pandemic period. This further indicates that terminating the Zero-COVID-19 policy has had a serious negative impact on the sleep quality of nurses.

Previous studies showed that regardless of their place of work, healthcare workers, mainly female nurses, experienced symptoms of anxiety and stress, which resulted in decreased sleep and quality of life [18]. Consistent with a previous study, we found that the front-line nurses were associated with severe sleep difficulty as they have a high risk of infection due to their heavy workload and long working hours [19]. A study clearly demonstrated high rates of stress, anxiety, and depression among front-line healthcare workers caring for COVID-19 patients [20].

Contrary to a previous study, which showed no significant association between age and insomnia [21], our study revealed that nurses with older age (46–55 years old) were more susceptible to sleep disorders. Our finding is similar to those of a 2007 survey of the general population in Brazil, finding that people aged 35 years or older appeared to experience higher levels of sleep disturbance [22]. Sleep problems have become an accepted normal change in sleep physiology with aging [23]. Older nurses were either in menopausal transition or menopausal, suffering from vasomotor instability and psychological symptoms due to changes in estrogen levels [24]. Therefore, the mechanism of neurobiological changes may explain the poor sleep quality of elderly head nurses. In addition, compared with young nurses, older nurses may bear more family responsibilities and economic burdens and are more likely to suffer from negative life events such as divorce and chronic physical diseases [25].

We found that nurses with lower education levels had better sleep quality; however, some cases showed lower levels of education may contribute to insomnia [26]. Nurses with a higher level of education may be more knowledgeable about the effects of COVID-19 on health, and they may be more frequently exposed to occupational stressors, which puts them at risk for developing psychiatric illnesses, leading to sleep difficulty. The current study is the first to compare the effect of nurses' different education levels on sleep quality during the COVID-19 epidemic. More attention should be paid to the education level of nurses affecting sleep quality. Findings from the current study, along with other investigations on the effect of the COVID-19 pandemic on the healthcare system, can be used to identify caveats and improve health provision [27, 28].

Our study has some limitations. First, we relied on self-reported symptoms collected through online questionnaires. While convenient, this approach may be susceptible to bias and inaccuracies inherent in self-reporting. Second, due to the pandemic, we were unable to utilize objective diagnostic tools for sleep disorders. Future studies could benefit from incorporating polysomnography for a more comprehensive assessment. Third, the study design employed a limited number of demographic variables and focused on nurses from a single healthcare center in China. This limits the generalizability of our findings. Future research should consider including a more diverse sample and data collection across multiple centers. While this study utilized age groups for data collection, it is acknowledged that using exact ages might provide a more granular analysis for future research. Finally, we recognize that the busy schedules of nurses may have influenced the time spent completing the questionnaires, potentially impacting data accuracy.

Sleep disorder was very common after the end of the Zero-COVID-19 policy in China. More frontline nurses suffered severe sleep difficulty in particular. The physical and mental health of nurses, including sleep disorders, is worthy of attention to help improve the quality of life among healthcare.