Globally, stress at work is a common issue. In the UK, the incidence of stress, depression and anxiety was 602,000 cases. The data showed that the incidence rate was 1.800 per 100.000 workers [1]. While in the US, 83% of workers suffer from stress and 30% of respondents reported that their work as the main cause of stress [2]. The responses of each individual or group to stress is certainly different. High level of work-related stress can interfere work activities, reduce productivity, decrease enthusiasm and energy and affect creativity and innovation [3].

Nursing is a profession that requires concentration, speed and proper caring for patients. In hospitals and healthcare centers, 50 to 60% of workers are nurses. In South Korea, 85.2% of nurses experienced work-related stress [4]. Similarly, in Australia, 10.8% of nurses felt severe stress and 24,51% mild/moderate stress [5].

A stressful work is also experienced by nurses in Indonesia and spread across all wide range of settings. Aini and Purwaningsih [6], found that 85,2% of nurses in Central Java perceived work stress. While dental nurses also suffering from this problem with a prevalence of 83.3% [7]. Specific to the critical treatment area, Megawati and Yuwono [8], mentioned that half of Emergency Department (ED) nurses and Intensive Care Units (ICU) got stressed. While in the inpatient department, stress was reported by 61,90% of nurses. The major causes are workload, feeling unsuitable of being a nurse, working period, interpersonal relationship, work demands and financial problem [9].

Excessive work stress will certainly make nurses disturbed both psychologically and physiologically. The Indonesian National Nurses Association reported that 50,9% of Indonesian nurses who perceived work stress often feel dizzy, tired, less friendly and lack of rest. Meanwhile, nurses are responsible for improving health, preventing disease, restoring and maintaining the health of patients [10].

The adverse impact of stress on the quality of nurse's sleep occured globally. In Portugal, nurses who experienced poor sleep disorder due to work stress was 73,33% [11], while in Turkey was 61,9% [12]. In Asia, 72,1-75% of nurses in China and Taiwan were poor sleepers [13,14].             Majority of nurses experienced poor sleep quality due to stress and workload, as well as nurses in Indonesia. Previous studies showed the prevalence of poor sleep quality in Indonesian nurses due to work stress, workload and shift work were 59,4-84,62% [15-17].

The majority of studies related to stress and the nurses’ sleep quality in Indonesia were conducted in major cities and information related to these two variables among nurses in suburban areas is quite limited. Therefore, investigating stress and sleep quality in hospital nurses, especially in other parts of Indonesia is imperative.

The current study employed a descriptive correlational and cross-sectional design. A total of 176 convenience samples were recruited from a public and a private hospital in Central Sulawesi, Indonesia, July to August 2020. 

The Inclusion Criteria 

• Actively working

• Providing direct care

• Willing to join the study

The Exclusion Criteria 

• Having a history of insomnia prior to working as a nurse

• Taking sedatives

• Anemic

Demographics included age, gender, marital status, education, salary, employment status and workplace. Health-related characteristics consisted of body mass index (BMI), chronic diseases, exercise, smoking status and alcohol consumption.

The Perceived Stress Scale (PSS) was used to measure work-related stress among nurses in this study. PSS was developed by Cohen et al.  [18], consisting of 10 questions with 5-point Likert scale (0-4): 0 = Never, 1 = Almost never, 2 = Sometimes, 3 = Fairly often and 4 = Very often. The score of questions 4, 5, 6, 7 and 8 must be graded in reverse (4 = 0, 3 = 1, 2 = 2, 1 = 3, 0 = 4). Overall stress score can be obtained by summing up all the answer. The internal consistency reliability of PSS in this study was 0,68.

The instrument to assess sleep quality in this study was the Pittsburgh Sleep Quality Index (PSQI). The questionnaire was originally developed by Buysse et al.  [19], consisting of 24 questions with 19 questions for individuals and 5 questions for roommates that are not included in the data analysis and only used for additional medical information. There are 7 sleep quality components and each score ranging from 0-3, with the Global PSQI score is 0-21. Scores above 5 indicate poor sleep quality. The Cronbach's alpha of PSQI in this study was 0,7.

This study has obtained data collection permission from hospitals where the study was conducted and ethical clearance from an Ethics and Health Research Committee from in Central Sulawesi province of Indonesia (No.: 330a/STIK-HM/KEPK/VI/2020). Nurses who met the study criteria were directed by the human resources department of each hospital. Then, the procedures and objectives of the study were elucidated in detail. Those agreed to join the study were contacted individually. Confidentiality of data is strictly maintained. Informed consent must be signed before data collection. Participants may withdraw when they feel uncomfortable.

The data was analyzed using the Statistical Package Social Science (SPSS for windows, version 17). The data was not normally distributed after being analyzed using Kolmogorov-Smirnov test. Data analysis in this study included: 

• Descriptive statistics (frequency, percentage, mean, standard deviation and range) 

• Bivariate analysis (Spearman Rank Correlation) was used to investigate the relationship of stress and sleep quality. Alpha level was set at 0,05

Demographic data of 176 participants is portrayed in Table 1. 

Table 1: Demographic Data and Health-Related Characteristics of Participants (N = 176)

The mean age of participants 32,45 years (SD = 4,77), ranging from 24-46 years. The mean BMI of participants was 24,33 kg/m2 (SD = 3,16) ranging from 18-38 kg/m2. The majority was female participants (76,1%) and were married (85,2%). Most of the participants (71,6%) had diploma III degree in nursing. 

More than half of the participants were non civil servants (65,3%) with the salary range of 1.000.000-1.900.000 Rupiahs per month (54,5%). Majority of nurses worked in inpatient department (78,4%). There were 10 participants (5,7%) with type 2 DM. Only 40 participants (22,7%) regularly exercised per week, 161 participants (91,5%) were passive smokers and 173 participants (98,3%) were not alcoholic.

The overview of participants’ stress is showed in Table 2. 

Table 2: Description of Stress in Nurses (N = 176)

The highest score was on PSS7 with the question "in the last month, how often have you been able to control irritations in your life?" with a mean of 2,06 (SD = 1,09), where 62 participants voted “sometimes” (35,2%). PSS3 had the lowest score with the question "in the last month, how often have you felt nervous and “stressed”?" with a mean of 1,54 (SD = 0,99) where 72 participants responded “sometimes” (40,9%) The mean stress score was 17,98 (SD = 4,17) with range score of 5-25.

Table 3 depicts the sleep quality based on the PSQI. Sleep latency had the highest mean score of 1,35 (SD = 0,83), ranging from 0-3. Daytime dysfunction was the second highest mean score of 1,11 (SD = 0,78), ranging from 0-3. The third highest component was sleep disturbances with a mean of 1,07 (SD = 0,42) and ranging from 0-2. 

Table 3: Nurses’ Sleep Quality (N = 176)

The mean of Global PSQI score in this study was 5,70 (SD = 2,07) with a score range of 0-12. Overall, 94 participants (53,4%) had poor sleep quality and the rest were good sleepers (46,6%).

Table 4 showed a significant correlation between perceived stress and Global PSQI (r = 0,16; p <0,05). Stress were not significantly correlated to all components of sleep quality: Subjective sleep (r = 0,12; p >0,05), sleep latency (r = 0,10; p>0,05), sleep duration (r = 0,07; p>0,05), habitual sleep efficiency (r = 0,04; p>0,05), sleep disturbances (r = 0,09; p>0,05) and daytime dysfunction (r = 0,03; p>0,05).

Table 4: Coefficient Correlations Between Stress, Sleep Quality Components, AMD Global PSQI Score (N = 176)

*p <0,05; **p <0,01 (2-tailed); PSQI: Pittsburgh Sleep Quality Index; PSS: Perceived Stress Scale

The mean age of 176 participants in this study was 32.45 years. This number is little bit younger than a nurses in Central Java province with the mean age of 34.32 years [20]. Age affects mental, physical and performance abilities. Older nurses may have decreased physically, but their performance has improved. This may be triggered by having a greater responsibility [20,21].

Female participants were more dominant in this study. This is similar with the study findings of Budiyanto and Umboh [22], in the same population. Nursing is a profession that is identical to women, this is due to their tender nature in caring for families [23]. 

Majority of nurses in the study were married. This finding is in line with a study by Budiyanto et al. [22].

Married nurses, especially female, often face multiple role conflicts, such as their role in the family and at work. This may affect their job and contribute to not optimal and maximal performance [24]. Family support, mainly from spouses, in working together to take care of housework and family members can help nurses become more focus on doing their jobs as professional health workers [25]. 

More than half of nurses in this study have Diploma III in nursing degree. Similar finding in a different study in another province of Indonesia [22,26]. Diploma III in nursing is a level of education that produces associate nurses with competency to provide nursing care [27].

Most of study participants were non-civil servant nurses. Another study in Indonesia also has similar result [28]. The high number of non-civil servant nurses is due to the low number of admissions for this position in the selection process every year. The difference in capacity between public and private hospitals is also a major cause [29].

Nurses in the current study mostly earned under 2 million Rupiahs per month. The amount of salary received is based on the regional minimum wage. In addition to basic salaries, nurses also receive additional wages. The higher income is expected to boost performance. Nurses who have low incomes find it difficult to meet their daily needs, therefor their performance in providing optimal nursing care decreases [30]. 

Most of the participants in this study served in the inpatient room. Nurses have high employment demands, especially those in inpatient department. In this working area, they are required to care for more patients who stay longer, therefore more nurses are required here than any other hospital areas [31]. 

The mean BMI of participants in this study belongs to the normal level. Similar to the study in Kediri with 85 nurses [32]. Less than one-third of participants suffered from chronic diseases, but more than three-quarters of participants did not exercise regularly. This is due to busy daily work activities. The majority of participants did not smoke and did not consume alcohol. Overweight can cause a variety of diseases, less attractive appearance and less agile movements [33]. Exercise is one of the physical activities that benefit from increasing endurance, improving brain function, lowering cholesterol and reducing stress by producing endorphin hormones that affect happiness [34].

The mean stress score of nurses in the current study was slightly higher than in an Indian study of 603 nurses [35]. A study by Purcell, Kutash and Cobb [36], in the United States found the mean nurse's stress even two times higher. What most affected by stress in nurses in this study was the ability to control painful things in life. Working pressure has a big influence on nurses both in physical and psychological health. If their coping is ineffective, this will affect performances at work [37].

The mean score of nurses' sleep quality in the study was 5.70, with the majority were poor sleepers. This is similar to the findings of Safitrie and Ardani [38], in inpatient and outpatient department nurses in Central Java province. The ability to initiate sleep is the worst component of sleep quality in this study. A similar result was found in a study of 390 nurses in Spain. Sleep is a basic human need and vital for health. Adult people need an average of 7 hours of sleep. An adequate sleep can help to restore the body and make people think better and clearer, while poor sleep may cause severe stress and chronic pain [39].

A positive and significant correlation was found between work-related stress and sleep quality among nurse in the current study. This is congruent with the findings of Susanti et al. [16], in East Java province. Stress experienced by nurses occurs due to excessive job demands. If this happens on a long term basis, it will affect the quality of the nurse's sleep. Chronic work stress may decrease immunity due to poor performance of all body organs that are influenced and controlled by the brain. When receptors in the brain suffered from stress, it may contribute to the disruption of sleep. Sufficient sleep is beneficial for quality of life. Getting enough sleep before work is essential for improving performance and alertness at work [40].

There are some limitations in the current study. Data collection was done during the early period of Covid-19 pandemic, where some nurses have to be quarantined. Measuring general stress condition may allow for the missing of some specific parts of this psychological aspect among nurses. Cross-sectional approach could not explain cause-and-effect relationship among variables.

The nurse's work-related stress in the current study was at a moderate level. The most disturbing aspect of stress is control over painful things in nurse's daily life. The majority of nurses were poor sleepers in the last month. Initiating sleep is the most problematic component. Nurses who had high work pressure also experienced poorer sleep quality. The study suggested nurses to arrange their time effectively prior to going to work, such as implementing sleep hygiene by limiting food and drink before bed, starting to sleep and waking up at the same time, limiting nap hours (20-30 minutes), creating special rituals before sleep, creating a comfortable sleep environment and exercise regularly. Future studies may include other factors such as working schedule and workload, as well as using specific stress instrument among nurse’s population.

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