An-Najah National University



An-NajahNational University

Faculty of Nursing

2015-2016

Effect of Sleepiness and Fatigue on Nursing Performance among Intensive Care Unit and Coronary Care Unit Nurses inWestBank

By

Ammar Khalil Shoroq Barhoush

Mohammad Joori Malek Diab

Supervisor by

Dr. Mariam Al-Tell

Submitted as the requirement for the final project thesis of the bachelor's degree in nursing.Faculty of medicine and health sciences at An-Najah National University, Nablus, Palestine.2015

Acknowledgement

First of all we would thanks the GOD then we want to thanks Dr. Mariam Al-Tell for her great help and instructions during this course and in our project also we acknowledge Dr. ImanShaweesh for her supervision during research and project course. We also acknowledge everyone how helped us in working and we thanks our family’s those support us.

Table Of Contents

|NO. |Content |Page |

| |Acknowledgment | |

| |Table Of Contents | |

| |List Of Tables | |

| |List Of Annexes | |

| |List Of Abbreviations | |

| |List of Conceptual Definitions | |

| |Abstract | |

| |Chapter One: Introduction |1 |

|1.1 |Introduction |2 |

| |Chapter Two Background |3 |

|2.1.1 |Sleep |4 |

|2.2.1 |Consequences Of Poor Sleep |5 |

|2.2.1 |Sleepiness |7 |

|2.2.2 |Causes Of Sleepiness |8 |

|2.2.3 |Symptoms Of Sleepiness |8 |

|2.3.1 |Fatigue |8 |

|2.3.2 |Classification Of Fatigue |10 |

|2.3.3 |Symptoms Of Fatigue |11 |

|2.3.4 |Factors Of Fatigue |12 |

|2.4.1 |Nursing Performance |12 |

|2.4.2 |Factor Affecting Nursing Performance |15 |

| |Chapter Three Literature Review |16 |

|3.1 |Literature Review. |17 |

|3.2 |Problem Statement. |28 |

|3.3 |Significant Of Study. |28 |

|3.4 |Aims Of This Study &Objective. |29 |

|3.5 |Research Question. |29 |

|3.6 |Hypothesis. |29 |

| |Chapter Four Methodology |30 |

|4.1. |Introduction |31 |

|4.2. |Study Design |31 |

|4.3. |Site And Setting |31 |

|4.4. |Study Population |31 |

|4.5. |Sample Size And Sampling Method |32 |

|4.6 |Eligibility Criteria |32 |

|4.7 |Data Collection Tool |32 |

|4.8.1 |Validity And Reliability |33 |

|4.8.2 |Reviewing By Experts |33 |

|4.8.3 |Pilot Testing |34 |

|4.8.4 |Cronbach’sAlpha |34 |

|4.9. |Ethical Consideration |34 |

|4.10 |AdminstrativeAndField Work. |35 |

|4.11 |Data Analysis (Operational Definition) |35 |

| |Chapter Five Result |37 |

|5.1 |Participant According To The Demographic Data |38 |

|5.2 |Participant According To Their Pattern Of Work |39 |

|5.3 |Participant To Their Quality Of Sleep |40 |

|5.4 |Participants Regarding Their Feeling Of Fatigue |41 |

|5.5 |Participants According Nursing Performance |42 |

|5.6 |Participants Regards Their Quality Of Sleep |43 |

|5.7 |Participants Regards Their Level Of Fatigue. |43 |

|5.8 |Participants According To The Level Of Performance |43 |

|5.9 |Participants Regards Their Physical Performance. |43 |

|5.10 |Participants Regards Their Metal Performance |44 |

| |Hypotheses Result. |44 |

|5.11 |Participants According To Their Level Of Performance In Relation To Their Sleep Quality |44 |

|5.12 |Participants According To Their Level Of Performance In Relation To Their Fatigue Level |45 |

|5.13 |Participants According To Their Level Of Fatigue In Relation To Their Type Of Performance. |45 |

| |Chapter Six Discussion |46 |

| |Discussion |47 |

| |Hypotheses Discussion. |50 |

| |Chapter Seven | 52 |

| |Conclusion And Recommendation And Limitations Of Study | |

|7.1 |Conclusion. |53 |

|7.2 |Recommendation. |54 |

|7.3 |Limitations Of Study |55 |

| |References. |56 |

| |Annxes. |66 |

List Of Tables

|NO. |Content |Page |

|Table (4. 1) |Distributed Of Number OfNurses According To Hospital Location . |31 |

|Table (4. 2) |The Result Of Cronbach's Alpha Test. |34 |

|Table (4. 3) |The Total Response Rate Of Participant In The Study |35 |

|Table (4. 3) |Variables Of The Study. |35 |

|Table (5. 1) |Distribution Of Percentages Of Participant According To The Demographic Data. |38 |

|Table (5. 2) |Distribution Of Percentages Of Participant According To Their Pattern Of Work. |39 |

|Table (5. 3) |Distribution Of The Percentage Of Participant To Their Quality Of Sleep. |40 |

|Table (5. 4) |Distribution Of Percentage Of Participants Regarding Their Feeling Of Fatigue. |41 |

|Table (5. 5) |Distribution Of Percentages Of Participants According Nursing Performance. |42 |

|Table (5. 6) |Distribution Of Percentage Of Participants Regards Their Quality Of Sleep. |43 |

|Table (5. 7) |Distribution Of Percentage Of Participants Regards Their Level Of Fatigue. |43 |

|Table (5. 8) |Distribution Of Percentages Of Participants According To The Level Of Performance. |43 |

|Table (5. 9) |Distribution Of Percentage Of Participants Regards Their Physical Performance. |43 |

|Table (5. 10) |Distribution Of Percentage Of Participants Regards Their Metal Performance. |44 |

|Table (5. 11) |Distribution Percentage Of Participants According To Their Level Of Performance In Relation To |44 |

| |Their Sleep Quality. | |

|Table (5. 12) |Distribution Percentage Of Participants According To Their Level Of Performance In Relation To |45 |

| |Their Fatigue Level. | |

|Table (5. 13) |Distribution Percentage Of Participants According To |45 |

| |Their Level Of Fatigue In Relation To Their Type Of | |

| |Performance | |

List Of Annexes

|NO. |Content |Page |

|Annex(1) |Questioner In English | |

|Annex(2) |Psqi Permission. | |

|Annex (3) |Npi Permission | |

|Annex (4) |Permission From IRB | |

|Annex (5) |ConcentForm | |

|Annex (6) |Permission Of MOH | |

List Of Abbreviations

ICU: Intensive Care Unit.

CCU:coronary care Unit.

PMC: palestenian medical complex .

IRB: Institutional Review Board.

NPI: Nursing Performance Instrument.

PSQI: The Pittsburgh Sleep Quality Index .

FSS: Fatigue Severity Scale.

WHO: WoridHeaith Organization.

SPSS: Statistical Package for Social Sciences.

CNA :Canadian Nurses Association.

RNAO:Registered Nurses’ Association of Ontario.

List of Conceptual Definitions

Sleep:

Is a period of rest for the body and mind, during which volition and consciousness are in partial or complete abeyance and the bodily functions partially suspended. Sleep has also been described as a behavioral state marked by characteristic immobile posture and diminished but readily reversible sensitivity to external stimuli “(Medical dictionary, 2007).

Sleepiness:

As defined by Stoppler (2007)is feeling sleepy at times, when sleepiness interferes with daily routines and bodily functions or shortens the ability to function as a person can be sleepy without realizing it.

Fatigue:

As total body feelings, ranging from tiredness to exhaustion, create an unrelenting overall condition that effect on function and capacity nursesEllis (2008). Also, Schaffner( 2006) defined it as a subjective feeling of tiredness.

Intensive care unit:

Is a specialized section ofa hospital that provides comprehensive and continuous care for persons who are critically ill and who can benefit from treatment(brilli et al., 2011).

Abstract

Introduction: Fatigue and sleeplessness is the major problem that has an effect on nursing performance. Long work hours and less numbers of nurses and the large number of patients this lead to increase the incidence of fatigue and sleeplessness among the nurses.

Aim: This study aimed at investigating the effects of fatigue and sleepiness on nursing performance among ICU and CCU nurses in governmental hospitals at west bank

Method:Quantitative cross sectional design study was used to achive the aim of the study utilizing a convenience sampling method . A self-administration questionnaire was distributed to 175 nurse's work in ICU and CCU in governmental hospital in West Bank; Rafidia and Al-Watany hospital on Nablus, Palestinian medical complex hospital on Ramallah and Alia governmental hospital on Hebron)

Results: The result of study concluded that 79.3% of participants have poor sleep, 50.4% of participants have fatigue, and 41.3% of them have good performance. In addition there is a relation between performance and sleep, and between fatigue and nursing performance.

Conclusion:Sleep and fatigue has an effect on nursing performance, In addition the mental performance has major effect on fatigue than physical performance. And there was a negatively relation between fatigue and nursing performance . Also there was a relation between sleep and nursing performance .

Recommendation: Help policies to conducting study to investigate other causes affecting sleep and fatigue of nurses, and increasing the number of nurses to ensure care establish scheduling practices and policies for nursing staff.

Keywards :Sleep , Sleepiness , Fatigue , Nursing Performance , Intensive Care Unit Nurses , Coronary CareUnit Nurses.

Chapter one: Introduction

1. Introduction

In an attempt to define and distinguish between fatigue and sleepiness, (Shen, Barbera, Shapiro, 2006) argued that the words “fatigue” and “sleepiness” are often used alternately, they are distinct phenomena. While sleepiness refers to a tendency to fall asleep, fatigue refers to the great feeling of tiredness, lacks energy, and a feeling of exhaustion associated with somatic and / or cognitive performance. On the other hand, Chen et al. (2015) said that fatigue is a subjective feeling, and its ill effect of fatigue is frequently seen in many ways, such as task performance decreased, cognitive impairment, and emotional disturbance.Moreover, some studies discussed fatigue factors, (Patterson et al., 2014) found that the extended shifts and long working hours increase the chances of negative safety outcomes.

In addition Akerstedt,Kenneth, Wright (2009) found that work hours that exchange between night sleep hours to daywork and work to the nighttime interfere with the biological clock and homeostatic regulation of sleep, these night work hours will lead to a health problem related to sleep and fatigue such as cardiovascular disease, accidents, and cancer. It also has an effect on the performance of nurses and so has an adverse effect on patients, nurses spend most of the time with patients more than any other health care providers, and patient outcomes are affected by nursing care quality, thus improving nurse performance lead to improving on patient safety,)DeLucia, Ott, Palmieri, 2009).

Nursing performance is a concept describe the nursing care performance thst represent three nursing functionaland interconnected groups that operate together to achieve three key functions: (1) acquiring, deploying and maintaining nursing resources, (2) transforming nursing resources into nursing services, and (3) producing positive changes in a patient’s condition as a result of providing nursing services (Dubois et al., 2013).

Chapter Two Background

1. Study background

1. Sleep

“Is a period of rest for the body and mind, during which volition and consciousness are in partial or complete abeyance and the bodily functions partially suspended. Sleep has also been described as a behavioral state marked by characteristic immobile posture and diminished but readily reversible sensitivity to external stimuli “(Medical dictionary , 2007 ).

A lot of study explaned the normal sleep types and stages . Kryger, Roth, Dement (2005),Judith,Owens (2007 ) explained two types of normal sleep ؛ non-REM (NREM) and REM . REM sleep is, of course, rapid eye movement. NREM sleep is divided into four distinct stages. . Kryger, Roth, Dement (2005) clarify these stages one through four is determined by alterations in the activity waves of brain as recorded and appeared in an electroencephalogram (EEG). Physiological changes occur through each sleep stage. During sleep, the body is defined to be in an inactive state while the brain remains active. A normal sleep pattern consist of four to five cycles throughout the night. NREM and REM sleep states alternate in cycles that usually continued from 90 to110 minutes. Normal NREM sleep occupies 75% of the night, and is characterized by a diminished in temperature of body , blood pressure, rate of breathing , and most physiologic functions. REM sleep is characterized by high brain activity contribute with essentially paralyzed body.

Moreover,Judith , Owens (2007 ) explained NREM sleep stages in more deatails as following : Stage 1 sleep (2%-5% of total sleep time), which occurs at the sleep-wake transition and is often called “light sleep." Stage 2 sleep (45%-55%), which is characterized by bursts of rhythmic rapid activity of electroencephalogram and high-amplitude slow wave activity . Stages 3 and 4 sleep (3%-23%) also known as “deep” sleep, slow wave sleep, or delta sleep. The highest arousal threshold (most difficult to awaken) occurs during stages 3 and 4 sleep. Delta sleep is considered generally as the most restorative stage of sleep, and the one that tends to be preserved if the total amount of sleep is restricted. The second stage known as (REM sleep), it take about (20%-25% of the normal sleep cycle) is characterized by paralysis or nearly absent muscle tone (except for control of breathing), high levels of cortical activity that are contributed with dreaming, irregular respiration and heart rate, and episodic bursts of periodic eye movements that are the hallmark of REM sleep. This stage of sleep in particular is believed to play a key role in memory consolidation.

2. Consequences of Poor sleep

A sufficient lack of restorative sleep over a cumulative period causes physical or psychiatric symptoms and affect routine performances of tasks (Medical Dictionary ,2012).

Many studies indicated that One of the more dangerous consequences of sleep loss is a significant decrement in attention and reaction time that has been shown to have a measurable impact on driving a motor vehicle. Car crashes are one of the most negative consequence of sleep loss in healthcare workers. (Barger,Cade,BAyas, 2005; Ruggiero, 2003; Lee, 1992 and Patel, Hu 2008 ), Also, many studies suggested that poor sleep quality has negative effects on personal and family relationships , also can lead to mood disturbances, increased stress, adverse health consequences ,it increased potential for alcohol and substance abuse, Self-perceived negative effects on mood, motivation, and life satisfaction as an effect of chronic sleep loss are almost occurred in occupations that involve prolonged periods without sleep. For example, nurses working night shifts report more depressive symptoms than those on day shifts. (Ruggiero, 2003;Lee, 1992 ) .

About Circadian rhythm , many studies explained it and discuss the effect of poor sleep on it . Van Dongen,Dinges (2005), talked about Circadian rhythm disruptions result from a mismatch between environmental demands on the individual and endogenous circadian sleep wake rhythms (eg, working night shifts). Because the internal periodicity of the circadian clock for human is slightly longer than 24 hours, it is easier shifts .

Moreover, Borbely ,Achermann(2005), talked about Wake fulness and sleep are highly regulated states that are explained mby what is known as the "2-process model." This model basically represents the interaction between the homeostatic drive for sleep, which regulates the length and depth of sleep, and endogenous circadian rhythms ("biological time clocks"), which affecton the internal structure of sleep and timing and duration of daily sleep-wake cycles. Poor sleep has some adverse effect on health. Also, Mesas et al.(2010 ), talked about that Poor sleep is a possible mechanism for adverse health outcomes, including mortality and explained that both short and long duration of sleep are important predictors of death in prospective population studies. In addition , Patel and Hu ( 2008), explained factor sassociated with sleep duration ,they indicated that decrease sleep duration is associated with increased risk for obesity, diabetes, hypertension, coronary heart disease, and stroke , increased risk for alcohol and substance abuse, and increased risk of motor vehicle crashes.

Regarding sleep loss Judith ,Owens(2007) ,talked about sleep loss and impairments related to resulting fatigue ,they explained that they are common among professionals working in healthcare settings. Long continuous hours, reduced opportunities for sleep with minimal recuperation time, and shift work .All of these are contribute significantly to impairments and decrease in physical, cognitive, and emotional functioning. Acute and chronic sleep loss, and whether partial or complete, basically impairs physical, cognitive, and emotional functioning in human beings. The influence of circadian physiology dictates that wakefulness and alertness are at optimal levels during daylight hours, and that sleepiness is maximized during the night. Failure to adhere to this need for both adequate amounts of and appropriately timed sleep results in an increase in sleepiness and fatigue levels and a decline in waking function.

2.2.1.Sleepiness

Sleepiness as defined by Stoppler ( 2007) is feeling sleepy at times, when sleepiness interferes with daily routines and bodily functions or shortens the ability to function as a person can be sleepy without realizing it.Sleepiness is one of the most public sleep-related patient symptoms, and it affects an estimated 20 percent of the residents, individuals with excessive daytime sleepiness are at risk of motor vehicle and work-related incidents, and have poor health than comparable adults (Pagel, 2006).Feel of sleepiness is clearly during the night shift, and may terminate in actual incidents of falling asleep at work. (Krueger, 1994).

The requirement of sleep differ according to individual, (Pilcher ,Huffcutt , 1996) found the adults typically need between 6 and 10 hours of sleep per 24-hour, most people requiring approximately 8 hours of sleep per day.

In some occupations this clearly constitutes a hazard that may endanger human lives and have large financial consequences. These risks clearly involve a larger number of people and should be of great significance to society, (Akerstedt, 1988).

2.2.2.Causes of Sleepiness

There are many different causes of sleepiness, according to (Mahowald, 2011)these arechronic pain, work long hours or different shifts (morning ,evening, night ), drugs (sedatives, sleeping pills, antihistamines), not sleeping for long enough, sleep disorders (such as sleep apnea syndrome and narcolepsy).

2.2.3.Symptoms of sleepiness

Sleepiness is subjective feeling, but there are some symptoms detect it like ,fall asleep while driving ,difficulty to stay awake when watching television or reading, difficulty paying attention or concentrating, performance problems, difficulty remembering slowed responses , difficulty controlling your emotions (Stoppler, 2007).

2.3.1. Fatigue

Robert ,Wachter ( 2001) talked about the effect of fatigue and sleepiness on patient’s safety in several ways, Physicians and nurses need good attention, good judgment, and often quick reaction time, especially in emergency situations. Decreased attention, memory, or coordination may affect performance and lead to adverse events. Research suggests that sleep requirements and patterns are individual.

Laurens et al. (2015 ) said night shift work disrupts the sleep cycle and wake up cycle and it’s concurrent with effect of body’s natural biological rhythms, which may lead to fatigue and sleepiness. As sleepiness and fatigue increased, alertness decreased, problemsolving and reasoning ability become slower, movement skills decline and the rate of false visual stimuli responses to increased. Lot of studies talked about the fatigue,Schaffner (2006) defined it as a subjective feeling of tiredness. Also , Ellis ( 2008)defined it as total body feelings, ranging from tiredness to exhaustion, create an unrelenting overall condition that effect on function and capacity nurses. Moreover,Berrios) 1990)considered fatigue from medical view as “Subjective feeling reported by person” .

Different study discussing fatigue in term causes of fatigue, and finding that association with shift , as work long hours (12 hour) per different study some those by (Geiger-Brown , Trinkoff , 2010) those the working 12-hour shifts were significantly more fatigued. Reviewed these studies found that , while employers prefer 12-hour shifts because of increased continuity of staffing, lower staffing costs, and potential improvements in staff morale, it has more significantly of fatigued. And he explained about iarge scale studies in US hospitals showed the risks of making an error are significantly increased when work shifts are longer than 12 hours. Reviewing the study, Calkin (2012) explained the mixed opinions regarding 12 hours shift. 12 hours shift reduced travel costs (by working double shift hours into fewer days), on the other side, others describe it as fatigued and their performance to be affected by it.

A study in Illinois and North Carolina at 71 acute care hospitals of 663 nurses by (Trinkoff et al., 2011) showed patient deaths from pneumonia and acute myocardial infarction occurs more, where nurses worked long hours (12-hour) work shifts. , a lack of time off from the job was linked to patient deaths from pneumonia and abdominal aortic aneurysms.Also, Estabrooks et al.( 2009) explained the effect of 12-hour shifts on quality and outcomes of care, effect on patient or healthcare outcomes.

Schaffner (2006) explained the perceived fatigue, 809 nurses identified the factors that contributed to fatigue: sleep disturbance, lack of exercise, home Environment, support (peer support, family support), work schedule (working >40 hours per week, on-call), work environment (work 12-hour shifts, work >12-hour/day, work >three 12-hour shifts in a row, rotating shifts, work 8-hour shifts, on feet 85% of shift). The 12-hour shift and shift work were also identified by nurses in the key informant interviews and focus groups as key contributing factors to fatigue in nursing.Novak,Auvil-Novak (1996)indeated that work in the night hours conflict with hours of sleep causes them to return to work without adequate rest, or prevent deep sleep, and need to twenty-four hours after a bout of the night before rotating to another shift. Nurses reported that they did not have career performance problems when the shifts and sleep patterns are consistent, but that's what they did have career performance problems when their shifts changed from night to day.

2.3.2. Classification of fatigue

Roger, Michael(1997)explained that night work have significant and challenging impact on the lives of nurses , because it leads to the accumulation fatigue after several days of night shift work, as the worker is deprived of deep sleep and enough hours of sleep. Krueger (1989) discussed fatigue and its relation with workload ,and pointed that fatigue depend on workload and work requires good and continuous attention, and complex work increase the risk of fatigue, in addition decrease in mental and physical performance are results from prolonged work, lack of quality sleep or disruption of the internal body clock.

Gandevia ( 2001)talked about causes of Physical fatigueas it can be caused by a lack of energy in the muscle, by a decrease of the efficiency of the neuromuscular junction or by a reduction of the originating drive from the central nervous system.Marcora, Staiano, Manning(2009), pointed that mental fatigue has also been shown to decrease physical performance.

Baumeister (2002) talked about sleepiness, a lack of energy and enthusiasm, decreased awareness is known as ego depletion and occurs when the limited 'self-regulatory capacity' is depleted symptoms of fatigue include increased anxiety, decreased short-term memory, slowed reaction time, decrease work efficiency, increased variability in work performance.

2.3.3. Symptoms of fatigue

Kenyon, Gluesing, White, Dunkel, Burlingame (2007) discussed symptoms of fatigue and indicated that these are; increased anxiety, decreased short term memory, slowed reaction time, decrease work efficiency, increase space in work performance and increased errors .Hagberg ( 1981) defined Physical fatigue is the inability of a muscle to maintain physical performance, and is made more severe by intense physical exercise or long work, and talked about Mental fatigue is temporary decrease in maximal cognitive performance resulting from prolonged periods of cognitive activity.

Wyller (2007) indicated that chronic fatigue syndrome (CFS) is an illness characterized by complaint fatigue of at least six months, chronic fatigue is a symptom of many diseases.

2.3.4. Factors Of fatigue

From a studies, a study by Stone et al.(2006) found that on average nurses working 12-hour shifts not satisfied with their jobs,experienced less emotional exhaustion, were more likely to be satisfied with their work schedule and less likely to miss shifts, and no differences in patient quality outcomes were found with 12-hour shifts when compared with eight-hour shifts, although there was repeated evidence that nurses who worked longer than 12.5hours were found to have decreased vigilance and an increased risk of suffering an occupational injury or making an error .

Kudo et al. ( 2008)discussed fatigue factor as the lack of free time at work to refresh oneself, resulting in physical fatigue, sleep and mental fatigue.Costa (2003 ) indicated to results of shift work that had an effects on physical and mental health, and social relationships and activities, disruption body biological clock such as the light dark cycle, this can lead to disruptions in the normal sleep rhythm of shift workers, causing sleep and fatigue problems. Stone et al. (2006) said that fatigue can lead to increased tendency to fall to sleep, lapses , decreased attention, inability to still focused, reduced motivation, compromised problem-solving, irritability , increase tenseness, memory lapses, incorrect information processing, reduced reaction time, indifference and loss of empathy, and a tendency to make errors in repetitive tasks .

2.4.1. Nursing performance

DeLucia et al. (2009) discussed several factors affecting performance: including cognitive, physical, and organizational factors that affect such performance. In addition the study of performance in nurse that discuss the nurse's work system often does not understand human border and capacity and that nurses work under cognitive, perceptual, and physical overtask specifically nurses participate in multiple tasks under cognitive load and frequent interruptions, and they face insufficient lighting, illegible handwriting, and poorly designed labels .

In addition he discussed many different factors that affect on performance like takes more time in walking, work long shifts, and experience a raise amount of musculoskeletal disorders. Research is overdue in the areas of cognitive processes in nursing, that effects of interruptions on nursing performance, communications during patient hand offs, and situation awareness in nursing. Human factors and ergonomics (HF/E) professionals must play a key role in the redesign of the nurses' work system to identify how overloads can be reduced and how the limits and capabilities of performance can be accommodated. Collaboration between nurses and HF\E specialists is important to promote nursing performance and patient safety.

Poor sleep has an effect on performance. papp et al.(2004), discussed medical residents when they described themselves as inattentive and emotionally unavailable in their relationships with patients, having difficulty listening to patients, and being and being more of directive in their discussions with patients when sleep deprived, as well as having less patience with and compassion for patients and families. Also fatigue has produce physical performance effects on cognitive functions including loss of attention, irritability, memory loss,low ability to detect and react to subtle changes, slowed data processing, difficulties dealing with unexpected situations, and even communication difficulties. In nursing, monitoring patients' situation depend on fast assessment, diagnosis, and intervention on their behalf. There is no doubt that cognitive slowing due to fatigue presentsthreats to the nursing process and to patient outcomes.(Harrison, Horne, 2000 andDinges et al., 1997).

According toWilson et al.(2004) discussed physically and mentally healthy nurses can increase organizational productivity and, therefore, provide more effective services, and play a key role in the continued success of the organization and in achieving its short-term objectives. And (Arab et al.,2012;Kim et al., 2013) discussed job stress and its effect; and indicated that it has an important influence on the reduction of organizational effectiveness, although the nurses with greatest job stress in the long term can causes harmful effects, including cardiovascular diseases, respiratory diseases and can reduce the nurses' quality of life , and the Work environments to hospitals and their place of work to nurse have considerable effects on the nurses ' mental health because of their stressful nature .

Holden et al. (2011) said that increasing number of patients and lack of nursing personal are two main reasons for the nurses and patients' discomfort with the provided services .Queijo et al .(2013) discussed the effect of large numbers of hospitalized patients in the ICUs in each year. He indicated that these patients need to receive special care such as ventilation, injections, prescribing antibiotics, etc. And this work load on nursing and effect on performance of nurse for a long time which focus the role of nurses, especially after the physicians' orders were prescribedIn the studies conducted in the ICU of hospitals, two factors have been determined as the main barriers to measure the workload: the nurses' interactions with the patients and the existence of many qualitative indicators in the process of providing care for patients. Moreover, two factors have been considered as the important factors affecting the failure to allocate adequate time to each patient by nurses: the increase in the load of services provided to patients, and the shortages of nursing personnel. (Kwiecien,WujtewiczandMedrzycka-Dabrowska,2012andSpence, 2006).

2.4.2. Factor affecting nursing performance

There are different author's (Wu et al., 1991;Nocera,Khursandi1998;Fahrenkopf et al., 2008 andMillenson 2003) discussed the factors affecting on performance such as human and general factor.

Human Factors

• Variations in healthcare provider training & experience

• Fatigue

• Depression and burnout (physical or mental collapse caused by overwork or stress. "High levels of professionalism that may result in burnout.

• Failure to acknowledge the prevalence and seriousness of medical errors.

General factor

• Insufficient practice and experience health staff

• lack of management skills

• poor working conditions and environment

• Inadequate remuneration.

• demotivated health personnel

Chapter three

Literature Review

3.1. Literature Review.

This chapter presents the experiences and results of others they found there are many studies take about fatigue and sleepiness.

The first one byScott, Arslanian-Engoren, Engoren(2014 ) who examined the association between selected sleep variables, impairment due to fatigue, and clinical-decision self-efficacy and regret among critical care nurses. Decision regret was the major outcome variable. A non-experimental, descriptive design was used. A questionnaire was use and sent to 3500 nurses, was randomly selected from approximately 14 000 full-time nurses (working at least 36 h/wk). The researcher found that nurses who had decision regret were more likely to work nights and to work 12-hour shifts than were nurses without decision regret. nurses with decision regret reported significantly more acute fatigue , daytime sleepiness ,significantly less inter shift recovery and poor sleep quality than did the nurses without decision regret.

Another study done by Griffiths et al. (2014) to describe shift patterns of European nurses and investigate whether shift length and working beyond contracted hours (overtime) is associated with nurse-reported care quality, safety, and care left undone. The target sample was 30 hospitals in each country, which was randomly with stratification for geographical location, type, and size. Nurses were asked to report the number of hours worked, the period of the day, and whether they had worked beyond their contracted hours on the last shift they worked. The result of this study indicated that 50% of nurses worked shifts of ≤ 8 hours, but 15% worked ≥ 12 hours. Typical shift length different between countries and inside some countries. Nurses working for ≥ 12 hours were more likely to report poor or failing patient safety poor/fair quality of care, and more care activities left undone. Working overtime was also associated with reports of poor or failing patient safety, poor/fair quality of care, and more care left undone.

Another study Yinghui et al. (2013) ,thataimedat clarifying the impact of long working hours on patient safety culture (PSC) in countries with different cultural backgrounds using the nurse PSC. The researcher was used questionnaire to measures PSC, with higher scores indicating a more positive PSC. The researcher found nurses who working ≥60 h/week in Japan and the US had a significantly lower OR for patient safety grade than those working ................
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