Relația dintre calitatea somnului, stresul perceput și calitatea vieții în rândul medicilor rezidenți

Background

Specialists in certain professional fields experience lower quality and shorter sleep duration. Among them, there are medical professionals⁽¹⁾, especially resident doctors⁽²⁾. Residency is commonly known as one of the most demanding periods in medical training due to the high workload, increased responsibilities, lack of predictability and constant emotional pressures^(3,4). Cognitive performance and professional functioning can be negatively affected by these aspects. Even a single night with less than five hours of sleep can cause a significant reduction in cognitive performance. Sleep deprivation has direct health consequences, manifested by mood changes, increased drowsiness, fatigue, irritability and difficulty concentrating^(2,5,6). Also, stress, nutrition or medical conditions influence the quality of sleep^(7,8). Research from the literature reports that doctors show more frequent signs of professional exhaustion than specialists from other fields. Their quality of life is also adversely affected by lack of sleep and elevated stress levels⁽⁹⁾. At the same time, sleep deprivation can significantly increase the risk of medical errors, with serious consequences for patient safety^(2,10). Considering the high prevalence of sleep disorders and stress among physicians, a more comprehensive understanding of their impact on quality of life is imperative.

Quality of life (QOL) is a complex concept that is influenced by a variety of factors at both the individual and collective levels. These factors include: physical, mental and spiritual health; financial well-being; freedom of expression; safety; educational attainment ⁽¹¹⁾; quality of work life (QWL); and the structure and quality of individuals’ social relationships within society⁽¹²⁾. This topic developed in the early 1970s, when quality of life was evaluated mainly through the prism of health status, being associated with the absence of diseases and disabilities. Resident doctors often experience a low quality of life, which may hinder their professional development⁽¹³⁾.

Occupational stress is a health problem worldwide that impacts employees, particularly health professionals^(14,15). In the medical field, stressors are numerous, and include heavy workloads, extended hours, on-call duties, high-pressure tasks, complex patient care, diverse demands, establishing therapeutic relationships with patients and their families, time constraints, high patient volumes, and the management of life-threatening emergencies^(16,17). Additional contributing factors include a mismatch between personal skills and the requirements of the chosen specialty, inadequate work management, and lack of support from colleagues or supervisors. Studies indicate that physicians exposed to chronic stress experience significant impairment of psychological well-being, with negative repercussions on the quality of patient care^(18,19).

Considering the above, it is important to evaluate sleep disorders and stress levels among resident doctors for understanding their impact on quality of life.

Methodology

We conducted a cross-sectional observational study involving 170 resident physicians working in university centers in Romania and Germany. The main objective of the study was to evaluate the correlations between stress level, sleep disorders and the quality-of-life level among surgical and medical specialists residing in Romania and Germany. The study hypotheses are represented by the possibility that: 1) doctors in surgical specialties are subjected to greater stress, have lower sleep quality, and a lower quality of life compared to nonsurgical specialties; 2) there are statistically significant correlations between the level of stress, quality of sleep and quality of life; 3) doctors from Germany may have a higher level of quality of life compared to doctors from Romania. A total of 190 resident physicians were initially included in the study; however, 20 were excluded for not meeting the eligibility criteria, resulting in a final sample of 170 participants. The inclusion criteria were as follows: 1) resident doctors with 1-6 years of training; 2) resident doctors who specialize in surgical and medical specialties; 3) resident doctors who graduated from the faculty of medicine in Romania. Exclusion criteria: specialist doctors and attending doctors; other medical professionals (nurses, orderly). Before being included in the study, the participants gave their consent by moving on to the next section of the questionnaire which was disseminated online by Google Forms through social networks. The Ethics Committee of the “George Emil Palade” University of Medicine, Pharmacy, Sciences and Technology from Târgu-Mureș approved the conduct of the study.

The study utilized a questionnaire comprising demographic questions and three standardized scales: the Pittsburgh Sleep Quality Index (PSQI) to assess sleep quality, the Perceived Stress Questionnaire (PSQ) to measure levels of perceived stress, and the World Health Organization Quality of Life – Brief Version (WHOQOL-BREF) to evaluate the quality of life.

The PSQI assesses sleep over the past month through 19 items evaluating subjective sleep quality, sleep latency, duration and efficiency, sleep disturbances, use of sleep medication and daytime disfunction. The scale score ranges from 0 to 21. The sleep quality decreases with a higher score. A score above 5 indicates sleep deprivation, while a score above 10 indicates poor sleep quality⁽²⁰⁾. The PSQI is a validated instrument for assessing sleep quality in the Romanian population⁽²¹⁾.

The WHOQOL-BREF, consisting of 26 items, was originally published in 1996 by the World Health Organization, being designed to assess an individual’s subjective perception of quality of life. The scale evaluates four areas, as follows: physical health, mental health, interpersonal relationships, and environmental factors. Scoring is performed on a 5-point Likert scale, with the final score ranging from 0 to 100. A score less than or equal to 45 indicates a low quality of life, 46-65 indicates a moderate level, and over 65 the quality of life is increased^(22-24). The instrument has been validated for use in the Romanian population, demonstrating good reliability and validity^(25,26).

The PSQ was created by Levenstein et al. in 1993, which assesses the level of stress in the last month. The scale evaluates perceived stress over the last month using 30 questions scored on a four-stage Likert scale, with scores ranging between 30 and 120. Subjects with scores between 30 and 59 are considered to perceive a low level of stress, those scoring between 60 and 89 are considered to perceive a moderate level, and those between 90 and 120, a high level of stress⁽²⁷⁾.

Statistical analysis was performed using GraphPad Prism 9 software, with the Mann-Whitney test being used to compare groups considering the nonparametric distribution of the data. The Spearman Test was used to identify correlations between quality of life, stress level, and sleep quality.

Results

The study included a group of 170 participants. Regarding gender distribution, 123 participants (72.35%) were female, and 47 (27.65%) were male. The age-group distribution was as follows: 60 people (35.29%) were aged 24 to 27 years old, 56 (32.94%) were aged 28 to 30, and 54 (31.76%) were over 30. By specialty, 37 participants (21.8%) were in surgical fields, while 133 (78.2%) were in nonsurgical fields. In most cases, the place of practice was Romania (111 participants; 65.3%), while 59 participants (34.7%) were practicing in Germany. Regarding marital status, 56 people (32.94%) were married, 110 (64.71%) were single, and four (2.35%) were divorced. The distribution by year of residency was as follows: 47 participants (27.7%) in year I, 39 (22.9%) in year II, 26 (15.3%) in year III, 17 (10%) in year IV, 26 (15.3%) in year V, and 15 (8.8%) in year VI.

Table 2 shows the descriptive statistics of the studied variables in relation to the specialty practiced, and in Table 3 it can be seen that there are no statistically significant differences between surgical and nonsurgical specialties in terms of the level of quality of life in all four domains (Domain 1: U=2390, p=0.79; Domain 2: t=1.466, p=0.14; Domain 3: U=2297, p=0.53; U=2339, p=0.64), perceived stress (U=2419, p=0.87), as well as sleep quality (U=2441, p=0.94).

Table 4 presents the descriptive statistics of the studied variables in relation to the country in which the participants carry out their professional activity. In Table 5, it can be seen that there is a statistically significant difference in the case of Domain 4 of quality of life, doctors from Germany having a higher value (U=2498, p=0.01). Regarding the rest of the subdomains (Domain 1: U=2966, p=0.31; Domain 2: U=3125, p=0.62; Domain 3: U=2936, p=0.26), there are no statistically significant differences, not even in the case of perceived stress (U=3182, p=0.76) and sleep quality (U=3174, p=0.74).

The results presented in Table 6 highlight the existence of significant correlations between sleep quality, perceived stress level, and the different domains of quality of life.

Thus, significant negative correlations were identified between sleep quality and quality of life in the domains of mental health (D2: r=-0.41; p<0.001), social relationships (D3: r=-0.34; p<0.001) and environmental (D4: r=-0.30; p<0.001). The strongest relationship was between sleep quality and physical health (D1), where the correlation coefficient was r=-0.61 (p<0.001).

These data indicate that poor quality sleep is correlated with a negative perception of overall health, especially in terms of the physical and psychological state of the person.

A significant positive correlation between sleep quality and stress levels (r=0.35; p<0.001) was also observed, suggesting that people who experience higher levels of stress typically have poorer sleep quality.

Regarding the relationship between perceived stress and quality of life, the results show statistically significant negative correlations between the PSQ and all four WHOQOL-BREF domains, with the strongest correlation coefficients observed in the mental health domain (D2: r=-0.50; p<0.001) and the physical health domain (D1: r=-0.44; p<0.001). These findings highlight the fact that stress affects more than just mental health; it also impacts physical health, social relationships (D3: r=-0.28; p<0.001), and perception of the living environment (D4: r=-0.30; p<0.001).

Discussion

The comparative analysis of the scores obtained on the WHOQOL-BREF, PSQI and PSQ instruments did not reveal statistically significant differences between residents in surgical specialties and those in nonsurgical specialties. Although it might be expected that residents in surgical specialties which involve a greater physical workload, longer shifts and increased pressure in decision-making would have a lower quality of life or higher stress levels compared to their colleagues in nonsurgical specialties⁽²⁸⁾, the data obtained do not support this hypothesis. Regarding sleep quality depending on the specialty practiced, the study did not reveal a statistically significant difference between surgical and medical specialties. This result is inconsistent with the literature, which suggests that resident doctors in surgical specialty training programs have lower sleep quality⁽⁹⁾.

The study indicated that there is a statistically significant difference in the quality of life of resident physicians related to the environment in which they work and live. Physicians practicing in Germany have a higher quality of life compared to those practicing in Romania. This difference could be explained by several factors: in Germany, doctors have a secured job after completing residency, a more attractive salary, more opportunities for professional development, as well as a better developed medical infrastructure. In Romania, the long-term job security among resident doctors is low, which may be due to the fact that after the end of the residency, they are forced to look for a new job, as they are usually employed with fixed-term contracts. Moreover, resident physicians report that their professional activity is influenced by the work environment. Job insecurity has a negative impact on well-being, with consequences for both physical and mental health^(28,29) according to the Big Five model, statistically associated with work relationships (A p<0.0001; ES p=0.0005).

A statistically significant negative correlation was also highlighted between stress levels and quality of life in Domains 1, 3 and 4, which referred to physical health, mental health, social relationships and environment factors. This result is also confirmed by the research conducted by Storman et al. which reported a statistically significant association between the number of hours spent at work and the level of quality of life⁽³⁰⁾. The study by Buddeberg-Fischer et al. suggests that prolonged exposure to stress should be a cause for concern because of the negative impact it has on health and life satisfaction that can cause physical and mental exhaustion⁽¹⁸⁾.

Another aspect studied is the level of quality of life among resident doctors, which is closely related to sleep, as evidenced by statistically significant negative correlations between Domains 2 (Mental health), 3 (Social relationships), and 4 (Environment) of the WHOQOL-BREF scale and sleep quality. Lee et al.’s study indicates that poor sleep quality leads to a deterioration in quality of life⁽³¹⁾.

The results of this study indicated a statistically significant positive correlation between stress levels and poor sleep quality among resident physicians, which is consistent with literature data. The study conducted by Almojali et al. aimed to assess sleep quality and stress among final-year medical students, the results highlighting a high prevalence of stress among participants, which was associated with poor sleep quality. Academic stress and professional pressure can negatively influence sleep, thus affecting students’ health and performance⁽³²⁾. Research conducted by Abdellah et al. during the COVID-19 pandemic, when stress levels were elevated, showed that most physicians reported low sleep quality⁽³³⁾.

Limitations

There are some limitations that must be taken into account when considering the possibility of conducting future research, such as the cross-sectional observational design of the study, which means that the variables were evaluated only at a single point in time. On the other hand, the study was conducted through self-administered questionnaires, which is why there is a risk that some responses may be influenced. The sample distribution was uneven, given the low number of responding physicians in Germany and the disparity between surgical and nonsurgical specialties. Furthermore, the Perceived Stress Questionnaire (PSQ) developed by Levenstein et al. is not validated for the Romanian population, which may limit the reliability of the stress measurements.

Conclusions

The study indicated statistically significant correlations between stress levels, sleep quality and quality of life levels among resident physicians. There were no significant differences between residents from surgical and nonsurgical specialties. In contrast, the professional environment proved to be an important factor: resident doctors in Germany reported a better quality of life than those in Romania, probably due to better job security and working conditions.

The results support the importance of implementing measures to reduce stress and improve sleep among residents, thus contributing to increased mental health and physical well-being.    

Abbreviations

CI – 95% confidence interval
D1 – Domain 1 (Physical health)
D2 – Domain 2 (Mental health)
D3 – Domain 3 (Social relationships)
D4 – Domain 4 (Environment)
df – Degrees of freedom
n – Number of subjects
PSQ – Perceived Stress Scale
PSQI – Pittsburgh Sleep Quality Index Scale
QOL – Quality of life
QWL – Quality of work life
r – Pearson correlation coefficient
t – Student’s t-test
U – Mann–Whitney test
WHOQOL-BREF – World Health Organization Quality-of-Life Scale – brief version

Corresponding author: Zorica Milenković E-mail: zorica.milenkovic1999@gmail.com

Conflict of interest: none declared.

Financial support: none declared.

This work is permanently accessible online free of charge and published under the CC-BY licence.