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

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
Mohammad Joori

Shoroq Barhoush
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

II

Page


1.1
2.1.1
2.2.1
2.2.1
2.2.2
2.2.3
2.3.1
2.3.2
2.3.3
2.3.4
2.4.1
2.4.2
3.1
3.2
3.3
3.4
3.5
3.6
4.1.
4.2.
4.3.
4.4.

4.5.
4.6
4.7
4.8.1
4.8.2

Acknowledgment
Table Of Contents
List Of Tables
List Of Annexes
List Of Abbreviations
List of Conceptual Definitions
Abstract
Chapter One: Introduction
Introduction
Chapter Two Background
Sleep
Consequences Of Poor Sleep
Sleepiness
Causes Of Sleepiness
Symptoms Of Sleepiness
Fatigue
Classification Of Fatigue
Symptoms Of Fatigue
Factors Of Fatigue
Nursing Performance
Factor Affecting Nursing Performance
Chapter Three Literature Review
Literature Review.
Problem Statement.

Significant Of Study.
Aims Of This Study &Objective.
Research Question.
Hypothesis.
Chapter Four Methodology
Introduction
Study Design
Site And Setting
Study Population
Sample Size And Sampling Method
Eligibility Criteria
Data Collection Tool
Validity And Reliability
Reviewing By Experts

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II.
III.
VI.
VIII.
IX.
X.
XI.
1
2
3
4
5
7

8
8
8
10
11
12
12
15
16
17
28
28
29
29
29
30
31
31
31
31
32
32
32
33
33


4.8.3
4.8.4
4.9.

4.10
4.11

Pilot Testing
Cronbach’sAlpha
Ethical Consideration
AdminstrativeAndField Work.
Data Analysis (Operational Definition)
Chapter Five Result

34
34
34
35
35
37

5.1

Participant According To The Demographic Data

38

5.2
5.3
5.4
5.5
5.6
5.7
5.8

5.9
5.10
5.11

Participant According To Their Pattern Of Work
Participant To Their Quality Of Sleep
Participants Regarding Their Feeling Of Fatigue
Participants According Nursing Performance
Participants Regards Their Quality Of Sleep
Participants Regards Their Level Of Fatigue.
Participants According To The Level Of Performance
Participants Regards Their Physical Performance.
Participants Regards Their Metal Performance
Hypotheses Result.
Participants According To Their Level Of Performance In

39
40
41
42
43
43
43
43
44
44
44

5.12

Relation To Their Sleep Quality
Participants According To Their Level Of Performance In

45

5.13

Relation To Their Fatigue Level
Participants According To Their Level Of Fatigue In Relation To

45

Their Type Of Performance.
Chapter Six Discussion
Discussion
Hypotheses Discussion.

46
47
50

Chapter Seven
7.1
7.2
7.3

Conclusion And Recommendation And Limitations Of Study
Conclusion.
Recommendation.
Limitations Of Study

References.
Annxes.

II

52
53
54
55
56
66


List Of Tables
NO.
Table (4. 1)

Content
Page
Distributed Of Number OfNurses According To 31

Table (4. 2)
Table (4. 3)

Hospital Location .
The Result Of Cronbach's Alpha Test.
The Total Response Rate Of Participant In The Study

34
35

Table (4. 3)

Variables Of The Study.

35

Table (5. 1)

Distribution Of Percentages Of Participant According

38

Table (5. 2)

To The Demographic Data.
Distribution Of Percentages Of Participant According

39

Table (5. 3)

To Their Pattern Of Work.
Distribution Of The Percentage Of Participant To Their

40

Table (5. 4)

Quality Of Sleep.

Distribution Of Percentage Of Participants Regarding

41

Their Feeling Of Fatigue.
Table (5. 5)

Distribution Of Percentages Of Participants According

42

Table (5. 6)

Nursing Performance.
Distribution Of Percentage Of Participants Regards

43

Their Quality Of Sleep.
Table (5. 7)

Distribution Of Percentage Of Participants Regards

43

Table (5. 8)

Their Level Of Fatigue.
Distribution Of Percentages Of Participants According

43

Table (5. 9)

To The Level Of Performance.
Distribution Of Percentage Of Participants Regards

43

Their Physical Performance.
Table (5. 10)

Distribution Of Percentage Of Participants Regards
Their Metal Performance.

9

44


Table (5. 11)

Distribution Percentage Of Participants According To

44

Their Level Of Performance In Relation To Their Sleep
Table (5. 12)

Quality.

Distribution Percentage Of Participants According To

45

Their Level Of Performance In Relation To Their
Table (5. 13)

Fatigue Level.
Distribution Percentage Of Participants According To
Their Level Of Fatigue In Relation To

45
Their

Type Of Performance

List Of Annexes
NO.
Annex(1)
Annex(2)
Annex (3)
Annex (4)
Annex (5)

Content
Questioner In English
Psqi Permission.
Npi Permission
Permission From IRB
ConcentForm

Annex (6)

Permission Of MOH

Page
I.
VII.
VIII.
IX.
X.
XII.

II


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.

9

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.

II


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.

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

II


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

9


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).

II


Chapter Two Background

1. Study background
1.1.1.

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 ‫ ؛‬nonREM (NREM) and REM . REM sleep is, of course, rapid eye movement. NREM

9


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.

II


2.1.2. 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

9

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,
complete, basically

and whether partial or

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

II


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

9


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

II


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 >12hour/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.

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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 'selfregulatory 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

II


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 12hour 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,

9


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

II


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

9


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
II


•

Insufficient practice and experience health staff

•

lack of management skills

•

poor working conditions and environment

•

Inadequate remuneration.

•

demotivated health personnel

Chapter three
Literature Review

9