Effect of four weeks of integrated yoga intervention on perceived stress and sleep quality among female nursing professionals working at a tertiary care hospital: A pilot study.

BACKGROUND: Studies have reported that significant nursing professionals experience tremendous stress which often affects their sleep quality leading to poor well-being. Yoga being a mind body intervention reported to improve sleep quality and reduce stress. AIM: The present pilot study was designed to assess the effect of yoga on perceived stress and sleep quality of the female nursing professionals working at tertiary care hospital.
MATERIALS AND METHODS: Thirty-three apparently healthy nursing staffs in the age range of 30-60 years (mean age 40.60 ± 10.26) were recruited as participants of the study, from a tertiary care hospital in Delhi. Participants were administered perceived stress scale (PSS) and Pittsburgh sleep quality index (PSQI) before and after the yoga intervention. Participants received 4 week of yoga intervention for 45 min/day for 5 days a week.
RESULTS: There was a significant reduction on the postscores of PSS (t = 5.86, P < 0.0001, paired t-test) and PSQI (z = -4.38, P < 0.0001, Wilcoxon signed-ranks test) in comparison to prescores. After the yoga intervention, perceived stress reduced by 27.01% and the sleep quality improved by 38.68%.
CONCLUSION: The finding of the study suggests effectiveness of yoga in reduction of the perceived stress and improvement of the quality of sleep of the nursing professional. However, the present findings need to be confirmed with further studies with larger sample size and robust research design. Copyright:

Nursing professionals in India as well as throughout the world experience high stress[123] and poor sleep quality.[4567] Negative consequences of stress and poor sleep quality in the health of nursing professionals are well established. Studies showed that stress and poor sleep quality are positively associated with anxiety, depression, fatigue, and confusion, and negatively associated with attention, memory, and concentration of professional nurses.[891011] High level of stress and poor sleep quality are also correlated with increased physical health complications such as hypertension, obesity, cardiovascular diseases, and low quality of life.[1213] Stress and poor sleep quality in nurses' even increases patient care errors.[1415]

The findings of scientific studies showed excessive workload, professional conflicts, poor leadership management style, inadequate pay, work shift pattern, and emotional cost of caring are some of the causes of stress and poor sleep quality in nursing professionals.[16171819] In addition, nurses are found neglecting their self-care needs when they are devoted to patient care.[20] Abandonment of self-care increases stress, reduces quality of life, deteriorates physical and psychological health of nurses as well as increases the health care cost.[21] It also compromises the patients care quality.[21] The present study also showed that stress negatively affects self-care in nurses.[22] Therefore, hospital managements are required to improve nurses' working environment and promote practices that nurture self-care in nurses, reduce their stress and improve sleep quality. Fostering self-care, improving sleep quality and helping to manage stress can enhance nurses' physical and psychological health, can minimize patient care errors and health-care cost of an institution.

Yoga is a practice to enhance self-care, coping strategies and sleep quality, and to reduce work stress of nurses.[232425] A randomized, control, pilot-study conducted in 40 nurses showed that yoga significantly improves self-care and mindfulness, and significantly reduces emotional exhaustion.[26] Another randomized control study conducted in nurses with chronic low back pain showed that yoga is an efficient intervention to improve their physical, psychological, and social health spheres of quality of life compared to physical exercise.[27] Even a systematic review reported yoga as an effective technique to manage the stress of health workers.[28] Yoga also improves nurses' problem-solving ability and ability to focus on patients' needs.[29] In addition, mindfulness meditation and mindfulness-based stress reduction techniques were found effective in improving general health, sense of coherence, coping ability, life satisfaction, relaxation, mental well-being and job satisfaction as well as reducing stress, anxiety, depression, burnout of professional nurses.[30313233]

Studies to assess the effect of yoga on stress and sleep quality of nursing professionals are rare, one study conducted in Chinese nurses reported 6 months of yoga intervention improves nurses sleep quality and reduces work stress.[24] Further studies are required to support the effect of yoga on stress and sleep quality of nursing professionals. Literature review showed no study to assess the effect of yoga on perceived stress and sleep quality in India. Therefore, the present pilot study was designed to assess the effectiveness of 4 weeks of yoga on perceived stress and sleep quality among the nursing professionals working at a tertiary care hospital.

MATERIALS AND METHODS

Convenient sample of 33 apparently healthy female nursing professionals within the age range of 30–60 years (mean age 40.60 ± 10.26), working at a tertiary care hospital in New Delhi were recruited as the participants for the present study. Registered Direct Care Giving nursing professionals' and those who were willing to participate were included in the study. Whereas those nursing professionals who were diagnosed with severe musculoskeletal, neurological or psychiatric illness, those who had recent surgical intervention and those who were practicing yoga on a regular basis were excluded from the study. The design of the study was a single group pre-post. Patients were assessed on baseline and after the 4 weeks of intervention. The study was approved by a project Evaluation Committee of Directorate of Distance Education, SVYASA deemed to be University, Bengaluru, Karnataka, India. Verbal informed consent was obtained from the nursing professionals before the study, after explanations of the nature of the study in detail.

Intervention

45 min of group yoga was given for 6 days a week for 4 weeks. 45 min of yoga intervention includes Sukshma Vyayama (Joints loosening) breathing exercise, asanas (postures), pranayamas and deep relaxation technique. Yoga intervention was given by an academically trained yoga therapist. Practices mentioned in Table 1 were repeated throughout the intervention period.

Table 1

Yoga module for professional nurses

Practices	Rounds	Durations (min)
Sukshma Vyayama (joints loosening)		10
Padanguli Namana (toes bending)	5
Gulpha Namana (ankles stretch)	5
Gulpha Chakra (ankles rotation)	5
Janu Namana (knees bending)	5
Purna Titali (butterfly)	5
Mushtika Bandhana (loosening of fingers)	5
Manibandha Naman (wrists stretch)	5
Kehuni Naman (elbows stretch)	5
Skandha Chakra (shoulders rotation)	5
Greeva Sanchalana and Greeva Chakra (neck bending and rotation)	5 each
Breathing exercises		10
Hands in and out breathing	5
Ankle stretch breathing	5
Tiger breathing	5
Alternate legs raising breathing	10
Yoga Asanas		10
Ardhakatichakrasana	1
Padahastasana	1
Ardha Chakrasana	1
Vakrasana	1
Bhujangasana	1
Salabhasana	1
Udarakarsanasana	1
Setubandhasana	1
Pranayamas		5
Kapalbhati	2
Nadisuddhi	9
Bhramari	9
DRT		10

DRT Deep relaxation technique

Assessments

Perceived stress

Perceived stress was assessed using the perceived stress scale (PSS). PSS is a self-reported 10-item questionnaire to assess perception of stress in one's day-to-day life.[34] PSS is easy-to-use questionnaire with well-established psychometric property.[35] Each item of PSS is rated on 5 points scales from 0 (never) to 4 (very often). Each item of PSS is rated on 5-point scale from 0 (never) to 4 (very often). The possible score ranges from 0 to 40. The total score is obtained by reversing the responses for the positively state items (4, 5, 7, and 8) and summing scores across all the scales items.[34] PSS score ranging from 0 to 13 would be considered low stress; score ranging from 14 to 26 would be considered to be moderate stress; and score ranging from 27 to 40 would be considered to be high stress.[36]

Sleep quality

Sleep quality was assessed using the Pittsburgh sleep quality index (PSQI) is a self-rated questionnaire to measure the quality of sleep and sleep disturbance over 1 month. PSQI contains 19 items and generates scores of seven components: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction.[37] PSQI has internal consistency and reliability coefficient (Cronbach's alpha) 0.83 and test-retest reliability 0.87.[38] PSQI has diagnostic sensitivity of 89.6% and specificity of 86.5%.[37] Each item is rated in four point scales: 0 (not during the past month), to 3 (three or more times a week) for items 1–8 and 0 (very good) to 3 (very bad) for item number 9. The seven component scores are added to obtain a global score ranging from 0 to 21 and global score 5 or greater indicates worse sleep quality.[39]

Statistical analysis

Statistical analysis was performed using IBM statistics Statistical Package for the Social Sciences (SPSS) using Version 19.0., (Armonk, NY: IBM Corp.). Data were found to be normally distributed for PSS and were not found to be normally distributed for PSQI when tested with Shapiro–Wilk test. Hence, paired t-test was used to analyze PSS scores and Wilcoxon signed-ranks test was used to analyze the PSQI scores, respectively. All statistical analysis was computed with two-tailed.

RESULTS

There was a significant reduction on the postscores of PSS (t = 5.86, P < 0.0001, paired t-test) and PSQI (z = ‒4.38, P < 0.0001, Wilcoxon signed-ranks test) in comparison with prescores. Cohen's d for PSS is 0.69 and for PSQI is 0.63 which indicates moderate effect size. Yoga reduces the perceived stress by 27.01% and improves the quality of sleep by 38.68%. The study suggests yoga helps to reduce the perceived stress and improve the sleep quality of the nursing professionals. Mean pre- and post-scores of PSS and PSQI, Cohen's d as well as t score and z scores are illustrated in Table 2.

Table 2

Mean±standard deviation, t score and Z score of perceived stress scale and Pittsburg sleep quality index before and after yoga intervention, and Cohen’s d

Variables	Mean±SD		Percentage changes	t score and Z scores	Cohen’s d
	Pre	Post
PSS score	15.82±6.67	11.55±5.62***	−27.01	t=−5.49	0.69
PSQI score	5.09±3.48	3.23±2.74***	−38.68	Z=−4.38	0.63

***P<0.001. PSS Perceived stress scale; PSQI Pittsburg sleep quality index

DISCUSSION

The present study was designed to assess the effect of the integrated yoga module in the perceived stress and sleep quality among nursing professionals working at a tertiary care hospital. The finding of the study indicated the significant reduction in the perceived stress and improvement in the sleep quality of the nursing professionals after integrative yoga intervention.

This finding of the present study was supported by the outcomes of previous studies which demonstrated yoga intervention significantly reduced work stress, anxiety, muscle fatigue and emotional exhaustion, and enhanced the quality of sleep, self-care, coping skills, and sense of well-being of nursing professionals.[244041] However, the possible mechanism of reduction of stress and improvement in the quality of sleep after yoga intervention is not yet understood clearly. A previous study had shown that yoga reduced the sympathetic nerves activities, increases parasympathetic activities and balances autonomic nervous system reactivity.[42] Another study showed that yoga increased the secretion of a neurotransmitter called gamma-amino butyric acid (GABA).[43] Thus, increase in parasympathetic nerve activities, reduction of sympathetic nerve activities, and secretion of the inhibitory neurotransmitters such as GABA after yoga practice could be the possible mechanism for reduction of the perceived stress and improvement of the sleep quality. Increase in positive affect and self-compassion as well as inhibition of the posterior hypothalamus and salivary cortisol after yoga practice can also play an important role in reduction of stress.[44]

The finding of the present study advocated yoga module is effective in reducing perceived stress and improving sleep quality of nursing professionals; however, further study is required to conform to the present finding. Based on the present finding, health agencies and hospital managements can design the integrated yoga program for nursing professionals to improve their overall well-being and enhance patients care. In addition, based on the current research outcome, medical professionals can encourage patients at risk of getting stress-related disorders to practice yoga on a regular basis to minimize the stress, improve the sleep quality and prevent serious physiological and psychological complications. Furthermore, corporations and other organizations also can incorporate yoga on their daily schedule to enhance employees' psychological health and to minimize health care burden.

The limitations of the present study are small sample size, lack of control group, and use of self-report measures to assess stress and sleep quality. These limitations can be addressed in future research by incorporating large sample size and robust research design. Three arm randomized control trials can be conducted including groups performing yoga and physical exercise and a group without intervention. Studies also can be conducted using biomarkers of stress such as serum or salivary cortisol as well as electroencephalography. In addition, future studies to evaluate the effect of yoga on nursing professionals' overall health as well as patients' care could quantify the actual benefit of yoga.

CONCLUSION

The finding of the present study suggested integrative yoga intervention significantly reduced the perceived stress and improved the sleep quality of the nursing professional. Therefore, yoga can be cost-effective tools to manage the stress and improve the quality of sleep of the nursing professional, which can lead to the improvement in overall health of nurses and reduction in patient care errors. Based on the finding of the present pilot study, further studies can be conducted with larger sample size and robust research design.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.