Association between anxiety and sleep quality in the general surgery residents of Udayana University

Background: Sleep quality not only affects physical health but also on individual performance. Anxiety is thought to associate with poor sleep quality. This study aims to determine the association between anxiety and sleep quality in surgery residents of Faculty of Medicine, Udayana


Introduction
Anxiety is a negative emotional state characterized by somatic disorders, such as heart beating fast, sweating, difficulty breathing. Anxiety is similar to fear but with a less specific focus.
Anxiety is characterized by concerns about the unexpected danger that lies in the future, while fear is a response to an immediate threat.¹ Anxiety disorder is one of the mental disorders that often occurs in societies with a worldwide prevalence of 2.5-7% in each country.2 An estimated 284 million people worldwide experience anxiety disorders in 2017. 3 Anxiety affects sleep quality. 4 The relationship of anxiety and sleep disorders is important to know because overcoming anxiety will improve sleep quality. Sleep is a physiological need for humans. Poor sleep and poor quality can cause impaired physiological and psychological balance.¹ Sleep disorder is disorder that often occurs but are often ignored. Sleep disorders will affect one's health status, morbidity, and are associated with increased mortality.5 Physiological and psychological effects that arise due to poor sleep quality include decreased daily activity, fatigue, impaired motor response, decreased endurance, stress, depression and anxiety. Lack of sleep can result in social disturbances, performance, learning achievement, mental health, and other functions. 6 General Surgery residents at Sanglah General Hospital often have to deal with tiring and unexpected schedules, financial challenges, as well as difficult emotional problems, high levels of stressors, and very potentially cause anxiety. Especially doctors participating in surgical specialist education programs. This anxiety can cause sleep quality disorders. Side effects of disruption of sleep quality, namely: drowsiness, reduced alertness, impaired concentration of attention, impaired cognitive function to perform complex functions, and impaired executive function so that it will affect the academic ability of students.
This study aims to determine the relationship between anxiety and sleep quality among the General Surgery residents of Udayana University.

Methods
This was an observational, analytic, cross-sectional study, using randomized sampling. The subjects were the General Surgery residents of Sanglah General Hospital. The study protocol was approved by the institutional review board of Sanglah General Hospital.
The inclusion criteria were General Surgery residents who were willing to be included in this study by signing a written informed consent. The exclusion criteria were the ones who were undergoing physical and mental pain therapy.

Results
There were 48 subjects enrolled in this study. Most of the study subjects were male (85.4%). The subjects of this study were mostly using addictive substances (52.1%) in the form of cigarettes and coffee (Table 1). Table 2 shows the results of the BAI and PSQI score. As displayed, most of the subjects were not anxious (66.7%) and have poor quality of sleep (87.5).  In this study, there was a difference in the proportion between anxiety and non-anxiety states between subjects with poor sleep quality and good sleep quality (p=0.044). The subjects who are in anxious state has triple the chance of experiencing poor sleep quality compared to those who are not anxious (Table 3).

Discussion
From this study it was found that the average age of the subjects his research and it is recommended that working hours be limited to 80 hours a week. 14 Some residents with normal sleep at the beginning of the residency end up having severe sleep disturbance, some even more severe than those who already have sleep disorders before. Recognition and management of fatigue are very important. [15][16][17][18][19] This research shows that there is a positive relationship between anxiety and sleep quality. This is similar to previous research on the relationship between anxiety levels and sleep quality in 278 medical students at the undergraduate, graduate, and doctoral levels. They reported that people with high stress levels had various levels of psychological suffering such as anxiety and depression. The results of the study showed that 73% of students experienced moderate anxiety and severe anxiety, and 46.4% had a PSQI score of ≥5 which reflects a poor sleep quality (p <0.001). 16 A study that assessed the relationship between anxiety, sleep quality, the branch of medicine studied and hours of work, the num- The research has several limitations. The first limitation is that this study was a cross-sectional design in which data collection is carried out once without follow-up. Secondly, subjects may tend to give more "acceptable" answers than "honest" answers to the questionnaire. Third, knowing the many factors that can affect anxiety and the quality of sleep, there are always a number of other biases that cannot be controlled. Last, the writer used BAI as an anxiety questionnaire and PSQI as a sleep quality questionnaire. The use of other questionnaires to assess anxiety and sleep quality in other studies can be a challenging comparison.

Conclusion
The prevalence of anxiety in the residents of General Surgery of Udayana University was 33.3%. The sleep quality was mostly poor at 87.5%. There is a significant relationship between anxiety and sleep quality amonst the study subjects.