Adile Neşe¹, Ercan Bakır², Sümeyra Mihrap Ilter³

1. PhD, Department of Internal Medicine Nursing, Gaziantep University, Vocational School of Health Services, Gaziantep, Turkey
2. PhD, Department of Nursing, Erzurum Technical University, Faculty of Health Sciences, Erzurum, Turkey
3. PhD, Department of Gerontology, Osmaniye Korkut Ata University, Faculty of Health Sciences, Osmaniye, Turkey

Received: 20 September 2024

Revised: 24 September 2024

Accepted: 24 September 2024

Published: 24 September 2024

Keywords:

Ramadan fasting, medical error, nurse.

Corresponding author:

Adile Neşe, PhD.

Department of İnternal Medicine Nursing, Gaziantep University, Vocational School of Health Services, Gaziantep, Turkey. acaparusagi@hotmail.com

doi: 10.5281/zenodo.13832662

Cite as:

Neşe A, Bakır E, Ilter SM. Examination of the Relationship Between Ramadan Fasting and Propensity for Medical Errors in Nurses: A Challenge for Nurses. Med J Eur. 2024;2(4):84-90. doi: 10.5281/zenodo.13832662

ABSTRACT

With Ramadan fasting, fasting time, daily energy deficit and sleep patterns change. Therefore, nurses’ approaches to Ramadan hunger are important. The purpose of this study is to examine the relationship between Ramadan fasting and the propensity for medical errors in nurses. The study was conducted a cross-sectional study with a nurses working at a university hospital in Turkey Research data were collected using an information form consisting of questions about the descriptive characteristics of the nurses prepared by the researchers and the Nurses’ Propensity for Medical Errors Scale. SPSS 25.0 (Statistical Package for Social Sciences for Windows) was used for the analysis of the research findings. According to the findings of the study; 76.7% of nurses believed that it was not easy to work while fasting, 74.4% stated that fasting did not hinder their work, and 52.2% expressed difficulties in performing treatment and care procedures while fasting. It was found that nurses had a low tendency for medical errors while fasting. It was determined that the ease of working while fasting, the organization of work shifts, and the duration of work affected the propensity for medical errors in nurses.

INTRODUCTION

Ramadan is the ninth month of the Islamic lunar calendar, and fasting during the month of Ramadan is a religious duty for all healthy adult Muslims. With over a billion people worldwide following Islam, millions observe Ramadan fasting each year (1,2). Ramadan fasting is considered one of the obligatory religious practices in Islam. It involves abstaining from food, drink, medication, smoking, and sexual relations from sunrise to sunset for one month each year (3). Fasting also serves as a means of spiritual training, encouraging individuals to refrain from negative thoughts, words, and actions (4). Muslims exert significant effort to observe Ramadan fasting due to their belief in spiritual rewards. While fulfilling the obligatory act of Ramadan fasting, Muslims may encounter various challenges (5).

Extended fasting periods can impact daily performance (6). Ramadan fasting can lead to changes in dietary habits, daily activities, physical and mental performance, and lifestyle (7). Furthermore, the effects of Ramadan fasting on sleep, anxiety, stress, and fatigue parameters have been reported (5,6,,8,9). Ramadan fasting may also affect both physical and mental changes, influencing work performance (9,10).

Nurses play a crucial role in ensuring patient safety, as they are directly involved in patient care and spend extended periods of time with patients (11). Medical errors are a significant concern for patient safety. The Joint Commission on Accreditation of Healthcare Organizations defines a medical error as “inappropriate or unethical behavior by a healthcare provider, inadequate or negligent conduct in professional practices resulting in harm to the patient”(12). Medical errors are a critical issue for all healthcare professionals, but due to the diverse and dependent roles of nurses in patient care, they may face a higher risk of making medical errors compared to other healthcare professionals (11,12).

Nurses contend with a heavy workload due to various negative factors in their work environment. Factors such as excessive workload, emotional stress due to patient problems, working with patients requiring intensive care and those nearing the end of life, and especially working in shifts, contribute to challenging working conditions (12,13). These challenging conditions negatively impact patient safety and contribute to the occurrence of errors in the care process (14). Studies assessing nurses’ propensity for medical errors in the literature have examined variables such as workload, institutional functioning, and knowledge deficiency (11,12,14). However, there is no research found that investigates the relationship between Ramadan fasting and medical errors.

This study aims to examine the relationship between nurses’ Ramadan fasting and their propensity for medical errors, considering variables such as the duration of fasting, daily energy deficit, cortisol release, and changes in sleep patterns associated with Ramadan fasting.

METHODS

Sample of the Research

This research was conducted as descriptive.

The research was conducted with nurses working at a university hospital in Turkey during the Ramadan month, from March 23 to April 20, 2023. As the study covered the month of Ramadan, no sampling was performed, and it was completed with the voluntary participation of 180 nurses. The study focused on nurses due to the potential risk of medical errors during Ramadan, considering their intensive working hours, night shifts, sleep problems, and irregular eating patterns.

Inclusion criteria

Inclusion criteria were being over 18 years old, volunteering, being a nurse, and observing fasting during Ramadan. Health professionals who did not volunteer, non-nursing staff, and those not observing fasting were not included in the study.

Data Collection

Data were collected through face-to-face interviews using a questionnaire. The questionnaire was individually filled out by the participants within the hospital environment and working hours and handed over to the researcher on the same day. The interview duration was approximately 10 minutes.

Data Collection Tools

Two tools were used for data collection: “Nurse Introduction Form” and “Nurses’ Propensity for Medical Errors Scale.”

Nurse Introduction Form

Parameters included gender, marital status, education, economic status, habits, and work style, focusing on nurses’ thoughts regarding Ramadan fasting and socio-demographic characteristics.

Nurses’ Propensity for Medical Errors Scale:

Developed by Özata and Altunkan in 2010 to measure nurses’ propensity for medical errors, this scale consists of 49 items and 5 sub-dimensions using a 5-point Likert scale. The Cronbach’s Alpha coefficient for the scale was found to be 0.95. The minimum score that can be obtained from the scale is 49, and the maximum score is 245. Increasing total scores are interpreted as a decrease in nurses’ tendencies to make medical errors (15). In this study, the Cronbach’s Alpha value was found to be 0.81.

Statistical Analysis

SPSS 25.0 (Statistical Package for Social Sciences for Windows) was used for the analysis of the research findings. The normal distribution of the data was evaluated using the Shapiro-Wilk test. Frequency, percentage, Mann-Whitney U, Kruskal-Wallis tests were used for data analysis. Cronbach’s Alpha coefficient was calculated for the reliability of the scale. A significance level of 95% confidence interval, p < 0.05, was considered.

Ethical Principles

The study obtained necessary permissions from the Clinical Research Ethics Committee of a state university (Date: 12.04.2023. Decision no: 2023/113) and institutional approval for its conduct. The purpose of the research was explained to the nurses, and their participation consent was obtained. The research was conducted following the principles of the Helsinki Declaration.

RESULTS

The average age of the nurses participating in the study was determined to be 30.85±6.65, with an average work experience of 8.45±6.27 years. Of the participants, 56.1% were married, 64.4% were female, 79.4% had a bachelor’s degree, 63.3% reported an equal income status, 42.8% worked during the day, 42.8% worked both during the day and night shifts, and 71.1% did not use tobacco.

Concerning the observance of Ramadan, 76.7% of the nurses believed that working while fasting did not provide convenience, while 74.4% expressed that observing Ramadan did not hinder their work. Additionally, 52.2% of the nurses reported facing difficulties in performing treatment and care procedures while fasting during Ramadan (Table 1).

Table 1. Distribution of nurses according to fasting and socio-demographic characteristics (n=180).

		Mean±SD	Min-max
Age (years)		30.85±6.65	19-52
Work Experience (years)		8.45±6.27	1-30
Variables		n	%
Marital Status	Married	101	56.1
	Single	79	43.9
Gender	Female	116	64.4
	Male	64	35.6
Education Level	High School	21	11.7
	Associate’s Degree	8	4.4
	Bachelor’s Degree	143	79.4
	Postgraduate Degree	8	4.4
Income Level	Income less than expenses	37	20.6
	Income equal to expenses	114	63.3
	Income greater than expenses	29	16.1
Smoking	Yes	52	28.4
	No	128	71.1
Presence of Chronic Disease	Yes	17	9.4
	No	163	90.6
Work Shift	Day	77	42.8
	Night	26	14.4
	Day + Night	77	42.8
Is it convenient to work while fasting?	Yes	42	23.3
	No	138	76.7
Does fasting hinder your work?	Yes	46	25.6
	No	134	74.4
Do you face difficulties in performing treatment and care procedures while fasting?	Yes	94	52.2
	No	86	47.8

SD: Standard deviation.

The gender status of the nurses participating in the study was found to have a statistically significant difference in the Medical Error Tendency Scale sub-dimensions and total score (p<.05), with females exhibiting lower tendencies towards medical errors (Table 2). Similarly, the work shift of the participating nurses showed a statistically significant difference in the sub-dimensions and total score of the Medical Error Tendency Scale (p<.05), indicating that those working continuously on night shifts had higher tendencies towards medical errors (Table 2). The ease of working while fasting among nurses was found to have a statistically significant difference in the sub-dimension of the Medical Error Tendency Scale, specifically in the “preventing falls” dimension, as well as in the total score (p<.05). Nurses who perceived that working conditions were convenient during fasting exhibited lower tendencies towards medical errors (Table 2).

The impact of Ramadan fasting on hindering work was also found to have a statistically significant difference in the sub-dimensions and total score of the Medical Error Tendency Scale (p<.05), with lower tendencies towards medical errors reported by nurses who did not find fasting to be a hindrance to their work. Furthermore, the difficulty faced by nurses in performing treatment and care procedures while fasting showed a statistically significant difference in the sub-dimensions and total score of the Medical Error Tendency Scale (p<.05). Nurses who reported facing challenges in treatment and care procedures while fasting exhibited higher tendencies towards medical errors (Table 2).

Table 2. Distribution of nurse medical error tendency scale (NMETS) sub-dimensions and total score averages according to nurses’ fasting and socio-demographic characteristics (n=180).

		Medication and Transfusion Applications (mean ±SD)	Prevention of Infections (mean ±SD)	Prevention of Falls (mean ±SD)	Patient Monitoring and Material Safety (mean ±SD)	Communication (mean ±SD)	NMETS Total  Score (mean±SD)
Variables
Marital Status	Married	82.32±11.25	54.50±6.65	21.45±3.34	40.47±5.38	22.36±3.69	221.12±27.75
	Single	83.00±8.12	54.24±6.53	21.46±3.59	39.98±5.82	22.27±3.37	220.97±24.15
	Z/p	0.-645/0.520	0.-433/0.665	0.-199/0.845	0.-502/0.615	0.-670/0.503	0.-513/0.608
Gender	Female	83.91±8.46	55.53±5.61	22.06±2.93	41.54±4.20	23.01±2.85	226.06±21.23
	Male	80.28±11.98	52.31±7.66	20.37±4.02	37.93±6.88	21.07±4.29	221.98±31.48
	Z/p	-2.485/0.013	-2.792/0.005	-2.742/0.006	-3.398/0.001	-2.939/0.003	-3.060/0.002
Education Level	High School	81.28±9.30	53.42±5.66	20.52±4.03	39.00±6.02	21.52±3.40	215.76±25.71
	Associate Degree	84.00±5.58	52.87±5.30	19.75±4.49	39.00±5.12	23.00±3.07	218.62±20.70
	Bachelor’s Degree	82.57±10.44	54.50±6.86	21.62±3.32	40.42±5.61	22.33±3.64	221.46±26.87
	Postgraduate	85.62±6.27	56.37±4.68	22.75±2.18	41.87±3.72	23.62±2.26	230.25±18.37
	KW/p	1.976/0.577	3.178/0.365	3.492/0.322	2.429/0.488	3.485/0.323	2.967/0.397
Income Level	Income less than expenses	83.35±12.75	54.81±7.33	21.72±4.20	40.16±6.36	22.59 ±3.86	222.64 ±32.06
	Income equal to expenses	83.45±8.03	55.05±5.35	21.57±3.06	40.81±4.61	22.60 ±2.93	223.50 ±20.97
	Income more than expenses	78.41±12.03	51.24±8.95	20.65±3.82	38.20±7.41	20.89 ±4.88	209.41 ±33.31
	KW/p	5.455/0.065	3.039/0.219	2.965/0.227	1.542/0.463	3.751/0.153	4.560/0.102
Smoking Status	Yes	82.96±8.18	54.40±5.55	21.36±3.58	39.86±5.83	22.28±3.85	220.88±24.26
	No	82.48±10.65	54.38±6.98	21.50±3.40	40.42±5.47	22.34±3.43	221.13±26.98
	Z/p	-0.375/0.707	-0.513/0.608	-0.149/0.882	-0.923/0.356	-0.267/0.789	-0.407/0.684
Chronic Illness	Yes	84.11±11.21	56.11±7.05	22.23±3.91	41.52±4.97	23.29±2.49	227.29±28.04
	No	82.46±9.86	54.20±6.53	21.38±3.40	40.12±5.62	22.22±3.62	220.41±25.96
	Z/p	-1.921/0.055	-2.134/0.033	-1.298/0.194	-1.199/0.230	-1.209/0.227	-1.742/0.081
Work Shift	Day	83.83±11.27	55.45±6.63	22.11±3.51	41.55±4.72	23.10±2.76	226.06±27.24
	Night	73.23±10.23	48.23±6.94	19.23±3.27	35.53±6.85	19.38±4.80	195.61±25.75
	Day + Night	84.58±6.11	55.40±5.20	21.55±3.16	40.55±5.09	22.54±3.27	224.64±19.79
	KW/p	34.149/0.000	27.526/0.000	16.085/0.000	17.974/0.000	18.582/0.000	29.225/0.000
Ease of Working While Fasting?	Yes	84.97±7.51	56.35±5.30	22.42±2.91	41.83±4.52	23.04±2.96	228.64±20.65
	No	81.90±10.53	53.78±6.83	21.16±3.55	39.78±5.78	22.10±3.68	218.75±27.26
	Z/p	-1.955/0.051	-2.387/0.017	-2.063/0.039	-2.170/0.030	-1.757/0.079	-2.294/0.022
Does Fasting Hinder Your Work?	Yes	80.58±9.63	51.69±6.69	20.26±3.58	38.58±5.86	21.91±3.72	213.04±25.20
	No	83.32±10.03	55.31±6.30	21.87±3.31	40.83±5.37	22.47±3.48	223.81±26.00
	Z/p	-2.851/0.004	-3.772/0.000	-2.924/0.003	-2,855/0.004	-1.400/0.162	-3.245/0.001
Difficulty in Treatment and Care Practices While Fasting	Yes	80.67±10.23	52.77±6.83	20.52±3.39	39.04±5.45	21.77±3.37	214.78±25.69
	No	84.75±9.29	56.15±5.84	22.48±3.22	41.59±5.42	22.93±3.65	227.91±25.05
	Z/p	-4.192/0.000	-4.223/0.000	-4.257/0.000	-4.251/0.000	-3.421/0.001	-4.527/0.000

SD: Standard deviation.

Table 3. Distribution of nurses according to medical error tendency scale (MEPTS) and sub-dimension total score averages.

	N	Min	Max	Mean±SD
Drug and transfusion applications	180	36.00	90.00	82.62±9.98
Prevention of infections	180	28.00	60.00	54.38±6.58
Prevention of falls	180	11.00	25.00	21.46±3.45
Patient monitoring and material safety	180	19.00	45.00	40.26±5.57
Communication	180	8.00	25.00	22.32±3.54
Total score of MEPTS	180	120.00	245.00	221.06±26.16

SD: Standard deviation.

When the Medical Error Tendency Scale sub-dimension and total score averages of the participating nurses were examined, it was found that the average score of the Medical Error Tendency Scale was 221.06±26.16. In this case, when the sub-dimension and total scores of the Medical Error Tendency Scale are evaluated, it is determined that nurses have a low tendency to make medical errors (Table 3).

When examining the relationship between the Medical Error Tendency Scale and its sub-dimensions, a significant and positive correlation at a high level was found (Table 4).

Table 4. Relationship between the medical error tendency scale (MEPTS) and its sub-dimensions.

		1	2	3	4	5
Medication and Transfusion Applications (1)	r
	p
Prevention of Infections (2)	r	.693
	p	.000
Prevention of Falls (3)	r	.830	.745
	p	.000	.000
Patient Monitoring and Material Safety (4)	r	.735	.699	.829
	p	.000	.000	.000
Communication (5)	r	.679	.577	.677	.808
	p	.000	.000	.000	.000
Total score of MEPTS	r	.930	.811	.935	.904	.813
	p	.000	.000	.000	.000	.000

DISCUSSION

The burden of healthcare professionals, including the intensity of workload, the pace of work, and the rotational shift system, creates a conducive environment for medical errors (12). Ramadan fasting, with factors such as hunger, thirst, lack of sleep, and fatigue, can lead to various changes that may affect job performance (7,9). Therefore, it is hypothesized that nurses may have a tendency toward medical errors due to fasting, and given the lack of research evaluating nurses’ inclination toward medical errors during Ramadan fasting in the literature, this study was conducted with the aim of contributing to and guiding the literature.

A statistically significant difference was found in the sub-dimensions and total scores of the Medical Error Tendency Scale concerning the gender of the participating nurses (p<.05). Accordingly, it was observed that females had lower tendencies toward medical errors. In a study by Yiğitbaş et al. (2016), female nurses were reported to have a higher tendency to make errors, while Ulusoy et al. (2020) found that male nurses had significantly higher medical error perceptions than female nurses (16,17). The differences in the results may suggest variations in the numerical distribution of gender groups and may be attributed to individuals’ medical error perceptions and professional experiences.

It is well-known that Ramadan fasting induces various changes in both metabolism and circadian rhythm. Particularly, it has been reported to have an impact on fatigue and attention, especially in relation to decreased night sleep or increased daytime sleep duration (18). In the literature, the negative effects of night shifts on health (due to sleep deprivation, fatigue, and exhaustion) are emphasized, which can jeopardize patient safety (19). A statistically significant difference was found in the Medical Error Tendency Scale between the working shifts of the participating nurses (p<.05). Accordingly, nurses working continuously on night shifts exhibited higher tendencies toward medical errors. A literature review revealed that Özen et al. (2019) observed high and significant medical error tendencies among nurses working night shifts (20). Similarly, other studies have reported an increased tendency toward medical errors among nurses working night shifts (17,21). The night shift system is already a significant challenge for nurses, and working night shifts during Ramadan may exacerbate the situation, as the rush for the pre-dawn meal (sahur) to observe fasting can lead to a slowdown and decrease in mental functions in the late hours of the night, potentially causing medical errors (22,23).

A significant statistical difference was found in the Medical Error Tendency Scale between nurses who reported a lack of ease in working during the Ramadan month (76.7%) and the prevention of falls, one of the sub-dimensions of the Medical Error Tendency Scale (p<.05). Nurses who perceived ease in working while observing Ramadan fasting had lower tendencies toward medical errors. Montgomery et al. (2021) reported that excessive workload increased the tendency toward medical errors (24). Ramadan fasting induces physiological changes, affecting activities such as physical activity, circadian rhythm, and glucose metabolism (1,25). Therefore, facilitating working conditions during Ramadan, allowing for the preservation of energy and addressing physiological needs such as sleep deprivation and fatigue through well-designed work schedules, can reduce the tendency toward medical errors. There is a lack of studies in the literature examining the organization of working conditions during Ramadan fasting, and therefore, our study is expected to contribute to and guide the literature in this regard.

The majority of participating nurses (74.4%) reported that fasting during Ramadan did not hinder their work. A statistically significant difference was found between the perception of whether fasting hinders work and the sub-dimensions and total scores of the Medical Error Tendency Scale (p<.05). Nurses who did not consider fasting a hindrance to work had lower tendencies toward medical errors. This situation is thought to be due to nurses working in both night and day shifts, heavy workloads, and the frequent postponement of their needs. The similarity between the physiological needs deferred during Ramadan fasting and other times might be the reason for this perception (3,7)

More than half of the participating nurses (52.2%) believed that they faced difficulties in providing care and treatment to patients while fasting. A statistically significant difference was found in the perception of facing difficulties in care and treatment applications while fasting and the sub-dimensions and total scores of the Medical Error Tendency Scale (p<.05). Nurses who felt challenged in care and treatment applications while fasting had higher tendencies toward medical errors. Due to the lack of studies examining the relationship between nurses’ fasting and patient care, it is not possible to compare our findings with other studies. The increased workload and effort due to Ramadan fasting, coupled with the inability to meet the increased energy requirements, disrupted circadian rhythm, and conditions such as fatigue and sleep deprivation during this month, are thought to contribute to an increased tendency toward medical errors.

When the sub-dimension and total score averages of the Medical Error Tendency Scale for participating nurses were examined, it was found that the Medical Error Tendency Scale score average was 221.06±26.16, indicating a low inclination of nurses toward medical errors. In studies by Özen et al. (2019) and Sivrikaya et al. (2019), it was reported that nurses have a low inclination toward medical errors (20,26). Although nurses postpone and do not adequately fulfill basic needs such as nutrition, eating, drinking, sleep, fatigue, and stress due to their shift work, this situation is not unique to the Ramadan month. Ramadan fasting is considered to positively affect medical error-inducing situations, such as increasing spiritual feelings and alleviating stress and anger.

The limitations of this study include being conducted at a single center and attempting to reach participants during a limited period, such as the Ramadan month.

CONCLUSION

The findings obtained from the study indicate that factors such as nurses working continuous shifts, long working hours, facing challenges in patient care and treatment while fasting, and the inability to allocate time for themselves during fasting may increase their tendencies toward medical errors. Based on these results, it is recommended to organize working hours, provide rest opportunities at regular intervals, and make relaxing arrangements regarding sleep, nutrition, and other aspects to help nurses spend Ramadan more comfortably and reduce their tendencies toward medical errors. Since there is a lack of research on the effects of Ramadan fasting on nurses and its relation to their tendencies toward medical errors, this study is believed to make a significant contribution to the field, and further studies focusing on different parameters are needed.

Conflict of Interest

The authors declared no potential conflicts of interest concerning the research, authorship, and/or publication of this article.

Funding

The author(s) recevied no financial support fort he research, authorship, and/or publication of this article.

Acknowledgments

The author thanks to all patients who participated in the study.

CC BY license

This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

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