How sleep quality and depressive symptoms shape safety behavior in rotating-shift nurses: Insights from mediation and network analyses

Safe behavior is critical for nurses to ensure patient safety, yet limited research has examined how physical and psychological health affect safety behavior in rotating-shift nurses. This study aimed to explore the underlying pathways and network connections among sleep quality, depressive symptoms, and safety behavior in rotating-shift nurses. A cross-sectional multicenter study focusing on rotating-shift nurses was conducted. Sleep quality, depressive symptoms, and nurses' safety behavior were assessed using validated questionnaires. Correlation and mediation analyses were applied to explore the relationships and mediating pathways among sleep quality, depressive symptoms, and safety behavior. Network analysis was conducted to identify their internal associations and core symptoms. A total of 1,749 rotating-shift nurses were included in the study, with a relatively high safety behavior level (median score: 55). The prevalence of screen-positive poor sleep quality and moderate-to-severe depressive symptoms was 66.1% and 38.0%, respectively. Poorer sleep quality and depressive symptoms were associated with lower nurse safety behavior level (ρ = -0.167, ρ = -0.286, respectively). Moreover, the depressive symptoms mediated the effect of sleep quality on nurses' safety behavior level. Network analysis further identified "Insomnia, disturbed sleep" of depressive symptoms, and "sleep duration" of sleep quality with higher centrality were bridge symptoms within the sleep-depression-safety behavior network. Rotating-shift nurses often experience poor sleep quality and depressive symptoms, which are associated with lower safety behavior level. Depressive symptoms may play a pivotal mediating role between sleep quality and safety behavior. Targeting key bridging symptoms - "Insomnia, disturbed sleep" and "Sleep duration" - may improve nurses' sleep-depression-safety behavior network.