Association between Insomnia, Demographic Characteristics and Self - Esteem in Nursing Personnel in Primary Care and in Emergency - Intensive Care Units on the Island of Crete
Citation: Association between Insomnia, Demographic Characteristics and Self - Esteem in Nursing Personnel in Primary Care and in Emergency - Intensive Care Units on the Island of Crete. American Research Journal of Nursing. 2019; 5(1): 1-16.
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Background: There is evidence that self – esteem is important for health. Especially, self – esteem is associated with better health in those with chronic conditions or disability.
Purpose: The objective of this study was to examine, in a comprehensive way: (a) the association between insomnia and self-esteem, (b) the association between insomnia and marital status in nursing personnel in the island of Crete, Greece.
Method: An investigation was carried out in the area of Crete between August 2017 and January 2018 in fourteen Health Centers, two Primary National Health Networks, four Emergency Department, eleven Intensive Care Units. The study involved 213 nurses. The Hamilton Anxiety Scale (HAM-A) and the Culture-free Selfesteem Inventories had been used.
Results: Prevalence of insomnia was 49.3% (from mild to very severe symptoms). Multivariate analyses showed that self-esteem was significantly associated with insomnia symptoms (p <0,002). Multivariate models also showed that insomnia-type symptoms were associated with marital status (p <0,026).
Conclusions: In a large population of nursing personnel insomnia symptoms are prevalent and associated with self-esteem and marital status. Future studies should assess whether the strengthening of self- esteem improves the sleep problems in nursing personnel.
Keywords: Insomnia symptoms, Self-esteem, Marital status, Nursing Personnel
Studies reports that the rate of insomnia in the united states, valued at 10% to 40%, and continue to raise these percentages, researchers try to understand and treat sleep disorders.1,2
Chronic insomnia is associated with psychiatric and physical conditions. Although it is a symptom of depression, insomnia is also a forerunner of depression and is associated with a substantial increase in the relative risk of major depression. Chronic insomnia is associated with deteriorated mood, subjective functioning, quality of life and increased daytime sleepiness. Chronic insomnia is a common problem, often associated with negative waking mood or function . Anxiety disorders and comorbid mood are associated with high rates of severe insomnia, which were independently associated with functional impairment . Insomnia is associated with anxiety and disorders mood, and longitudinal evidence shows that insomnia predates the onset of mental illness .
Further, in a study, Lemola et al. demonstrated that short sleep (sleeping less than 6 hours) was negatively related to self – esteem. Also, the same study showed that long sleep (sleeping more than 9 hours) was negatively related to self-esteem. Moreover, the relation of long sleep with lower self-esteem was statistically significant when adjusting insomnia symptoms.
According Gregory et al., family influences may be important in the association between insomnia . Marital status is considered to be of importance among the sociodemographic determinants of insomnia. Furthermore, although in univariate analysis the odds for insomnia was lower for single persons but higher for divorced or widowed persons compared to married subjects. This association was not statically significant in multivariate analysis. Therefore, marital status did not subscribe to the occurrence of insomnia contrary to what is generally reported in the literature [8,9]. In another study, it was not found significant association between marital status and insomnia in males. However, divorced/widowed females were more conquerable to insomnia (age-adjusted OR 1.78; 95% CI 1.20–2.63) .
The gender differences marriages have been suggested as disadvantageous to females because of genderspecific demand and burden as well as restricted roles available to females in the marriage [11,12]. Also, being a housewife or being widowed and divorced were most strickened .
In our study, the first approximation comprises the investigation the association between insomnia and selfesteem and the second approximation the association between insomnia and marital status in nursing staff in Primary Health Care, in Emergency Departments (ED) and in Intensive Care Units (ICU) of five major hospitals and 11 Health Centers in the island of Crete, Greece. In addition, no study has examined the role of insomnia symptoms compared with self – esteem and marital status in nursing personnel worldwide.
The general objective of the study was to investigate the insomnia in nursing staff in Primary Health Care, in Emergency Departments (ED) and in Intensive Care Units (ICU) of five major hospitals and 11 Health Centers in the prefecture of Crete.
o To study the association between insomnia and self-esteem in nursing staff.
o To study the association between insomnia and family status in nursing staff.
SIGNIFICANCE OF THE STUDY
The present study is expected to be used by Human Resource Management of the Hospitals and Health Care Centers to design appropriate policies that can curb insomnia in nursing staff.
The survey involved 213 nurses from five (5) hospitals and eleven (11) Health Centers in the island Crete. Of these, 24.9% were working at the Emergency Departments, while the other 45.5% were working in Intensive Care Units and 29.6% in Primary Health Care. The present study was carried out from August 2017 to January 2018 and included the voluntary and anonymous participation of nursing staff. The psychometric tools included in the study are presented below:
For the purpose of the present research, the Hamilton Anxiety Scale (HAM-A) and the Culture-free Self-esteem Inventories were applied.
The Hamilton Anxiety Scale (HAM-A) was one of the first rating scales developed to measure the severity of anxiety symptoms, and is still widely used in both research and clinical settings. The scale consists of 14 statements, each defined by a series of symptoms, and measures psychic anxiety (mental agitation and psychological distress) and somatic anxiety (physical complaints related to anxiety). Scoring: Each item is scored on a scale of 0 (not present) to 4 (severe), with a total score range of 0–56, where<17 indicates mild severity, 18–24 mild to moderate severity and 25–30 moderate to severe .
The Culture-free Self-esteem Inventories is a self-referencing questionnaire, which includes (without the lie scale) 32 items. These statements seek to measure the general, personal and social perception of themselves (self-perception) and are divided into two groups: those that are high and those showing low self-esteem. Each question answers either with “yes’ or with “no”. Three self-assessment sub-scales are included: general (16 statements), social (8 statements) and personal (8 statements). There is also a lie scale o (8 statements) .
Permissions were obtained from the developers of the Hamilton Anxiety Scale (HAM-A) and Culture-free Selfesteem Inventories. The time needed to fill out the questionnaire was 8–10 minutes.
The present research conducted among nurses working in primary health-care setting with the participation of 14 Health-care Centers and 5 Hospitals in the island of Crete. Our sample consisted of 213 nurses take part in the study. The study was performed in the following departments: 14 Health-care Centers, 4 Emergency Departments (ED) and 11 Intensive Care Units (ICU). The study was performed during August 2017 to January 2018.
• Selected participants had to work to Hospitals and Health Centers that had been included in the National Health System and had the same system of shift to ensure the homogeneity of the sample.
• Selected participants have to be nursing personnel with any educational level with each working relationship
• Participants had not to be nursing student
With respect to the statistical analysis, the quantitative variables are reported based on the mean ± standard deviation (mean ± sd) as well as the median and the interquartile range (IQR), while for the qualitative variables we have the corresponding frequencies and percentages. Depending on the appropriate statistical and / or graphic controls, it is recommended that median and the interquartile range (median, IQR) are used as representative descriptive measures.
The appropriate parametric and non-parametric statistical checks were also performed to investigate any differences between the three structures (ICU, Primary Health Care and ED) and the scales under study, defining the materiality level at 0.05. Where necessary, exact tests and / or Monte Carlo simulation (10000 samples) were used.
Finally, reliability and internal consistency was assessed by internal consistency using Cronbach ‘s alpha test. The statistical analysis was performed using statistical software IBM SPSS statistics (version 21.0). A p value<0.05 was considered statistically significant.
The necessary written permissions were issued from the Research and Ethics Committees of the 7th Health District of Crete, the University General Hospital of Heraklion, General Hospital of Heraklion “Venizelio Pananio”, General Hospital of Chania, General Hospital of Rethymno and General Hospital of Agios Nikolaos. The results of the current study were announced in the Administration of the 7th Health District of Crete. Written consent was given by all participants to take part in the study.
Characteristics of the Study Sample
In the present study, the participants were nursing personnel (n=213) and the majority of them 89.2% of the total sample were women and Intensive Care Units (ICU) nurses represented 45.5% of the study population. The mean age for the nursing staff of the total sample was 41.73 years. The 75.1% (n=160) of the sample were married. The majority of the total sample of the study 64.8% (n=138) was graduates of Technological Educational Institute and the 8.9% (n=18) had a master’s degree. Demographic characteristics of the study population are shown in Table 1. The mean length of employment was 15.78 (SD = 8.49 years). In regard of the average of work in the current department was 8.00 years (SD = 10.50 years) Table 2.
Reliability of Culture-Free Self-Esteem Inventories (James Battle)
Cronbach’s α coefficient was 0.763 suggesting high internal consistency (General self-esteem: alpha = 0.737, Social self-esteem: alpha = 0.442, Personal self-esteem: alpha = 0.724, General self-esteem: alpha = 0.763).
Valuation of Self-Esteem
From the results of the Culture-free Self-esteem Inventories, it was found that 51.6% of the total sample who participated in the research had a middle self-esteem, while the lowest percentage 8.0% had very high selfesteem and the 8.0% had very low self-esteem. Also, it was found that 17.4% had low self-esteem and 15% had high self-esteem. Also, the results showed that the mean General self-esteem was 12.27, the mean Social selfesteem 6.35, the mean Personal self-esteem was 3.86 and the scale of lie was 4.77 as shown in Table 3. There are no statistically significant differences between the three departments Intensive Care Unit (ICU), Emergency Departments (ED) and Primary Care. Below are analyzed the level of self-esteem for the three departments (ICU, ED, Primary Care): ICU: very low self-esteem 8.2%, low self-esteem 17.5%, middle self-esteem 50.5%, high self-esteem 13.4%, very high self-esteem 10.3%, ED: very low self-esteem 11.3%, low self-esteem 26.4%, middle self-esteem 37.7%, high self-esteem 20.8%, very high self-esteem 3.8%, Primary Care: very low selfesteem: 4.8%, low self-esteem 9.5%, middle self-esteem 65.1%, high self-esteem 12.7%, very high self-esteem 7.9% as shown in Table 4.
Reliability of Hamilton Anxiety Scale (HAM-A)
Reliability of Hamilton Anxiety Scale (HAM-A)
The reliability Of Hamilton Anxiety Scale (HAM-A) expressed by Cronbach α was 0.905.
The reliability Of Hamilton Anxiety Scale (HAM-A) expressed by Cronbach α was 0.905.
Valuation of Intensity of the Symptoms Anxiety and Insomnia
The intensity of the symptoms of anxiety had an average 11.41 based on their Hamilton Anxiety Estimation Scale. The most common mild intensity symptoms according Hamilton Anxiety Scale were, “ anxious mood “ (33.8%), “tension” (32.4%), “intellectual” (26.8%), “ somatic (muscular system)” (26.3%), “insomnia” (23.9%), “somatic (physical symptoms)” (23.5%), “cardiovascular symptoms” (23.0%), “depressed mood” (21.6%), “gastrointestinal symptoms” 22.5 %, “fears” 20.7%, “automatic symptoms” 20.2 %, “genitourinary symptoms “ 17.8% and “respiratory symptoms” 16.9 % ) as shown in Table 5.
The most common moderate intensity symptoms according Hamilton Anxiety Scale were, “anxious mood “ (27.7%), “tension” (17.8%), “intellectual” (19.2.8%), “somatic (muscular system)” (26.3%), “insomnia” (23.9%), “somatic (physical symptoms)” (23.5%),” cardiovascular symptoms” (23.0%), “depressed mood” (11.7%), “gastrointestinal symptoms” 14.1 %, “fears” (7.5 %), “automatic symptoms” (8.9 %), “genitourinary symptoms “ (6.1%) and “respiratory symptoms” (7.5% ) as shown in Table 5.
The most common severe intensity symptoms according Hamilton Anxiety Scale were, “ anxious mood “ (11.3%), “tension” (12.2%), “intellectual” (5.6%), “ somatic (muscular system)” (26.3%), “insomnia” (23.9%), “somatic (physical symptoms)” (9.9%), “cardiovascular symptoms” (3.8%), “depressed mood” (7.0%), “gastrointestinal symptoms” (4.2 %), “fears” (4.2 %), “automatic symptoms” (4.2 %), “genitourinary symptoms “ (3.8%) and “respiratory symptoms” (4.2% ) as shown in Table 5.
The most common very severe intensity symptoms according Hamilton Anxiety Scale were, “anxious mood “ (3.3%), “tension” (3.3%), “intellectual” (3.3%), “ somatic (muscular system)” (6.1%), “insomnia” (23.9%), “somatic (physical symptoms)” (23.5%), “ cardiovascular symptoms “ (2.3%), “depressed mood” (7.0%), “gastrointestinal symptoms” 3.3 %, “fears” (1.4 %), “automatic symptoms” (1.9 %), “genitourinary symptoms” (1.4%) and “respiratory symptoms” (1.9% ) as shown in Table 5.
In our sample, 49.7% of the nursing personnel had possible insomnia based on their Hamilton Anxiety Estimation Scale of the overall study sample. The 23.9% of the total sample had mild insomnia, the 15.5% had moderate insomnia, the 6.6% had severe insomnia and the 3.3 % had very severe insomnia as shown in Table 5.
Association of Insomnia with Self-Esteem and Demographic Characteristics
We calculate the observed p-value with the Monte Carlo (2-sided) simulation method. Multiple regression
analyses were performed to examine association between insomnia and marital status Table 6. Moreover,
analyses were performed to examine association between insomnia and self-esteem as shown in Table 7. As
shown in Table 6, Table 7 marital status and self-esteem were significant predictors of insomnia. Results verified
the significant positive association between insomnia and self – esteem. Also, results verified the significant
positive association between insomnia and marital status.