Sexual Satisfaction,Marital Intimacy,and Depression in Married Iranian Nurses With and Without Symptoms of Secondary Traumatic Stress

Abstract

Nurses tend to experience a lot of stress and psychological pressure in their workplace. Secondary Traumatic Stress (STS) is a condition that can cause marital and psychological problems in married nurses. The present study was conducted to compare sexual satisfaction, marital intimacy, and depression in married nurses with and without severe symptoms of STS. The statistical population consisted of 303 married nurses selected through cluster sampling from three hospitals in Kermanshah, Iran, including Imam Reza (86 nurses), Imam Ali (110 nurses), and Taleghani (107 nurses) hospitals. Data were collected using the STS Scale, the Sexual Satisfaction Scale, the Marital Intimacy Questionnaire, and Beck's Depression Inventory (short-form) or BDI-13. The results obtained showed that 22.4% of all the nurses, 22.9% of the female nurses, and 21.8% of the male nurses had symptoms of STS and the mean score of the symptoms was higher in the female compared with the male nurses (P < .01). The results of the two-way multivariate analysis of covariance showed higher mean scores of sexual satisfaction and marital intimacy in the group without STS symptoms and a higher mean score of depression in the group with STS symptoms (P < .01). Psychologists and hospital authorities should pay more attention to the psychological problems faced by nurses, such as STS and its effects on sexual satisfaction, marital intimacy, and depression.

Keywords

Depression marital intimacy married nurses secondary traumatic stress sexual satisfaction

Introduction

Nurses are exposed to high levels of stress in their workplace (Lim, Bogossian, & Ahern, 2010; McGibbon, Peter, & Gallop, 2010). Stress can lead to inefficiency at work, increased sick leaves, reduced quality of patient care, increased healthcare costs, and reduced job satisfaction (Murgia & Sansoni, 2011). The occupational stress experienced by nurses includes poor job control, high job demands (Webster & Hackett, 1999), poor workplace support (Chapman, 1993), patients' death, heavy workloads (Lambert, Lambert, & Ito, 2004), the non-cooperation of patients and their families, extended work shifts, unfamiliar situations, and the inability to work closely with the doctors (Walcott-McQuigg & Ervin, 1992).

Sexual satisfaction indicates happiness with the sexual dimension of one’s relationship (Lee, Lung, Lee, Kao, & Lee, 2012) and is the subjective evaluation of its positive and negative aspects (Lawrance & Byers, 1995). Sexual satisfaction has a physiological and a psychological aspect (Higgins, Mullinax, Trussell, Davidson, & Moore, 2011) and is an important component of sexual health and well-being (World Health Organization, 2010). Sexual satisfaction has a significant positive correlation with marital satisfaction (Ziaee et al., 2014), marital intimacy (Taghiyar, Mohammadi, & Zarie, 2015), and protects against many disorders. For instance, it has been linked to a lower rate of heart attack in men, reduced migraine headaches in both men and women, and reduced symptoms of premenstrual syndrome and chronic arthritis in women (Paul, 1998; cited in Rahmani, Merghati Khoei, Sadeghi, & Allahgholi, 2011). Sexual satisfaction has a positive correlation with sexual desire in nurses (Lee et al., 2012). According to reports, 51.9% of shift nurses suffer from at least one sexual desire disorder, 10.9% have impaired sexual satisfaction, and 68.85% have more than one sexual dysfunction (Lin, 2008). According to a study conducted in China, 14.5% of all nurses in this country have low sexual satisfaction due to their work shifts, special job contracts, poor job control, poor social support, and depression (Ji et al., 2017). In a study conducted in Iran, 7% of married women employed at Golestan University of Medical Sciences were unhappy with their sexual relationship (Ziaee et al., 2014).

Marital intimacy is the subjective experience of a profound relationship between two sexual partners who share affection for each other and have a relationship built on trust and empathy (Wynne, 1986, 1988; cited in Rampage, 1994). Intimacy is a vital communication skill that fosters attachment and mutual care between spouses (Rampage, 1994). Marital intimacy has five dimensions, including emotional, social, intellectual, sexual, and recreational dimensions (Schaffer & Olson, 1981; cited in Zerach, Anat, Solomon, & Heruti, 2010). Intimacy has been defined as a multidimensional concept that includes the ability to trust another person, share one’s thoughts and feelings with them, and engage in friendly sexual relations with that person (Mills & Turnbull, 2001). Marital intimacy affects sexual satisfaction (Babaie, Keshvari, & Zamani, 2016) and is negatively correlated with marital burnout (Gohari, Zahrakar, & Mohammad Nazari, 2015). Marital intimacy is also negatively correlated with postpartum depression (Schweitzer, Logan, & Strassber, 1992) and general depression (Morris, Morris, & Britton, 1988). Low marital intimacy is also associated with emotional problems in the couple (Waring, Patton, & Neson, 1986). It has a negative effect on family and social issues in shift nurses and impairs their engagement in mutual social activities with their spouses (Pines & Nunes, 2003). There is a negative correlation between marital intimacy and marital burnout in nurses (Khodadadi Sangdeh, Hajizadeh, Amousti, & Rezaie, 2016), and nurses with fixed work shifts show greater intimacy compared with those with rotating work shifts (Bayrami & Movahedi, 2014).

Depression is a psychological disorder that is characterized by depressed moods, loss of interest, pleasure and energy, feelings of guilt, poor self-worth, loss of appetite, sleep problems, poor concentration, reflecting and decision-making problems, and more severely, suicidal or death ideations (Marcus, Yasamy, van Ommeren, Chisholm, & Saxena 2012). Many studies have examined the prevalence of depression in nurses. For instance, 28.4% of ICU nurses (De Vargas & Dias, 2011), 18% of all hospital nurses (Letvak, Ruhm, & McCoy, 2012), 38% of nurses in China (Gong et al., 2014), 29.9% of nursing students in China (Xu et al., 2014), 20% of nurses in Brazil (Gherardi-Donato, Cardoso, Teixeira, Pereira Sde, & Reisdorfer, 2015), 14.4% of domestic nurses in New York (Teresi, Abrams, Holmes, Ramirez, & Eimicke, 2001), 15% of nurses in Saudi Arabia (Abbas, Abu Zaid, Hussaein, Bakheet, & AlHamdan, 2013), 17% of nurses in Nepal (Sigdel & Pokharel, 2015), and 14.18% of nurses in India (Swapnil, Harshali, & Snehal, 2016) reportedly suffer from depression. In Iran, 24.9% of nurses in military hospitals (Asad Zandi, Sayari, Ebadi, & Sanainasab, 2011), 26% of nurses in Neyshabur (Khani, Ghodsi, Nezhadnik, Teymori, & Ghodsi, 2016), 75.4% of nurses in Yazd (Halvani et al., 2012), 11.2% of nurses in Shiraz (Ardekani, Kakooei, Ayattollahi, Choobineh, & Seraji, 2008), and 10.7% of nurses in Tehran (Nazemi et al., 2013) are reported to have symptoms of depression. Research shows that depression in nurses is associated with aggression in the workplace, long work hours, and night shifts (Gong et al., 2014). Nurse–patient interactions have also been shown to affect nurses' depression (Haugan, Innstrand, & Moksnes, 2013).

Secondary Traumatic Stress (STS) is a common health condition in nurses. STS is defined as the behavioral and emotional outcomes experienced by an individual upon gaining knowledge of another person’s stressful experiences (Figley, 1995). STS results from helping a person with injury or trauma (Bride, Robinson, Yegidis, & Figley, 2004). The clinical symptoms of STS are similar to those found in people with direct exposure to trauma, including intrusive imagery associated with the patient’s recounting of an event, avoidance responses, psychological arousal, debilitating emotions, and impaired function (Figley, 1995; cited in Hosaini & Ariapooran, 2014). People with STS show problems such as intrusive thoughts about a stressful event, avoidance, sleep disorder, arousal/being alarmed, impaired interpersonal relations (Senter, Morgan, Serna-McDonald, & Bewley, 2010), reduced job performance, and the experience of conflict with others (Figley, 1995). STS has been reported in nurses working at coroner’s offices, emergency units, cancer wards, pediatric wards, and nursing homes (Beck, 2011). The prevalence of STS symptoms among nurses has been reported as 26% in nursing homes, 25% in coroner’s offices, 7% in emergency units, and 35% in maternity wards (Beck, LoGiudice, & Gable, 2015). According to studies, 33% of nurses in California (Dominguez-Gomez & Rutledge, 2009), 49% of emergency nurses (Von Rueden et al., 2010), 16% to 37% of oncology personnel (Quinal, Harford, & Rutledge, 2009), 67.64% of nurses in Ireland (Duffy, Avalos, & Dowling, 2015), 49.4% of nurses in Greece (Mangoulia, Koukia, Alevizopoulos, Fildissis, & Katostaras, 2015), and 40.6% of Muslim nurses in Turkey (Günüşen, Wilson, & Aksoy, 2017) suffer from STS. In two different studies conducted in Iran, the prevalence of STS was reported as 39.3% in nurses in Malayer (Ariapooran, 2013) and 16.7% in nurses in Kermanshah (Hosaini & Ariapooran, 2014).

STS is associated with conflicting behaviors and low or poor communication satisfaction, social intimacy, social support, and communication patterns (Glenwright, 2015; Robsinon-Keilig, 2014). Marital intimacy acts as a mediator between posttraumatic stress symptoms and sexual satisfaction (Zerach et al., 2010). Exposure to traumatic stress leads to sexual dysfunction (Yehuda, Lehrner, & Rosenbaum, 2015), and Post-Traumatic Stress Disorder (PTSD) causes the avoidance of sex and the loss of feelings of sexual arousal (Letourneau, Resnick, Kilpatrick, Saunders, & Best, 1996; Nunnink, Goldwaser, Afari, Nievergelt, & Baker, 2010). In Iran, a negative correlation was observed between stress and sexual performance (Yazdanpanahi, Beygi, Akbarzadeh, & Zare, 2016), and sexual arousal and mental stimulations were found to decrease in the presence of stress (Hamilton & Meston, 2013; Ter Kuile, Vigeveno, & Laan, 2007). A positive correlation has been reported between arousal as one of the dimensions of STS and depression (Lev-Wiesel & Amir, 2001). Studies have also demonstrated the relationship of depression with secondary trauma (Lombardo & Motta, 2008), recollections of trauma (Ashbaugh, Marinos, & Bujaki, 2017), and stressful events (Thabet, Thabet, & Vostanis, 2016). Despite the very few studies on the relationship between STS and depression, many have demonstrated the relationship between PTSD and depression (Elhai, Contractor, Palmieri, Forbes, & Richardson, 2011; Wang, Tsay, & Bond, 2005; Ying et al., 2015).

The present study was conducted to compare married nurses with and without symptoms of STS in terms of sexual satisfaction, marital intimacy, and depression. Due to their direct contact with the patients' health, nurses are considered one of the main target groups for exposure to psychological stress and problems. The psychological problems faced by nurses should therefore be more carefully addressed, including STS and its role in sexual satisfaction, marital intimacy, and depression.

Method

Study design and variables

The present comparative study was conducted to determine the difference between married nurses with and without STS symptoms in terms of sexual satisfaction, marital intimacy, and depression.

Participants

The statistical population consisted of all the married nurses working at hospitals across Kermanshah (approximately 1200 nurses). Using the Krejcie and Morgan equation (1970), the initial sample size was estimated as 291. Using cluster sampling, Imam Reza, Imam Ali, and Taleghani hospitals were randomly selected, and all the married nurses working in these hospitals were included in the study. Ultimately, 311 questionnaires were distributed among the married nurses. Eight questionnaires were returned as incomplete and were excluded from the study and the sample size decreased to 303. Of these 303 nurses, 86 (28.4%) were selected from Imam Reza Hospital, 110 (36.3%) from Imam Ali Hospital, and 107 (35.3%) from Taleghani Hospital. Given that 68 (22.4%) of the nurses showed symptoms of STS (scores > 52.72), they were selected as group with symptoms of STS and the remaining 235 nurses (77.6%) as the control group. The study inclusion criteria consisted of being married, a minimum work experience of one year, a minimum duration of marriage (living under the same roof) of one year, and no history of hospitalization for psychological or physical problems in the past year.

The descriptive results showed that, of the 303 participating nurses, 124 (40.9%) were male and 170 (59.1%) were female; 85.5% had bachelor's degrees, 11.9% master's degrees, and 20% associate degrees; 17.5% of the nurses worked in emergency units, 10.2% in intensive care units, 9.2% in coronary care units, and 63.1% in other wards. The mean (SD) age of the female nurses was 32.48 (7.63) years, the male nurses 34.72 (8.01) years, and all the nurses together 33.39 (7.85); the mean duration of marriage was 6.52 (6.33) years in the female nurses, 8.19 (7.45) in the male nurses, and 7.21 (6.85) in all the nurses; the mean work experience was 8.18 ± 6.66 years in the female nurses, 10.72 (7.58) in the male nurses and 9.22 (7.15) in all the nurses.

Measures

Sociodemographic variables

In our study, the sociodemographic factors were age, gender, educational level, duration of marriage, job history, job wards, and number of offspring.

The STS Scale

In this 17-item scale (Bride et al., 2004), the items are scored based on a 5-point Likert scale from never (1 point) to very often (5 points), and the final score ranges from 17 to 85 (Bride et al., 2004). This scale consists of three subscales, including intrusive imagery (five items), avoidance (seven items), and arousal (five items). The reliability and evidence of validity were found in similar samples (Ariapooran, 2013; Bride et al., 2004). Given the lack of a cut-off point for the scale, previous studies in Iran took one unit of standard deviation above the mean score as the cut-off point, and 51.12 was thus taken as the cut-off point (Ariapooran, 2013). In the present study, the overall mean score of this scale was 41.29 and its standard deviation was 11.43; therefore, 52.72 was considered the cut-off point, which is relatively similar to the cut-off points used in previous studies (Ariapooran, 2013). The Cronbach's alpha coefficient obtained for the entire scale in this study was 0.88 and for intrusive imagery, avoidance, and arousal were .71, .74, and .8, respectively.

The Sexual Satisfaction Scale

In this 25-item scale (Hudson, Harrison, & Crosscup, 1981), the items are scored based on a 7-point scale from never (0 point) to always (6 points), and the final score varies from 0 to 150. High scores in this scale reflect sexual satisfaction. The test–retest reliability with a one-week interval was .93; the validity of the scale was found using the differential validity method, and the results showed that this scale can differentiate between couples with and without sexual problems (Hudson et al., 1981). In Iran, the reliability and validity of the scale have been confirmed (Mehdizadegan & Sharifi Ranani, 2015). The present study found the scale’s Cronbach's alpha as .83.

The Marital Intimacy Scale

This 17-item scale was developed by Thompson and Walker (1983; cited in Sanaiy, 2000). The range of scores for each item varies from 1 point (never) to 7 points (always), and higher scores indicate a greater intimacy. The respondent’s score is calculated by adding the scores of all the items. With Cronbach's alpha coefficients of .91 to .97, this inventory has a good internal consistency (Thompson & Walker, 1983; cited in Sanaiy, 2000). In Iran, the reliability and validity of the scale have been confirmed (Naderi & Azadmanesh, 2012). The present study found the scale’s Cronbach's alpha as 0.925.

Beck's Depression Inventory

This questionnaire was developed by Beck (1961; cited in Beck, Rial, & Rickels, 1974) and is one of the most common tools used for measuring psychological disorders. The inventory examines 21 groups of depression symptoms, each consisting of four to five items scored from 0 to 3 (Beck et al., 1974). The present study used the short 13-item form (Beck et al., 1974) of the questionnaire. The total score ranges from 0 to 39. The correlation coefficient between the short and long forms of the questionnaire ranges from .89 to .97 (Beck et al., 1974). The validity and reliability of the inventory have been confirmed (Furlanetto, Mendlowicz, & Romildo Bueno, 2005; Wang & Gorenstein, 2013). The short form of the inventory has been assessed in Iran and its validity and reliability have been confirmed (Rajabi, 2005). As for the cut-off point of the scale, scores of 0 to 3 suggest normal health, 4 to 7 indicate mild depression, 8 to 11 mild to moderate depression, 12 to 15 moderate depression, and 16 to 39 severe depression in the normal population (Rajabi, 2005). The present study found its Cronbach's alpha as .79.

Procedure and data analysis

After identifying the intended hospitals in Kermanshah (Imam Reza, Imam Ali, and Taleghani hospitals), the researcher visited them and used convenience sampling to distribute the questionnaires its married nursing personnel to complete and return within approximately 30 minutes. The researcher briefed the eligible nurses on the study objectives and methods and invited them to a private briefing session. The willing candidates submitted an informed consent form. They filled out the questionnaire after their work shift and returned it to the researcher. Participation in the study was completely voluntary. The participants were ensured of the confidentiality of their data. The data extracted were analyzed in SPSS-23 using the independent t-test and multivariate analysis of variance (MANOVA) to compare the average scores of STS and its dimensions between men and women and the two-way multivariate analysis of covariance (MANCOVA) to compare the average score of sexual satisfaction, marital intimacy, and depression among nurses with and without symptoms of STS by controlling the age, educational level, duration of marriage, job history, job wards, and number of offspring; gender was considered as secondary independent variable.

Results

The results obtained showed that 22.4% of all the nurses, 22.9% of the female nurses, and 21.8% of the male nurses had symptoms of STS. The mean (SD) score of STS symptoms was 42.69 (10.95) in the female nurses and 39.27 (11.82) in the male nurses; based on the independent t-test, this mean score was higher in women than in men (P < .01, t = 2.595; Cohen’s d = 0.3). The mean (SD) scores obtained in the dimensions of STS, including avoidance, arousal, and intrusive imagery, were 16.97 (5.17), 12.56 (4.36), and 13.17 (3.09) in the female nurses and 15.96 (5.9), 11.23 (4.08), and 12.06(3.21) in the male nurses; according to the MANOVA results, the difference was significant in arousal (F = 7.179; P < .008; effect size[η_p²] = 0.023) and intrusive imagery (F = 9.038; P < .003; effect size[η_p²] = 0.029), but not in avoidance (F = 2.471; P < .117; effect size[η_p²] = 0.008). Table 1 presents the mean and standard deviation of sexual satisfaction, marital intimacy, depression, and STS in the nurses with (68 nurses) and without (235 nurses) symptoms of STS.

Table 1.

Mean and Standard Deviation (SD) of the scores of sexual satisfaction, marital intimacy, depression and STS in female and male married nurses with the symptoms of STS and the control group.

Dependent variables	With symptoms of STS (68)				Control group (235)
	Female (41)		Male (27)		Female (138)		Male (97)
	Mean	SD	Mean	SD	Mean	SD	Mean	SD
Sexual satisfaction	81.80	18.30	81.88	17.57	102.14	18.51	99.48	19.38
Marital intimacy	68.49	23.59	66.04	22.26	93.85	19.38	89.20	19.66
Depression	12.58	5.19	13.59	5.06	4.76	3.83	5.02	4.91
Intrusive imagery	16.24	2.14	15.48	2.04	12.25	2.71	11.11	2.81
Avoidance	23.71	2.84	24.00	2.70	14.96	3.85	13.73	4.23
Arousal	17.49	4.79	16.55	2.77	11.10	2.93	9.75	3.01
STS	57.44	6.40	56.03	3.63	38.32	7.72	34.59	8.62

Note. STS = secondary traumatic stress.

Before performing the multivariate analysis, the Box's test was carried out to assess the homogeneity of the covariance matrices and the results showed homogeneous matrices (F = 0.816; P < .094). The equality of variances was also assessed using Levene’s test for sexual satisfaction (F = 0.384; P < .765), marital intimacy (F = 0.813; P < .488), and depression (F = 1.911; P < .128).

As shown in Table 2, by controlling the age, educational level, duration of marriage, job history, job wards, and number of offspring, the results of the two-way MANCOVA suggest a significant difference between the nurses with STS symptoms and the control group in terms of sexual satisfaction, marital intimacy, and depression (Wilks' Lambda F = 59.34; P < .001). The effect sizes (Partial Eta²) were calculated by this formula: η_p² =

\frac{SSeffect}{SSeffect + SSerror}

(Keppel, 1991; cited in Lakens, 2013).According to Cohen (1988) and Murphy and Myors (2004), suggested norms for partial eta squared are: small = 0.01; medium = 0.06; large = 0.14.

Table 2.

Results of two-way MANCOVA for comparing the sexual satisfaction, marital intimacy, and depression among female and male married nurses with the symptoms of STS and the control group by controlling the sociodemographic variables.

Effect	Dependent variables	SS	df	MS	F	P	Effect size
Group	Sexual satisfaction	15,457.001	1,292	15,457.001	47.604	.001	.14
	Marital intimacy	31,380.557	1,292	31,380.557	84.462	.001	.224
	Depression	3159.690	1,292	3159.690	161.926	.001	.357
Gender	Sexual satisfaction	46.645	1,292	46.645	0.144	.705	.001
	Marital intimacy	102.864	1,292	102.864	0.277	.599	.001
	Depression	22.454	1,292	22.454	1.151	.284	.004
Group*Gender	Sexual satisfaction	17.458	1,292	17.458	0.054	.817	.001
	Marital intimacy	172.794	1,292	172.794	0.465	.496	.002
	Depression	11.962	1,292	11.962	0.613	.434	.002

Note. SS = sum of squares; MS = mean square.

In our results, the impact of gender (Wilks' Lambda F = 0.387; P < .762) and group × gender (Wilks' Lambda F = 0.561; P < .641) was not meaningful. According to the table of means (Table 1), the mean scores of sexual satisfaction and marital intimacy were higher in the group without STS symptoms and the mean score of depression was higher in the group with STS symptoms.

Discussion

The present study was conducted to compare married nurses with and without STS symptoms in terms of sexual satisfaction, marital intimacy, and depression in Kermanshah, Iran. The prevalence of STS symptoms was 22.4% in the nurses. Many other studies have reported different prevalence rates for STS symptoms, including 33% (Dominguez-Gomez & Rutledge, 2009), 49% (Von Rueden et al., 2010), and 40.6% (Günüşen et al., 2017). In Iran, prevalence rates of 39.3% (Ariapooran, 2013) and 16.7% (Hosaini & Ariapooran, 2014) have been reported for STS symptoms in nurses. STS develops in individuals who are in direct contact with patients in severe need of care and those who suffer from excessive pain as a result of disease or injury. Nurses are very likely to develop symptoms of STS, since the exposure to patients' traumas is a risk factor for STS (Figley, 1995; Pearlman & Saakvitne, 1995).

The results of the independent t-test showed higher mean STS symptoms in women than in men, and based on the results of the tow-way MANCOVA, the mean scores of arousal and intrusive imagery were higher in the female nurses; however, the female and male nurses were not different in terms of the mean score of avoidance. Previous studies have shown that women experience STS symptoms more than men (Konistan, 2016; Robsinon-Keilig, 2014; Tehrani, 2016). This finding could be because of the different amounts of time each gender dedicates to the provision of care to a given patient, as women have been shown to spend more time on a given patient than men (Yee & Schulz, 2000). This difference may be associated with gender expectations and the fact that women are considered natural caregivers (Akpınar, Küçükgüçlü, & Yener, 2011; Gallicchio, Siddiqi, Langenberg, & Baumgarten, 2002; Papastavrou, Tsangari, Kalokerinou, Papacostas, & Sourtzi, 2009). Spending more time on providing care to a given patient means that women are more likely than men to share in on their patients’ suffering and are therefore more exposed to STS symptoms.

The results of the two-way MANCOVA showed lower mean scores of sexual satisfaction and marital intimacy in nurses with STS symptoms compared with those without such symptoms. Prior to this study, no researchers had compared sexual satisfaction and marital intimacy between nurses with and without STS symptoms, although some had confirmed the relationship between STS and relationship conflicts (Glenwright, 2015), poor relationship satisfaction, and problems in intimacy (Glenwright, 2015; Robsinon-Keilig, 2014). Moreover, sexual dysfunction has been proposed as a consequence of STS (Yehuda et al., 2015).

People who deal with traumas (for example, nurses) might seek to emotionally distance themselves from the patients in order to control the negative feelings experienced through the exposure to trauma (Collins & Long, 2003). By distancing themselves from the patients, they try to inhibit their emotional reactions, but these efforts might lead to a sort of distancing from their own family, friends, and colleagues as well (Harbert & Hunsinger, 1991; cited in Konistan, 2016). As a result, STS symptoms, such as avoidance, could cause problems in sexual satisfaction and marital intimacy in nurses. Previous studies have shown that STS affects both the work life and private life of those involved (Collins & Long, 2003; Ting, Jacobson, Sanders, Bride, & Harrington, 2005). The low sexual satisfaction and marital intimacy scores obtained in nurses with STS symptoms can be explained by the Vulnerability-Stress-Adaptation Model (Karney & Bradbury, 1995). Although this model does not discuss the effects of STS on sexual satisfaction and marital intimacy directly, the ongoing changes experienced due to the exposure to trauma, such as the transitional stressors experienced by couples as a result of trauma, can affect marital life. Changes in sexual satisfaction and marital intimacy can therefore be due to nurses’ poor compatibility with STS.

Another finding of this study was the higher mean depression score in the group of nurses with STS symptoms compared with the control group, which agrees with previous findings on the positive correlation between arousal (a dimension of STS) and depression. In addition, research suggests that secondary trauma (Lombardo & Motta, 2008), recollections of trauma (Ashbaugh et al., 2017), and stressful events (Thabet et al., 2016) have a positive correlation with depression. Nurses show STS symptoms as a result of perceiving the different symptoms experienced by their patients, and witnessing this pain and suffering on a daily basis can be a severe source of stress for them. The first-hand exposure to patients’ pain and suffering can cause symptoms such as sadness and depression in nurses, since one of the risk factors of depression and its symptoms is daily exposure to stressful events (Kendler, Kuhn, & Prescott, 2004). STS symptoms might lead nurses to emotional avoidance (Collins & Long, 2003), but a certain level of interaction remains in place between the nurses and the patients, and nurses continue to provide care services to their patients. As a result, nurse–patient interactions might contribute to further depression symptoms in nurses, and previous studies have also reported the effect of nurse–patient interactions on depression symptoms (Haugan et al., 2013).

The results gained from the two-way MANCOVA showed that the effects of gender and also interaction between STS and gender on sexual satisfaction, marital intimacy, and depression were not statistically significant. This finding is not in line with the findings yielded from previously conducted studies revealing that the female nurses' marital satisfaction turned out to be lower than that of the men (Baghipour, Jadidi, & Doosti, 2013). However, such studies also showed that there was no statistically significant difference between men and women in terms of marital satisfaction (Zakhirehdari, Arbabisarjou, Shahraki Vahed, & Asadi Bidmeshki, 2015) and intimacy (Khamseh, 2009). Perhaps one of the reasons for this issue is the similarity between the environments in which male and female nurses were working.In effect, both male and female nurses behaved with their patients similarly, and their occupational activities were quite similar. Given such inconsistencies between the findings, a replication of the current study seems to be necessary.

The present findings confirm the differences between female and male nurses in terms of STS symptoms and differences between nurses with and without STS symptoms in terms of sexual satisfaction, marital intimacy, and depression. Hospital personnel and authorities should pay more attention to STS symptoms in nurses and their effect on sexual satisfaction, marital intimacy, and depression. These symptoms and their psychological and marital consequences can be eliminated through psychological treatments and programs. Future studies are recommended to use interviews if possible to assess STS symptoms and to also take account of the role of nurses' unit of service in their analysis of the data.

Footnotes

Article Notes

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