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Mental Health Shame, Self-Compassion and Sleep in UK Nursing Students: Complete Mediation of Self-Compassion in Sleep and Mental Health

Abstract

Aims: To explore relationships between mental health problems, mental health shame, self- compassion and average length of sleep in UK nursing students. The increasing mental health problems in nursing students may be related to a strong sense of shame they experience for having a mental health problem. Self-compassion has been identified as a protective factor for mental health and shame in other student populations. Further, studies highlight the importance of sleep relating to mental health. Design: A cross‐sectional design. Methods: A convenient sampling of 182 nursing students at a university in the East Midlands completed a paper-based questionnaire regarding these four constructs, from February to April 2019. Correlation, regression and mediation analyses were conducted. Results: Mental health problems were positively related to shame, and negatively related to self- compassion and sleep. Mental health shame positively predicted, and self-compassion negatively predicted mental health problems: sleep was not a significant predictor of mental health problems. Lastly, self-compassion completely mediated the impacts of sleep on mental health problems (negative relationship between mental health problems and sleep was fully explained by self-compassion). Conclusion: The importance of self-compassion was highlighted as it can reduce mental health problems and shame. Self-compassion can protect nursing students from mental distress when they are sleep-deprived. Impact: Nurses and nursing students are required to work irregular hours (e.g., COVID-19), and mental distress can cause serious consequences in clinical practice. Our findings suggest that nurturing self-compassion can protect their mental health, and the negative impacts of sleep deprivation on mental health.
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Template Empirical research Quantitative
TITLE
Mental Health Shame, Self-Compassion and Sleep in UK Nursing Students:
Complete Mediation of Self-Compassion in Sleep and Mental Health
Citation
Kotera, Y., Cockerill, V., Chircop, J. & Forman, D. (2020). Mental health shame, self-
compassion and sleep in UK nursing students: Complete mediation of self-compassion in sleep
and mental health. Nursing Open.
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ABSTRACT
Aims: To explore relationships between mental health problems, mental health shame, self-
compassion and average length of sleep in UK nursing students. The increasing mental health
problems in nursing students may be related to a strong sense of shame they experience for
having a mental health problem. Self-compassion has been identified as a protective factor for
mental health and shame in other student populations. Further, studies highlight the importance
of sleep relating to mental health.
Design: A cross‐sectional design.
Methods: A convenient sampling of 182 nursing students at a university in the East Midlands
completed a paper-based questionnaire regarding these four constructs, from February to April
2019. Correlation, regression and mediation analyses were conducted.
Results: Mental health problems were positively related to shame, and negatively related to self-
compassion and sleep. Mental health shame positively predicted, and self-compassion negatively
predicted mental health problems: sleep was not a significant predictor of mental health
problems. Lastly, self-compassion completely mediated the impacts of sleep on mental health
problems (negative relationship between mental health problems and sleep was fully explained
by self-compassion).
Conclusion: The importance of self-compassion was highlighted as it can reduce mental health
problems and shame. Self-compassion can protect nursing students from mental distress when
they are sleep-deprived.
Impact: Nurses and nursing students are required to work irregular hours (e.g., COVID-19), and
mental distress can cause serious consequences in clinical practice. Our findings suggest that
nurturing self-compassion can protect their mental health, and the negative impacts of sleep
deprivation on mental health.
Key words: mental health; mental health shame; self-compassion; sleep; self-care; nursing
students; mediation analysis
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Main paper
INTRODUCTION
Nursing is a rewarding but challenging profession. In the United Kingdom (UK), nurses
are highly respected, and at the same time, known to have poor mental health (Kinman, Teoh &
Harriss, 2020). This impairment in mental wellbeing can be attributed to a lack of resilience,
something that has been recognised and addressed in the new standards of proficiency for nurses
(Nursing and Midwifery Council [NMC], 2018). One solution for this problem is to educate
nursing students about the importance of their own mental wellbeing, so that they will be better
prepared to cope with occupational stress to protect their mental health, once they are in
professional practice (Pulido-Martos et al., 2012; Reeve et al., 2013). This is essential because
not only professional nurses but also nursing students suffer high rates of mental health problems
(Hsiung, Tsai, Chiang & Ma, 2019; Lamont et al., 2016). As reported in other healthcare
students in the UK (Kotera, Green & Sheffield, 2019a; 2019b), poor mental health of nursing
students may be associated with shame about having a mental health problem. Mental health
problems may be positively associated with mental health shame in nursing students. Similarly,
self-compassion—understanding and kindness towards oneself—has been identified as a
negative correlate, and predictor of shame and mental distress in other healthcare students
(Kotera et al., 2019a; 2019b). Nursing students who are kind towards themselves may have
lower levels of shame and mental health problems. Lastly, recent studies highlight the
importance of enough hours of sleep in relation to mental health. Nurses are required to work
irregular hours, particularly so during a crisis such as COVID-19, therefore evaluating the
relationship between sleep and mental health would be useful. Moreover, how a lack of sleep
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may be associated with mental health has not been explored. Accordingly, this study evaluated
the relationship between mental health problems, mental health shame, self-compassion and
sleep, in a cross-sectional design with correlation, regression and mediation analyses.
BACKGROUND
Nursing studies is the study of caring for individuals of all ages, families, groups and
communities by promoting health, preventing illness and advocating (International Council of
Nurses, 2010; Ayala, 2020). It is one of the most popular subject disciplines in the United
Kingdom (UK) and has been so for the past six years (Higher Education Statistics Agency
[HESA] 2019); every year, more than 40,000 prospective students apply (Universities and
Colleges Admissions Service, 2019). One notable reason for this popularity is a high
employment rate (Van Sabben, 2020): more than 90% of graduates being in employment (i.e.,
becoming a professional nurse) six months after graduation (Royal College of Nursing, 2019;
HESA, 2017). Nursing is an attractive profession because of high job satisfaction with over 80%
feeling satisfied with their career (AMN Healthcare, 2017), high job security (Buchan,
Charlesworth, Gershlick & Seccombe, 2019), and respect from many patients appreciating the
demands of nurses’ work (Dolton, Marcenaro, De Vries & She, 2018). As seen in the current
coronavirus 2019 (COVID-19) pandemic, having a sturdy nurse workforce is crucial for the
country (Adams & Walls, 2020).
Despite the popularity of nursing programmes in the UK, many nursing students
experience mental health problems. Having good mental health is essential for students as it is
linked with various student outcomes such as higher academic engagement (Kotera & Ting,
2019), reduced dropout rate (Hjorth et al., 2016), and higher achievement (Bostania, Azami &
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Nasabc, 2014). However, almost a quarter (22%) of nursing students are at risk of developing
depression, anxiety, stress or a combination of these (Hsiung et al., 2019). Suicide is reported in
6.5% of nursing students (Aradilla-Herrero, Tomás-Sábado & Gómez-Benito, 2014), more than
the rate of the general university student population (4.2%) (Sivertsen et al., 2019). In addition to
stressors that students in many disciplines experience (stress before exams and submission
deadlines, juggling adult and student identities; Laidlaw, McLellan & Ozakinci, 2016; Lipson,
Zhou, Wagner, Beck & Eisenberg, 2016; Shankland et al., 2019), nursing students experience
more pressure to satisfy their academic and professional standards (Findlow, 2012; Gimenez,
2012), which require good performance in academic work and clinical practice where they
encounter difficult situations such as death (Jamshidi, Molazem, Sharif, Torabizadeh & Kalyani,
2016). Furthermore, demands in the nursing profession have been expanding: more
compassionate care for patients and more technical interventions are required for professional
nurses today (NMC, 2018). These demands can add pressure on nursing students. Poor mental
health is associated with numerous negative consequences: increased risk of suicide and self-
harm (Lipson et al., 2016), limited academic performance, dropping out (Brydges et al, 2012;
Arria et al., 2013; Eisenberg, Hunt & Speer, 2013), and decreased social connectedness
(Eisenberg et al., 2013). Among professional nurses, poor mental health was related to increased
risk of medical errors (Melnyk et al., 2018), undermining patient safety and public protection -
pivotal elements for fitness to practice in nursing education (Hayes, 2017). This underlines the
need for investigating nursing students' mental health.
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Mental health shame
The high rates of mental health problems among nursing may be exacerbated by their
‘mental health shame’ (Kotera, Green & Sheffield, 2019c, p.136), that is feeling ashamed for
having a mental health problem (Kotera et al., 2019c). Shame is a negative emotion of self-
attributions, based on the perceived evaluation of self by others (Miceli & Castelfranchi, 2018).
Mental health shame has been associated with poor mental health in diverse populations
including UK social work, psychotherapy, occupational therapy and business students (Kotera,
Conway & Van Gordon, 2019; Kotera et al., 2019a; 2019b). Particularly among social work
students, mental health shame was strongly associated with increased self-criticism and
decreased self-compassion (Kotera, et al., 2019a), and a significant predictor of mental health
(Kotera, Green & Sheffiled, 2019d). Unsurprisingly, students with high mental health shame
tend not to seek out help, leading to poor clinical outcomes (Ting, 2013). Despite the strong
relationship between mental health problems and mental health shame in various student
populations, this relationship in UK nursing students has not been explored to date. Therefore,
we hypothesised;
H1a. Mental health problems are related to mental health shame.
H2a. Mental health problems are predicted by mental health shame.
Self-compassion
Self-compassion—self-understanding and self-kindness aimed at easing suffering during
times of hardness (Neff, 2003) —is related to mental health. Self-compassion improves mental
health problems by promoting resilience, and decreasing self-criticism and shame (Braehler et
al., 2013; Trompetter, de Kleine & Bohlmeijer, 2017). Relating to the three emotion regulatory
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systems of compassion focused therapy, self-compassion engages with our soothing system that
deals with affects such as safety and contentment to protect our mental health, instead of the
other two systems (thread systems and drive systems; both are associated with mental distress)
(Gilbert, 2010). This can explain why self-compassion intervention often employs slow
breathing or mindfulness practice, aiming to access our soothing system (Neff & Germer, 2018).
Among nursing students in China, self-compassion was negatively associated with, and predicted
by anxiety and depression (Luo et al., 2019). In Turkish nursing students, self-compassion was
positively associated with their emotional intelligence (Şenyuva, Kaya, Işik & Bodur, 2013), and
negatively correlated with mental distress (Ciarrochi, Deane & Anderson, 2002; Resurrección,
Salguero & Ruiz-Aranda, 2014). Among UK student populations, self-compassion was
negatively associated with mental health problems among social work, counselling, occupational
therapy and business students (Kotera, Conway & Van Gordon, 2019; Kotera et al., 2019a;
2019b). However, these relationships have not been explored in UK nursing students to date.
Accordingly, we hypothesised;
H1b. Mental health problems are related to self-compassion.
H2b. Mental health problems are predicted by self-compassion.
Sleep
Poor sleep is common in university students and often results from academic demands
and social, personal and employment factors (Cheng et al., 2012). Research into sleep and its
health effects has been increasingly developed, reporting that appropriate sleep quantity is
positively associated with good mental health (Scott, Webb & Rowse, 2017). Having sufficient
sleep is also associated with decreased risks for cognitive and emotional health problems
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(Hirshkowitz et al., 2015a; Hirshkowitz et al., 2015b). Contrarily, poor sleep increases the risk of
stress (Knutson et al., 2017) and mood disorders (e.g. depression and dysthymia) as well as
anxiety disorders (e.g. panic disorder and generalised anxiety disorder) (Stein, Belik, Jacobi &
Sareen, 2008; Shi et al., 2020). Poor sleep is also a predictor of mental health problems (Baglioni
et al. 2011). Among professional nurses, who work at night shifts and irregular hours, poor sleep
increases the risk of nursing errors in clinical examination and medication administration,
possibly leading to serious clinical outcomes (Rahimian & Ghodrati 2013). Moreover, poor sleep
was associated with higher job stress and poorer health status (Lin, Liao, Chen & Fan, 2014).
Unsurprisingly, regulatory bodies such as the Institute of Medicine noted sleep as an important
factor for health of medical staff, relating to the quality of patient care and lower risk of burnout
(Ulmer, Miller, Wolman & Johns, 2008). Sleep was positively associated with self-compassion
and mental health in young health professionals (Kemper, Mo & Khayat, 2015). In nursing
students, an American study reported that all participating nursing students were sleep-deprived
(n=179), and more than half (n=91) were using sleeping-related medicines (Thomas, McIntosh,
Lamar & Allen, 2017). Sleep was associated with mental health in Indian nursing students
(Menon, Karishma & Mamatha, 2015) and American nursing students (Zhang, Peters & Chen,
2018). Despite the strong relationship between sleep and mental health, no studies have explored
the relationship between these factors in UK nursing students.
H1c. Mental health problems are related to sleep.
H2c. Mental health problems are predicted by sleep.
Sleep and self-compassion
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Lastly, sleep has been associated with self-compassion in German students (Butz &
Stahlberg, 2018) and in American young health professionals and trainees (Kemper et al., 2015):
individuals who have better sleep reporting higher levels of self-compassion (Butz & Stahlberg,
2020). Self-compassion was a protective factor for mental health problems and sleep
disturbances among adults over 65 years old in Korea, suggesting that self-compassionate
participants tended to have good mental health and sleep (Kim & Ko, 2018). While these
findings imply strong relationships among these three variables, namely mental health, sleep and
self-compassion, how these variables are related to each other has not been explored (e.g.
Kemper et al. [2015] explored those variables, however only correlations with sleep).
Considering the strong impact of self-compassion on mental health (Kotera, Conway & Van
Gordon, 2019; Kotera et al., 2019a; 2019b), we hypothesised that self-compassion would
mediate the relationship between sleep and mental health problems: the negative impacts of sleep
deprivation on mental health can be explained by low levels of self-compassion.
H3. Self-compassion mediates the impacts of sleep on mental health problems.
THE STUDY
Objectives
This study aimed to explore relationships between mental health problems, mental health
shame, self-compassion and sleep in UK nursing students. Mental health was evaluated in terms
of depression, anxiety and stress, considering that these are the commonest mental health issues
for both the general population (Mental Health Foundation, 2016; Mirzaei, Mojtaba, Ardekani,
Mirzaei & Dehghani, 2019) and nursing students (Hsiung et al., 2019). Three hypotheses were
established;
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H1. Mental health problems are related to mental health shame (a), self-compassion (b) and
sleep (c).
H2. Mental health problems are predicted by mental health shame (a), self-compassion (b) and
sleep (c).
H3. Self-compassion mediates the impacts of sleep on mental health problems.
Design
A cross-sectional design was employed to produce timely output, and to investigate all
variables altogether. Data were examined through correlation, regression and mediation analyses
to test our three hypotheses.
Sample/Participants
Participants needed to be at least 18 years old and studying in a nursing programme at a
UK university at the time of the study: students who were on a study break were excluded.
Participants were recruited using convenient sampling through hard copy questionnaires
distributed by programme tutors instead of the researchers to avoid response biases. Of 198 full-
time students who were introduced to the study, 182 (92%; 144 females, 30 males and 8 did not
respond; Age 30.04 ± 8.31 years old, range 18-52 years old; 164 British, 10 Africans, 6 other
Europeans, and 2 did not respond; 146 undergraduates and 36 postgraduates) completed three
mental health measures, satisfying the required sample size calculated by power analysis (84:
two tails, p H1 (r) = 0.30 (medium; Cohen, 1988), α = 0.05, Power = 0.80, p H0 = 0; Faul,
Erdfelder, Buchner & Lang, 2009). Compared with the general population of UK nursing
students (10%; Office for Students, 2020), our sample recruited slightly more males (16%). No
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compensation was awarded for completing the survey. Following the ethical guidelines, the
withdrawn/incomplete 16 participants were not asked for the reason: no reason nor complaint
was received.
Data collection
Four self-report measures regarding each construct were used.
Mental health problems were measured using the Depression Anxiety and Stress Scale
(DASS21), a shortened version of DASS42 (Lovibond & Lovibond, 1995). DASS21 consists of
21 items on a four-point Likert scale divided into three seven-item subscales; depression (e.g. ‘I
couldn’t seem to experience any positive feeling at all’), anxiety (e.g. ‘I felt scared without any
good reason’) and stress (e.g. ‘I felt that I was rather touchy’). High scores indicate poor mental
health. These subscales had good reliability; α=.87-.94 (Antony, Bieling, Cox, Enns & Swinson,
1998).
Mental health shame was measured using the Attitudes Towards Mental Health Problems
(ATMHP), comprising 35 four-point Likert items. ATMHP consists of four sections: i) their
community’s and family’s attitudes towards mental health problems (community and family
attitudes, e.g. ‘My community/family sees mental health problems as something to keep secret’),
ii) their perception of how their community and family would perceive them if they had a mental
health problem (community and family external shame, e.g. ‘I think my community/family
would look down on me’), iii) how they perceive themselves if they had a mental health problem
(internal shame, e.g. ‘I would see myself as inferior’), and iv) how their family would be seen if
they had a mental health problem (family-reflected shame, e.g. ‘My family would be seen as
inferior’) and how worried they become about themselves when a close relative had a mental
health problem (self-reflected shame, e.g. ‘I would worry that others will look down on me’).
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High score indicates high shame for mental health problems. All of the subscales had good
Cronbach’s alphas of between .85 and .97 (Gilbert et al., 2007).
Self-Compassion Scale-Short Form (SCS-SF) was used to measure self-compassion. This
self-report measure is a shortened version of the Self-Compassion Scale, comprising 12 five-
point Likert items (e.g. ‘I try to be understanding and patient towards those aspects of my
personality I don’t like’; Neff, 2003). High score indicates a high level of self-compassion.
Cronbach’s alpha was high (.86; Raes, Pommier, Neff & Van Gucht, 2011).
Sleep was asked with a one question item ‘How long do you sleep every day on
average?’
Ethical considerations
Ethics approval was obtained from the University Research Ethics Committee. Because
the questionnaire concerned students’ mental health, at least one nursing lecturer who was a
registered nurse and was not a co-researcher of the study, was present at the site. Physical
distance among students was maintained for privacy, helping them respond comfortably.
Information about available mental health services inside and outside university was offered
before and after the study. Visual aids (e.g., large font print, coloured papers) were prepared for
students with visual impairments, however no students used them.
Data analysis
First the collected data were screened for outliers and the assumptions of parametric tests.
Second, correlations between their mental health, mental health shame, self-compassion and
sleep were explored (H1). Third, multiple regression analysis was performed to examine the
relative contribution of mental health shame, self-compassion and sleep to mental health
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problems (H2). Finally, mediation analysis was conducted to appraise whether self-compassion
would mediate the relationship between sleep and mental health problems (H3). Analyses were
conducted using IBM SPSS version 25.0 and Process Macro (Hayes, 2013).
Reliability
All scales used were validated with high reliability. Before the present study, the same
study design was employed to explore mental health of other healthcare students (Kotera et al.,
2019a; 2019b).
RESULTS/FINDINGS
No outliers were identified. All variables demonstrated good internal reliability (α=.87-
.96; Table 1).
[Please insert Table 1 about here]
Relationships between mental health, mental health shame, self-compassion and sleep
As all variables apart from self-compassion were not normally distributed (Shapiro-
Wilk’s test, p < .05), data were square-root-transformed to satisfy the assumption of normality
(Field, 2017). Pearson’s correlation was calculated (Table 2).
[Please insert Table 2 about here]
Mental health problems were positively associated with all the mental health shame subscales
(internal shame being the strongest positive correlate), and negatively associated with age, self-
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compassion and sleep (self-compassion being the strongest negative correlate). Additionally,
self-compassion was positively related to sleep and negatively related to external shame and
internal shame. Lastly, sleep was associated with female gender. H1 was supported.
Predictors of mental health problems
Multiple regression analyses were conducted to explore the relative contributions of
mental health shame, self-compassion and sleep to mental health problems (Table 3). Mental
health shame was calculated by summing all the subscale scores (Kotera et al., 2019c). First,
gender and age were entered to statistically adjust for their effects (step one), and then mental
health shame, self-compassion and sleep were entered (step two). Adjusted coefficients of
determination (Adj. R2) were reported. Multicollinearity was not a concern (VIF < 10). Mental
health shame, self-compassion and sleep accounted for 50% of the variance for mental health
problems indicating a large effect size (Cohen, 1988; F(5, 166) = 39.31, p < .001). Mental health
shame was a positive, and self-compassion was a negative predictor of mental health problems.
Self-compassion predicted mental health problems (B = -6.65) to a larger degree than mental
health shame (B = .32). Sleep did not predict mental health problems. H2 was partially supported
(H2a-b were supported whilst H2c was not).
[Please insert Table 3 about here]
Mediation of self-compassion between sleep and mental health problems
Lastly, a mediation analysis was conducted to appraise whether the relationship between
sleep (predictor variable) and mental health problems (outcome variable) was mediated by self-
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compassion (mediator variable), using model 4 in the Process macro (parallel mediation model;
Hayes, 2013) (Figure 1).
[Please insert Figure 1 about here]
While the direct effects of sleep on mental health problems were not significant (b = -.79, t(179)
= -1.54, p = .13), the total effects and indirect effects of sleep on mental health problems were
significant (total b = -1.79, t(180) = -2.63, p = .009; indirect b = -1.00, BCa CI [-1.94, -.20]). An
increase in sleep was associated with an increase in self-compassion, which then was associated
with a decrease in mental health problems. Self-compassion completely mediated the effect of
sleep on mental health problems. H3 was supported.
DISCUSSION
This study explored relationships between mental health problems, mental health shame,
self-compassion and sleep in UK nursing students. Mental health problems were positively
associated with mental health shame, and negatively associated with self-compassion and sleep
(H1 was supported). Mental health shame and self-compassion were significant predictors of
mental health problems, and sleep was not (H2 was partially supported; while H2a-b were
supported, H2c was not). Lastly, self-compassion completely mediated the impact of sleep on
mental health problems (H3 was supported). Relevancy to practice and future research were
discussed for each item, as suggested in a review explored mental health in nurses (Edwards &
Burnard, 2003).
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Complete mediation of self-compassion in sleep and mental health problems
One of the original values this study offers is that the negative association between sleep
and mental health problems (i.e. students who sleep long tend to have good mental health) was
explained by self-compassion. It was not sleep by itself that impacts mental health: it was self-
compassion that impacted mental health. Short sleep negatively impacted self-compassion,
which then damaged mental health. Recently, the relationship between sleep and mental health
(Menon et al., 2015; Zhang et al., 2018) and, sleep and self-compassion (Butz & Stahlberg,
2018; Kemper et al., 2015) have been reported. However how these three variables are related to
each other had not been explored (e.g. Kemper et al., [2015] explored sleep’s correlations with
mental health and self-compassion separately). Indeed, sleep was correlated with both mental
health and self-compassion in our sample too, and we further identified that self-compassion was
a complete mediator between the two. This suggests the importance of incorporating self-
compassion in nursing curricula: when in employment many graduates will be required to work
night shifts and irregular hours, leading to sleep deprivation and sleep problems (Stanojevic,
Simic & Milutinovic, 2016) and therefore, as our analyses show, increasing their risk of mental
health problems. An example of sleep deprivation in nurses is the coronavirus disease 2019
(COVID-19) pandemic; sleep deprivation occurred despite nurses being aware of its effect on
mental health (Sun et al., 2020; Zhang et al., 2020). In addition, self-compassion would facilitate
nursing students to report mental health problems (Lipson et al., 2016). Therefore, nursing
students developing skills to practise self-compassion will allow them to maintain good mental
health both during their studies and when in employment. For example, an eight-week self-
compassion training (2.5 hours each) increased self-compassion and reduced mental distress
among UK nurses (Delaney, 2018). Likewise, an eight-week self-compassion training (1.5 hours
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each) increased self-compassion in Iranian nursing students (Khorami, Moeini & Ghamarani,
2016). This type of training being embedded in nursing curricula will help nursing students
prepare for the demanding nursing practice. New competency standards for registered nurses
have recently been implemented, focusing on emotional resilience and emotional intelligence
(NMC, 2018). Though compassionate care for patients is noted as important, self-compassion is
not highlighted in these standards. Considering that self-compassion is a better predictor of
mental health than emotional resilience among UK social work students (Kotera et al., 2019d),
UK nursing students may benefit from practising self-compassion. Moreover, future research
should evaluate the effects of self-compassion training on sleep and mental health for nursing
students.
Importance of self-compassion and challenges in implementation
In line with previous findings from other healthcare students (Kotera et al., 2019a;
2019b), mental health problems were positively related to and predicted by mental health shame
and negatively related to and predicted by self-compassion. These findings suggest that reducing
mental health shame and cultivating self-compassion would be helpful for nursing students to
maintain good mental health. Mental health education is needed for nursing students to reduce
mental health shame. Recent findings demonstrated that the risk of depression was not related to
whether the person is weak or inadequate; instead it was related to social components including
fatigue and stress (Kobayashi et al., 2020). Having the right knowledge about mental health can
help to reduce mental health shame that nursing students may have. Moreover, as increased self-
compassion is associated with a lower level of shame (Sedighimornani, Rimes & Verplanken,
2019), developing self-compassion would be a helpful approach for nursing students to protect
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their mental health. By cultivating self-compassion, nursing students can reduce their mental
health shame and mental health problems.
Despite self-compassion already being taught in other caring professions (Nelson, Hall,
Anderson, Birtles & Hemming, 2018), educators need to be aware of the challenges of nurturing
self-care in nursing curricula: in nursing, taking care of oneself is stigmatised (Glass & Rose,
2008) and sometimes referred to as ‘responsible selfishness’ (Adam & Taylor, 2014). In line
with the authors’ experience of teaching self-compassion to healthcare students, many students
feel guilty about taking care of themselves. Therefore, theoretical understanding, before
practising exercises, may be important. For example, Watson’s (2008) Theory of Human Caring
describes that nurses’ care for self and others is interdependent, suggesting a need for self-care
for nurses (Mills, Wand & Fraser, 2015). To offer compassion for others, we need to offer
compassion to ourselves first, as caring for others requires caring for oneself (Dalai Lama, 2003;
Lloyd, Muers, Patterson & Marczak, 2018). The importance of self-care in nursing is highlighted
in the competency standards for registered nurses established by the International Council of
Nurses (Alexander & Runciman, 2003). However, in many countries, including the UK, self-care
is not emphasised (e.g. the competency standards for registered nurses by the NMC [2018] does
not emphasise self-care). Recently, partly because of the COVID-19 pandemic, the importance
of nursing has been recognised more (Ford, 2020), and the stigma of taking care of oneself may
be diminishing. Educators in the UK nursing programmes can take advantage of this to
incorporate a self-care component into their curriculum.
Lastly, the full mediation of self-compassion in the relationship between sleep and mental
health problems may offer helpful insight for nursing students who are sleep deprived. While
previously believed that insufficient sleep leads to poor mental health, our analyses did not find a
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direct linkage between sleep and mental health problems. This may mitigate the noebo effects of
sleep deprivation, by which students believe that their mental health should suffer when they fail
to secure enough sleep (Weimer, Enck, Dodd & Colloca, 2020). Our findings suggest that if a
student has a strong self-compassion, the impacts of sleep deprivation on mental health can be
minimum, therefore the student does not have to believe that they would not feel good on that
day.
Limitations
While this study offers helpful insights into the mental health of UK nursing students,
several limitations should be noted. First, our sample was recruited through convenient sampling
from one UK university, which limits the generalisability of our findings (e.g., our sample
recruited more males than the general sample of UK nursing students). Second, self-report
measures were used, which restricts the accuracy of participant responses for social desirability
bias (Kotera, Van Laethem & Ohshima, 2020). Further, we only evaluated the length of sleep;
other aspects of sleep (e.g., sleep quality and efficiency and time in bed) were not considered.
Also self-compassion was measured using the Self-Compassion Scale-Short Form (Raes et al.,
2011), which has been debated for its accuracy (Kotera & Sheffield, 2020). Likewise, mental
health problems were assessed using the total scale of DASS21, however difference among
depression, anxiety and stress has been debated, thus should be considered (Magalhaes et al.,
2010). Lastly, because we employed a cross-sectional design, the causal direction of the
relationships among these variables could not be ascertained. Longitudinal studies would be
useful to identify the causality.
20
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CONCLUSION
Nursing is one of the most popular subjects in the UK partly because of good graduate
prospects. Despite the popularity, many nursing students live with mental health problems. We
found that mental health problems were positively associated with mental health shame, and
negatively associated with self-compassion and sleep length (H1a-c). Mental health shame was a
positive predictor, and self-compassion was a negative predictor of mental health problems
(H2a-b). Lastly, self-compassion completely mediated the relationship between sleep and mental
health problems (H3). Our findings suggest the importance of self-compassion for nursing
students, and recommend self-compassion training to be embedded in the current nursing
curriculum, whilst addressing guilt for self-care by introducing self-care theories. Further, the
UK nursing competency standards can support practising nurses more by further emphasising
self-care, as is done in the international framework.
Conflict of Interest statement
No potential conflict of interest was reported by the authors.
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... Self-compassion improves people's mental health by promoting resilience and reducing self-criticism. Compassion itself, instead of being associated with systems of mental agitation and distress, has a system of emotion monitoring that leads to increased mental health by creating peace, safety and satisfaction (Kotera, Cockerill, Chircop & Forman, 2021). This may explain why self-compassion-based interventions often use mindfulness and slowbreathing exercises to gain access to the soothing system (Neff, 2003). ...
... People with high self-compassion try to deal with the difficulties and difficulties ahead with problemoriented rather than avoidant coping styles (Li et al., 2020). Compassion itself is also important during the Coronavirus 2019 pandemic (Kotera et al., 2021). Negative self-compassion is one of the strongest predictors of psychological disorders (Li et al., 2020& Meng et al., 2020. ...
... They also experienced less anxiety and fear during the pandemic and home quarantine. Kotera et al. (2021) studied nurses' mental health, shame, self-compassion, and sleep quality during the COVID-19. Findings showed that psychological problems were associated with shame, sleep quality and self-compassion. ...
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Coronavirus 2019 (COVID-19) as the biggest threat to public health in 2020, is a two-year period that has caused many problems to people around the world. The aim of this study was to compare spirituality, resilience and self-compassion in students with high and low levels of COVID-19 anxiety. The method of the present study is descriptive causal-comparative. The statistical population of the study consisted of male and female students of the Faculty of Literature and Humanities of the University of Guilan in the academic year 2020-2021. Participants were selected by available methods from each group of 135 students with high levels of COVID-19 anxiety and 135 students with low levels of COVID-19 anxiety. Students were assessed using COVID-19 Anxiety Scale Wheaton et al. (2012), spirituality Parsian & Dunning (2009), resilience Connor & Davidson (2003), and Self-Compassion Questionnaire Neff (2003). Data analysis was performed using multivariate analysis of variance by SPSS software version 24. Findings from multivariate analysis of variance showed that there was a significant difference between students with and without COVID-19 anxiety in terms of spirituality, resilience and self-compassion; So that the average scores of spirituality, resilience and self-compassion in students with COVID-19 anxiety are lower compared to students without COVID-19 anxiety (P<0.001). According to the findings of the present study, students with high levels of COVID-19 anxiety have less spirituality and resilience, which in turn aggravates the symptoms in individuals. On the other hand, it was found that self-judgment, feelings of isolation and over-assimilation are high in people with COVID-19 anxiety; For this reason, psychologists and counselors need to pay more attention to these areas in order to reduce the unreasonable severity of anxiety in students.
... As a marker of psychopathology, shame has been linked to depression [39], anxiety [40], and eating disorders [41]. "Mental health shame" ( [42], p. 136)-feeling ashamed for having a mental health problem-is linked in university students to poorer mental health [43] and is especially prominent in students who prepare to enter demanding careers such as business management [44] and health care [45]. Doblytė [13] qualitatively explored feelings of shame regarding mental health problems in an adult Czech sample and observed that shame was a dominant theme for delayed treatment seeking and the adoption of destructive coping strategies to prevent stigmatisation. ...
... Self-compassion has also been found to mediate the relationship between shame and symptoms of depression [84] and students' psychological health [85]. This research supports the beneficial role of self-compassion on shame reduction [31,42,45,48]. Though mental health shame is often a by-product of socially constructed attitudes and beliefs about mental health [14], our findings indicate that despite their strong relationship in our sample, these negative attitudes do not directly affect mental health but somewhat com- ...
... Selfcompassion has also been found to mediate the relationship between shame and symptoms of depression [84] and students' psychological health [85]. This research supports the beneficial role of self-compassion on shame reduction [31,42,45,48]. Though mental health shame is often a by-product of socially constructed attitudes and beliefs about mental health [14], our findings indicate that despite their strong relationship in our sample, these negative attitudes do not directly affect mental health but somewhat compromise the positive impact of self-compassion on mental health. ...
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High rates of mental health problems are a growing concern in Czech higher education; negatively impacting on students' performance and wellbeing. Despite the serious nature of poor mental health; students often do not seek help due to negative attitudes and shame for mental health problems. Recent mental health research reports self-compassion is strongly associated with better mental health and reduced shame. However, relationships between those constructs remain to be evaluated among Czech students. This study aimed to appraise the relationships between mental health problems; negative mental health attitudes; mental health shame; and self-compassion in this population. An opportunity sample of 119 psychology students from a Czech university completed questionnaires regarding these constructs. Correlation, regression and path analyses were conducted. Mental health problems were positively associated with neg-ative mental health attitudes and shame; and negatively associated with self-compassion. Self-compassion negatively predicted mental health problems, while negative attitudes and shame did not. Lastly, self-compassion fully mediated the negative attitudes-mental health problems relationship, and partially mediated the shame-mental health problems relationship. Findings suggest self-compassion is essential for mental health in Czech students; and associated with negative mental health attitudes and mental health shame. Czech universities can benefit from incorporating self-compassion training in their curriculum to protect students' mental health.
... Moreover, many therapists showed an intention to continue using online therapy, which can have implications for clients, including employed clients. For example, shame regarding mental health problems tends to be high in many occupational groups, reducing help-seeking in this population [5,8,39,40]. Online therapy can offer access to treatment for these shame-sensitive employees, as they can access therapy from home without any time and costs associated with physically accessing a therapy room. ...
... Online therapy can offer access to treatment for these shame-sensitive employees, as they can access therapy from home without any time and costs associated with physically accessing a therapy room. As mental health shame is strongly associated with poor mental health in many different occupational groups [21,39], access to therapy without causing shame can be a safer approach to protect employee mental health. Moreover, as many employees receive therapy, the normalisation effects may be present, reducing shame in order to facilitate help-seeking in the workplace [40]. ...
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Online therapy has been increasingly utilised during the COVID-19 pandemic by many including working populations. However, few qualitative studies have explored how online therapy is ex-perienced in practice, and discussed its implications for those working clients. Semi-structured interviews attended by nine integrative psychotherapists practising in California, United States, were conducted. Thematic analysis of the transcripts identified three themes: i) ‘Positive experi-ences of online therapy’, ii) ‘Challenges experienced by therapists and clients in online therapy’, and iii) ‘Preparation and training for online therapy’. Online therapy was experienced as helpful, particularly in terms of mitigating against previous geographical and temporal barriers to up-take. However, due to technological disruptions and potential blurring of professional bounda-ries, online therapy may detract from the emotional salience of therapy, negatively impacting the therapeutic relationship and containment. Considering the positive experiences, participants ex-pected the demand for online therapy would continue to increase. Particularly in the occupational context, online therapy can offer intervention without jeopardising mental health shame. The findings provide preliminary qualitative evidence that online therapy can be a useful adjunct to traditional forms of face-to-face therapy. However, therapists require more explicit training in implementing online therapy. Results are discussed in particular regarding the utility of this therapy for working clients.
... On the other hand, while some extrinsic rewards do act as an attractor [45], many healthcare students, categorised as 'soft' disciplines, are inspired by intrinsic motivators such as an altruistic desire to help others [46,47]. For example, nursing is often seen as a 'calling' rather than a job, where the opportunity to care for others, being part of a team, and a sense of pride in the services provided are cited as primary drivers of pursuing a nursing degree and subsequent career [48,49]. When examining motivation in students taking nutrition classes, Maurer et al. [29] found these students to be principally driven by intrinsic motivation, specifically the contribution that the course would have to their understanding of their own health status. ...
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While the demand for online education and the diversity of online students have been increasing worldwide, how online students motivate themselves to continuously engage in learning remains to be appraised. Research in the face-to-face contexts reports that academic motivation is central for student success and wellbeing, and the type of motivation can differ by subject. In particular, motivation of business students and healthcare students can differ considerably. This study aimed to understand the motivation of online students, and compare them between business and healthcare students using a concurrent nested mixed-method design with correlation and the-matic analyses. Survey regarding motivation, learning enjoyment and study willingness was re-sponded by 120 online students (61 business and 59 healthcare). Business students were associ-ated with extrinsic motivation, whereas healthcare students were associated with intrinsic mo-tivation. While students in both groups enjoyed the pursuit of knowledge, healthcare students valued the process and accomplishment, whereas business students regarded education as step pingstones in their career. Findings can help educators develop effective motivational support for these student groups.
... Indeed, working hours alone do not represent self-care; however, these positive regards on long working can support the participants' comments about difficulties implementing self-care. Culture and self-care need to be further evaluated [53] to identify a better approach to embed self-care into the Japanese healthcare sector. Moreover, recognizing guilt and shame associated with self-care in other countries [15], our findings highlighting the importance of a sector-level and organizational understanding of self-care may not be limited to Japan (e.g., [54,55]). ...
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The COVID-19 pandemic has negatively impacted the mental health of healthcare workers in many countries including Japan. While many survey-based findings have reported the serious state of their wellbeing among healthcare workers, the first-hand experience of the mental health and coping in this population remains to be evaluated. Accordingly, this study aimed to appraise them using constructionist thematic analysis on semi-structured interviews attended by a pur-posive and snowball sample of 24 healthcare workers in Japan conducted in December 2020–January 2021. Four themes were identified: (1) Increased stress and loneliness, (2) Reduced coping strategies, (3) Communication and acknowledgement as a mental health resource, and (4) Under-standing of self-care. Participants noted that the characteristics of Japanese work culture such as long hours, collectivism and hatarakigai (i.e., meaning in work) to explain these themes. These findings suggest that robust support at an organisational and individual level, capturing intrinsic values, are particularly important for this key workforce to cope with increased stress and lone-liness, leading to better patient care.
... Most empirical research on mental illness, help-seeking behaviours and stigma has concentrated on the general population, without examining factors that may be specific to religious groups or subcultures. While stigma may influence the degree to which the general population accesses professional mental health services (e.g., Kotera et al., 2020a), evidence suggests that those in religious communities may underutilise them even more (Mayers et al., 2007;Trice & Bjorck, 2006). Considering the negative impact of self-stigma for both physical and psychological functioning, this study will make a timely contribution to the literature. ...
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Background: A large body of research supports the central importance of religious and spiritual belief systems for personal wellbeing. Many religious communities hold beliefs about the causes and suitable treatments for mental health conditions, which can influence how an individual experiences their mental health, as well as the likelihood of seeking professional or religious help for their psychological difficulties. Research suggests that this is especially the case for evangelical Christians, who are more likely to view mental illness as caused by demons, sin, diminished faith, or generational curses. Whilst recent qualitative evidence suggests that such beliefs can hold negative effects for evangelical Christians, there is little research exploring quantitative pathways. Objective: This study protocol paper presents a pilot study, which aims to explore how beliefs about the causes of mental illness, religious fundamentalism, help-seeking, stigma and mental health are related in evangelical Christian communities. Whilst there is some existing research exploring this area, most is drawn from a US context. The findings of the present study, therefore, will uniquely apply to a UK context. Study Design: A quantitative design is proposed, which will involve statistical analyses such as correlation, regression, moderation and path analysis, to explore associations between these variables. Ethical considerations and dissemination plans are discussed, with awareness of characteristics of our target sample.
... However, universities must consider this dramatic rise in student numbers, and infectious status of the country and beyond (e.g., vaccination has started in the UK in December 2020). Registered nurses and allied health professionals undertaking study are facing an increased demand to provide care and treatment (Kotera et al., 2020a). They must balance these competing pressures while negotiating the pandemic's harmful effects on their psychological wellbeing, including heightened stress due 5 to worries associated with high risk of infection (Kotera, 2021). ...
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Online education has been regarded as a lifeline for many education institutions during the COVID-19 pandemic, offering students a means to advance their education and career. While face-to-face teaching universities convert their education curricula to the online settings, many institutions lack effective online teaching strategies, leading to reduced student enrolment and satisfaction. Contrarily, we have been receiving an ever-increasing number of healthcare professional students in our learning department since the outbreak, while maintaining high satisfaction. These students work as registered professional key workers and study online. Among numerous measures taken to support this student group, this short paper reports four effective teaching practices we have implemented: (a) active use of adaptive learning, (b) Padlet discussions, (c) wellbeing webinars, and (d) resilience building. These teaching strategies are deemed to address weaknesses of online learning and offer emotional support to students. Our teaching practices will be useful to many universities supporting this crucial group of students in the online environment. Citation Kotera, Y., Spink, R., Brooks-Ucheaga, M., Green, P., Rawson, R., Rhodes, C., Chircop, J., Williams, A., Okere, U. & Lyte, G. (2021). Teaching healthcare professional students in online learning during covid-19: Reflection of university lecturers. Journal of Concurrent Disorders. https://concurrentdisorders.ca/2021/05/13/teaching-healthcare-professional-students-in-online-learning-during-covid-19-reflection-of-university-lecturers/
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Though the importance of mental health education has been emphasised, how learning about mental health helps the learners’ mental health remains to be evaluated. Accordingly, this study aimed to appraise the mental health effects of online mental health classes in a controlled before-after study with a one-month follow-up. The Depression, Anxiety and Stress Scale-21 and Depression Stigma Scale were completed by 16 students in a mental health class and 12 in a non-mental health class. While there was no significant difference in depression, anxiety and stress, between groups (type of class) and within groups (assessment points), the levels of stigma were significantly lower in mental health students than non-mental health students at post-semester (p = .004). Findings illustrate temporal effectiveness of mental health classes on stigma, however continuous education is needed to maintain the effects. Educators in mental health are recommended to design a long-term plan to support learners’ mental health.
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Student nurses' well-being is essential to achieving academic targets and goals. This scoping review article aimed to explore the well-being among student nurses, its antecedence and consequences, as well as interventions that could help maintain and improve the well-being. PRISMA-ScR was used as a guideline, and a literature search was retrieved from four databases: Scopus, Web of Science, CINAHL, and PubMed. Fifty-four of 1104 articles were included and analyzed in this review. The review results indicated that the internal factors of well-being include the student's personality, psychological perceptions, sociodemographic, and health conditions. In contrast, the external factors were university location, facilities, graduate program, services, support, and learning environment. In addition, physical activity is considered a major intervention to improve well being. Therefore, this review serves as an input for universities, nursing schools, and nurse educators to pay attention to internal and external factors as well as to provide a physical activity intervention and good learning environment that make the students feel confident to achieve academic goals as a foundation to good nursing practice.
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Academic motivation is recognised as a key factor for academic success and wellbeing. Highly motivated students actively engage with academic activities and maintain higher levels of wellbeing. Despite the importance of motivation in education, its relationship with engagement and wellbeing remains to be evaluated. Accordingly, this study explored the relationships between motivation, engagement, self-criticism and self-compassion among UK education postgraduate students. Of 120 postgraduate students approached, 109 completed three self-report scales regarding those constructs. Correlation, regression and moderation analyses were performed. Intrinsic and extrinsic motivation were positively associated with engagement, whereas amotivation was
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Little is known about the effect of latent-phase herpesviruses on their host. Human herpesvirus 6B (HHV-6B) is one of the most ubiquitous herpesviruses, and olfactory astrocytes are one of the most important sites of its latency. Here, we identified SITH-1, an HHV-6B latent protein specifically expressed in astrocytes. Mice induced to produce SITH-1 in their olfactory astrocytes exhibited olfactory bulb apoptosis, a hyper-activated hypothalamic-pituitary-adrenal (HPA) axis and depressive symptoms. The binding of SITH-1 to the host protein calcium-modulating ligand (CAML) to form an activated complex promoted the influx of extracellular calcium. The serum antibody titers for depressive patients with respect to this activated complex were significantly higher than for normal controls (P = 1.78 × 10⁻¹⁵), when the antibody positive rates were 79.8% and 24.4%, respectively, and the odds ratio was 12.2. These results suggest that in the latent phase, HHV-6B may be involved in the onset of depression.
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Objective: The outbreak of the 2019 novel coronavirus disease (COVID-19) not only caused particularly large public health problems, but also caused great psychological distress, especially for medical staff. We aimed to investigate the prevalence rate of insomnia and to confirm the related social psychological factors among medical staff in hospitals during the COVID-19 outbreak. Method: Medical staff members in China were recruited, including frontline medical workers. The questionnaire, administered through the WeChat program, obtained demographic data and asked self-design questions related to the COVID-19 outbreak, insomnia/depressive/anxiety symptoms, and stress-related symptoms. We used a logistic regression analysis to examine the associations between sociodemographic factors and insomnia symptoms. Result: There were a total of 1,563 participants in our study. Five-hundred-and-sixty-four (36.1%) participants had insomnia symptoms according to the Insomnia Severity Index (ISI) (total score ≥ 8). A multiple binary logistic regression model revealed that insomnia symptoms were associated with an education level of high school or below (OR = 2.69, p = 0.042, 95% CI = 1.0-7.0), being a doctor (OR = 0.44, p = 0.007, 95% CI = 0.2-0.8), currently working in an isolation unit (OR = 1.71, p = 0.038, 95% CI = 1.0-2.8), is worried about being infected (OR = 2.30, p < 0.001, 95% CI = 1.6-3.4), perceived lack of helpfulness in terms of psychological support from news or social media with regard to COVID-19 (OR = 2.10, p = 0.001, 95% CI = 1.3-3.3), and having very strong uncertainty regarding effective disease control (OR = 3.30, p = 0.013, 95% CI = 1.3-8.5). Conclusion: Our study found that more than one-third of the medical staff suffered insomnia symptoms during the COVID-19 outbreak. The related factors included education level, an isolation environment, psychological worries about the COVID-19 outbreak, and being a doctor. Interventions for insomnia among medical staff are needed considering the various sociopsychological factors at play in this situation.
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Poor sleep quality is highly prevalent in modern societies and negatively linked to various health outcomes. While previous research has demonstrated preliminary evidence for self-compassion as a tool for improving sleep quality, this review provides a meta-analysis of respective published and unpublished results of our own research group using German samples. A total of nine studies are included (N = 956 participants), consisting of both correlational and experimental data. Across these studies, there was a medium correlation between self-compassion and subjective sleep quality, r = 0.303, 95% CI (0.244; 0.360). In three experimental studies, a small increase in participants’ self-reported sleep quality emerged, in comparison to control conditions, Hedges’ s g = 0.484, 95% CI (0.148; 0.821). Limitations on study level concern both the small sample sizes and short-term analyses of intervention effects. As a conclusion, this review supports both the correlational and causal relationship between self-compassion and increased subjective sleep quality across diverse operationalizations and samples. Future research should focus on the moderating effects of intervention type, duration of intervention effects, and type of target population.
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As mental health awareness increases, more students enrol to therapeutic subjects, aspiring to help others' mental wellbeing. While mental health of other caring students has been explored, therapeutic students' mental health has not been investigated thoroughly. This study aimed to explore relationships between mental health, mental health attitudes, self-criticism/self-reassurance, self-compassion, and caregiver identity of counselling and occupational therapy students. One hundred forty-five students, recruited through opportunity sampling, completed measures about those constructs. Correlation and regression analyses revealed that their mental health was associated with attitudes, self-criticism/self-reassurance and self-compassion. Self-criticism and internal shame were independent predictors of mental health. Findings will inform the mental health status of therapeutic students and help identify better solutions for their challenging mental health.
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Malaysia plays a key role in education of the Asia Pacific, expanding its scholarly output rapidly. However, mental health of Malaysian students is challenging, and their help-seeking is low because of stigma. This study explored the relationships between mental health and positive psychological constructs (academic engagement, motivation, self-compassion, and wellbeing), and evaluated the relative contribution of each positive psychological construct to mental health in Malaysian students. An opportunity sample of 153 students completed the measures regarding these constructs. Correlation, regression, and mediation analyses were conducted. Engagement, amotivation, self-compassion, and wellbeing were associated with, and predicted large variance in mental health. Self-compassion was the strongest independent predictor of mental health among all the positive psychological constructs. Findings can imply the strong links between mental health and positive psychology, especially self-compassion. Moreover, intervention studies to examine the effects of self-compassion training on mental health of Malaysian students appear to be warranted.
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Objective: To investigate the relationship of sleep duration and sleep quality with anxiety in the elderly aged 60 years and older in China. Methods: The elderly aged 60 years and older were selected from the China Short-term Health Effects of Air Pollution Study conducted between July 18, 2017 and February 7, 2018. Multivariate logistic regression models were used to analyze the association of sleep duration and sleep quality with anxiety. Results: A total of 3 897 elderly aged 60 years and older were included in the study. The age of the elderly was (73.4±8.0) years old. Among the elderly surveyed, 6.5% were defined with anxiety, and 18.7% reported poor sleep quality. Multivariate logistic regression models showed shorter sleep duration was the risk factor for anxiety in the elderly that after adjusting for factors such as general demographics, socioeconomic factors, lifestyle, health status, social support and ambient fine particulates exposure. Compared with the elderly with 7 hours of sleep duration daily, the OR (95%CI) of anxiety for those with sleep duration ≤ 6 hours was 2.09 (1.49-2.93). Compared with those with good sleep quality, the OR (95%CI) of anxiety for those with poor sleep quality was 5.12 (3.88-6.77). We also found statistically significant correlations of the scores of subscales of Pittsburgh sleep quality index with anxiety, in which the effects of sleep disturbance, subjective sleep quality and daytime dysfunction scores were most obvious, the ORs (95%CI) were 4.63 (3.55-6.04), 2.75 (2.33-3.23) and 2.50 (2.19-2.86), respectively. Subgroup analysis showed that the association of sleep duration and sleep quality with anxiety was more obvious in males and in those aged <80 years. Conclusion: Shorter sleep duration and poor sleep quality are associated with anxiety in the elderly in China.
Book
Towards a Sociology of Nursing offers fresh insights from recent research into the nursing profession. Nurses represent an important part of the professionally trained female workforce and, being a middle-class profession, changes in nursing reflect changes of many working women worldwide. Scholarship addressing these changes, however, often consists of narratives of nurses talking about themselves, which can be enriched by a sociological background that foregrounds hypotheses. In this book, Ricardo A. Ayala problematises the realities which inform, affect and shape nursing, offering new perspectives on the consequences of those social realities for the nursing profession and society more broadly. He draws on extensive field research with nurses in the workplace, spending time with them, interviewing key actors and reading and analysing documents critically through a distinctive sociological lens.