Is there a relationship between somatization symptoms and communication skills?

Introduction and Purpose: This study was conducted to determine the relationship between somatization symptoms and communication skills in nursing students. Material and Method: The study was conducted with the 481 students from Turkey and Turkish Republic of Northern Cyprus. The data were collected with the “Personal Information Form”, “Somatization Scale” and “Communication Skills Scale”. Results : A negative correlation was found between the “Somatization Scale” score averages of the nursing students and the “Self-expression”,” Communication principles and basic skills” subscales


INTRODUCTION
Somatization is the expression of psychological distress that cannot be explained by another mental disorder through somatic symptoms and has no organic basis (1,2). It has been included in the classification with the title of "Somatic Symptom Disorders and Associated Disorders" in the DSM V (3).
Many factors play a role in somatization symptoms. In addition to biological factors, psychological or social factors such as difficulties in expressing emotions, social isolation or lack of appropriate coping skills can also be effective in the emergence and maintenance of somatic symptoms (4). It is thought that these psychological and social factors may be related to communication skills. It is thought that with the development of communication skills, individuals can express their feelings better, use more effective coping mechanisms, and thus reduce somatization symptoms.
workers compared to other workers, especially during the pandemic period (5). Both nurses and somatization are in the risk group. Working conditions such as heavy workload, overtime and shift work can be effective in the appearance of somatization symptoms in nurses. In a study conducted with more than 13 thousand healthcare professionals in China, it was determined that nurses had more somatization symptoms than doctors (6). In addition, nurses are in the risk group because the majority of nurses are women and somatization symptoms are more common in women (7). Presence of somatization symptoms may affect the health care given by nurses. In a study, it was observed that nurses with somatization symptoms experienced more depersonalization (8). Korkmaz et al. (2020) detected that nurses with alexithymia had more somatization symptoms and experienced more burnout (9). In another study, the relationship between the mental status of students studying in the field of health and their social support was examined. According to the results of the research, it was determined that somatization symptoms increased as the perceived social support level of the students decreased (10).
It is estimated that individuals with somatic symptoms have more hospital admissions (11), use healthcare resources much more, and increase healthcare costs nine times (12). Determining the effect of communication skills on the emergence of somatic symptoms in nurses in the risk group and conducting studies on this will ensure the protection of the mental health of nurses. Therefore, if there is a relationship between somatization symptoms and communication skills in nursing education, increasing the syllabus for communication skills may be effective in reducing the occurrence of somatization symptoms.
In this direction, this study was conducted to determine the relationship between somatization and communication skills, somatization symptoms and communication skills in students from two different countries receiving nursing education.

MATERIAL AND METHOD Aim
This study was conducted to determine the relationship between somatization symptoms and communication skills in nursing students.

Place of Study
This research has two centers. The study was conducted with the students of the nursing department of the faculty of health sciences located in the Turkish Republic of Northern Cyprus (TRNC), and the students of the faculty of nursing (center 2) located in Ankara, Turkey. Both universities are public universities.

Participants
Research is completed with a total of 481 students from both universities. Before starting the research, necessary permissions were obtained and the consent of the participants was obtained.

Measures and Procedure
The data of the research were collected through Google forms. It was stated to the students that the decision about whether or not to participate in the research is entirely their own, that they should not write their names on the questionnaire, that the information to be collected from this study will be used only within the scope of the research, and that confidentiality will be strictly adhered to. It takes an average of 12-15 minutes to fill out the surevey. The data were collected with the "Personal Information Form", "Somatization Scale" and "Communication Skills Scale".
Personal Information Form: It consists of descriptive information about students' class, gender, country, education level of parents, place of staying in the education process, satisfaction with receiving nursing education, and evaluation of success level.  (13). It consists of 33 items and its validity and reliability study into Turkish was conducted by Dülgerler (2000) (14). The items in the scale are answered as yes and no. The maximum score of the scale is 0, and the maximum is 33. A high total score indicates a high level of somatization. The internal consistency reliability coefficient of the SS was 0.83 (14). Cronbach alpha value of the somatization scale was determined as 0.82 in the present study.
Communication Skills Scale (CSS): Korkut-Owen and Bugay (2014) was developed the scale to measure communication skills (15). It has a 5-point likert structure and consists of 25 items. It was has four subdimensions; self-expression (SE), Active Listening and Non-Verbal Communication (ALNVC), Willingness to Engage (WE), Communication principles and basic skills (CPBS). The high score obtained from the scale is considered to indicate that the communication skills of the individual are developed (15). In this study, the internal consistency coefficients were found as follows; 0.76 for CPBS; 0.76 for SE; 0.77 for ALNVC 0.70 for WE. The overall scale internal consistency coefficient was found 0.90.

Analysis of Data
The package program SPSS for Windows Version 18.0.0 (SPSS Inc., Chicago, IL, USA) was used. Number, percentage, mean ± standard deviation were used to define the data. The Kolmogorov-Simirinov test was used to evaluate the fit for the given normal distribution, and the Kruskal Wallis or Mann Whitney test was used for multi-group comparisons. Examination of the relationships between the data was done with the Spearman's Correlation Test. Statistical significance was taken as p<0.05.

Ethical Aspect of Research
Before beginning the research, permission from the university's ethics committee was obtained. Both universities' nursing departments granted institutional permission. The participants were informed about the research before it began, and data were collected after their consent was obtained. The study was carried out in accordance with the Helsinki Declaration.

RESULTS
32.8% of the students are in third grade, 54.7% are from Turkish Republic of Northern Cyprus, and 78% are female. Participants' mothers have a primary school education level of 35.3%, and their fathers have a primary school education level of 28.5%. 56.3% of participants live with their families while pursuing their education, 51.8% are satisfied with their nursing education, and 51.1% consider themselves successful (See Table 1). The mean scores of the students on the "SS" were 12.64±5.75, and the total mean scores on the "CSS" were 104.61±11.09 (See Table 2).
The "SS", "CSS" and its subscales' median scores of the participants do not change according to the education level of the mothers and class of the participants (p≥0.05). The sudents' "SS" and "WE" subscale median scores from TRNC were found to be lower than students  studying in Turkey (p<0.05). The median score of the "SS" of the women was higher than that of the men (p<0.05) (See Table 3, Table 4) The "ALNVC" subscale median scores of the students whose fathers are middle school graduates (Z=-2.994, p=0.003) are higher than students whose fathers are high school graduates (Z=-2.413, p=0.016). "ALNVC" subscale median scores were higher than university graduates or higher. It was determined that the median scores of the "CSS" and sub-scales of the students who stayed at home (at home, alone, with relatives) were higher than the students who stayed with their families and in the dormitory (p<0.05). "CSS" and its subscales median scores of very successful students; were found to be higher than successful, moderately successful and unsuccessful students (p<0.05). In addition, the "CSS" and sub-scale median scores of successful students are higher than moderately successful students, and students who are moderately successful are higher than unsuccessful students (p<0.05). On the other hand, the somatization scale median scores of the students who were moderately successful were found to be higher than the successful students (p<0.05). The "SS" median scores of the students who were not satisfied with their nursing education were higher than the students who did (Z=-2.419, p=0.016); who were partially satisfied were higher than who were satisfied (Z=-3.059, p=0.002) (p<0.05) (See Table 4) On the other hand, the self-expression subscale (Z=-3.100, p=0.002) and the willingness to relate scale (Z=-3.044, p=0.002) score averages of the students who were satisfied with their nursing education were higher than partially satisfied students (See Table 3).

DISCUSSION AND CONCLUSION
Nursing students' communication skills and somatization levels were assessed in this study. In the current study, students' somatization levels were low. Yüksel (2015) found that nursing students' somatization levels were low in a study with nursing students. Nursing entails assisting people who are in distress, suffering, or dying, as well as showing compassion and guiding them in problem solving (16). Nurses work in highly stressful physical and psychological environments (17). On the other hand, it is well understood that the nursing education process is a stressful training program (18). However, nursing students' low somatization level suggests that the education process they receive also contributes to their ability to cope with stress. Given that the nurses of the future will practice in busy working environments, this situation can both strengthen them and indirectly contribute to patient satisfaction.
The somatization levels of the students from Turkey were found to be higher than those of the students studying in the TRNC. In a study conducted with university students in Spain during pandemic, it was stated that somatic symptoms such as fatigue and sleep problems were observed intensely (19). In Çoban and Karaman (2013)'s study with university students in Turkey, it was found that students showed mild somatic symptoms (20). In another study conducted with Japanese and Korean students, it was stated that somatic symptoms were more common in Korean women than Japanese women (21). Somatization is a concept that emerges with the effect of biological, cognitive, psychodynamic and cultural factors, and the mind-body relationship is deeply felt (22). Somatic symptoms; The stress experienced and the burdens encountered appear with bodily symptoms (23). Kirmayer (1984) stated that each culture has its own symbols, different forms of expression and social rituals that it uses to express the difficulties it experiences (24). These data show that the prevalence of somatization symptoms is also affected by culture. It is thought that the reason for the change in the level of somatization in nursing students according to the geography and culture they live in is cultural differences.
It was determined that women's somatization levels were higher than men's. In Gerdan and Kurt (2020)'s study with university students, it was observed that the somatization levesl of women were higher than men (25). Dönmez et al. (2021)' study with healthcare professionals during the Covid 19 pandemic, it was shown that being a woman is associated with experiencing somatic symptoms (26). Gender was found to be a factor affecting the responses to stressors and thus the level of somatization. The burdens attributed to women by the society suggest that the stress they experience is intense and this is reflected in the level of somatization.
It was observed that the somatization levels of the students who were satisfied with receiving nursing education were lower than those of the students who were dissatisfied and partially satisfied. In addition, the somatization levels of students who consider themselves successful were found to be lower than those of moderately successful students. In a study, it was stated that there is a relationship between the satisfaction of nursing students and their academic achievement (27). In addition, in a study evaluating the factors affecting academic achievement in nursing students, it was stated that there was a negative relationship between students' anxiety levels and academic achievement (28). Papazizis, Vlasiadis & Papanikolaou (2008) conducted with nursing students in Greece, it was stated that one of the major causes of somatic symptoms and depression is stress (29). It is thought that students' being satisfied with nursing education and evaluating themselves as successful will reduce anxiety and this will reduce the level of somatization. High levels of anxiety and depression in university students are also associated with social factors, family factors and academic stressors (30). Somatic complaints are among the symptoms that can be seen in depression and anxiety disorders. In the research conducted by Göger and Çevirme (2019) with nursing students; It has been stated that there is a negative relationship between students' self-efficacy levels and nursing education stress (31).
It was observed that the communication skills levels of the students participating in the research were at a good level. Söğüt, Cangöl & Dinç (2018) examined the communication skills of nursing students studying at a health school, and the communication skills of the students were found to be moderate. In addition, with the average of communication skill levels; It was stated that there was a significant relationship between the variables of difficulty in relations with friends, difficulties with the patient while applying nursing care, and thinking of oneself as a social individual (32). The communication skills of nurses were found to be above average in a study conducted by Özkan and Aydoğan (2020), which evaluated nurses' communication skills and anger management (33). Nursing education includes a program that focuses on students' communication skills. Communication skills, on the other hand, are at the forefront of the patient's care process. Nursing students with good communication skills are expected and desired in this direction. The environments in which health care services are provided are fraught with crises and conflicts. It is believed that using good communication skills in these situations will aid in the resolution of the difficulties encountered.
It has been observed that students studying in the TRNC are less willing to communicate than students studying in Turkey. This suggests that cultural differences are to blame. It leads us to believe that the Turkish people's warm, sensitive, and sociable nature may have contributed to this situation. Furthermore, factors such as the students' personality traits and the education they received suggest that this difference can be explained.
Students with a father's education level of university or higher have better active listening and nonverbal communication skills than those with a high school diploma; those with a high school diploma have better nonverbal communication skills than those with a middle school diploma. This finding indicates that a high level of father education has a positive effect on students' active listening and nonverbal communication skills. Given that the father figure serves as a role model in the family, it is assumed that fathers with a high level of education will set a good example for their children in terms of interpersonal relations and communication skills, and these skills will help them develop. However, studies show that a father's education level has no effect on students' communication skills (34,35).
Students who live alone or with relatives have better communication skills than those who live with their families or in a dormitory. This discovery is intriguing. Being alone at home is thought to improve the ability to take responsibility for a house and solve problems, as well as improve communication skills. It is believed that living in a dormitory or with a family reduces students' level of responsibility when compared to the other group, and this situation is reflected in their communication skills. According to Yuksel and Erzincanlı's (2020) study of nursing students' social skill levels and influencing factors, students who live at home with their families outperform those who live at home with their families, in a state dormitory, in a private dormitory, and in the same house as their friends (36).
It was discovered that students who were completely satisfied with their nursing education had a higher level of self-expression and willingness to form relationships than students who were partially satisfied. In a study with nursing students in Norway (2013), satisfaction with clinical training was associated with motivation; highly motivated students experience a positive and supportive educational environment that fosters learning opportunities and competency development (37).
It was discovered that among the nursing students who took part in the study, those who consider themselves successful have better communication skills. Unlike our study, Arifolu and Razi (2011) discovered that the relationship between students' empathic disposition, empathy, and communication skills and the academic achievement score of the Self-Knowledge and Communication Management course was not included in their study with nursing students in the TRNC (38). A negative relationship was discovered between nursing students' somatization levels and their self-expression levels, communication principles and basic skills levels, and communication skills levels. In this case, high communication skills show that the level of somatization decreases. The frequency of psychiatric symptoms in nursing students was low, and their somatization average score was high, according to a study conducted by Yüksel (2015) with nursing students (16).

CONCLUSION
The current study investigated the relationship between somatization levels and communication skills of students studying in two different locations. Communication skills are essential for providing the best possible patient care in healthcare settings. However, health care services are frequently provided in settings where active crisis management, problem solving, and effective coping skills are required. The students' somatization levels were low, and their communication skills were excellent. My students' somatization scores and communication skills had a low negative correlation. The students' levels of somatization and communication skills are unaffected by their class or their mother's educational status. Students studying in the TRNC have lower levels of somatization and are less willing to form relationships than students studying in Turkey. Women's somatization levels are higher than men's; students with a high father education level have good listening and nonverbal communication skills. Furthermore, students who were satisfied with their nursing education had higher levels of self-expression and willingness to form relationships, whereas students who considered themselves successful had better communication skills. In addition to providing students with professional skills, university education enriches their social skills and continues their personal development. In addition to providing students with professional skills, university education enriches their social skills and continues their personal development. It is recommended that studies with larger sample groups be conducted in order to evaluate the factors influencing students' communication skills and somatization levels.