The Influence of Marriage Communication Skills and Sexual Satisfaction on the Marriage Quality of Female Nurses at Mental Hospital

This research aims to investigate the influence of marriage communication skills and sexual satisfaction on the marriage quality of female nurses who work at a mental hospital and whose husbands also work. Working females, especially those who work in shifts, have less time to spend with their families and spouse, which, in turn prove to be great challenges to building a good relationship between partners. Our principal instrument of data collection is questionnaires. 108 female nurses who work at Dr. Radjiman Wediodiningrat Mental Hospital and have working husbands participated on this study. The results of the multiple regression analysis demonstrated that marriage communication skills and sexual satisfaction can influence marriage quality. This finding suggests that the marriage communication skills variable and the sexual satisfaction variable exert 58.1% influence on the marriage quality variable, while the remaining 41.9% influence is exerted by other variables. These findings are expected to support our recommendation for employing institutions to reconsider the distribution of their employees' working hours, so that each individual can spend more time with their families. Besides that, every couple must proactively find the best way to maintain their marriage quality by taking into account communication quality and sexual satisfaction factors.


Introduction
Equality between men and women increasingly becomes a hallmark of this modern age. This conclusion is based on statistical data which show that more and more women are pursuing education at colleges. According to the data released by the Directorate General of Higher Education (2009), the percentage of women acquiring formal education (51.2%) is even higher than that of men (48.48%), which is a sign of a significant social transformation and women's departure from their traditional gender roles.
It is only natural that an increase in the number of women acquiring higher formal education will result in an increase in the number of general workforce each year and, more interestingly, an increasing level of women's participation in the general workforce (O'Brien, 2011). According to data from Statistics Indonesia (2012), the amount of general workforce in Indonesia has reached 111.9 million people, which suggests an increase of 2 million people compared to the amount of general workforce in August 2007 which reached 109.9 million people. The amount of female workforce in 2006 reached 38.6 million people and increased to 46.5 million people in 2012. Such an increase is very interesting and clearly deserves attention, considering the social impacts brought about by this transformation.
An increasingly competitive working climate has brought about pressures and conflicts of priority on the part of the workers since they have to divide their time between family and work (O'Brien, 2011). The burdens and anxiety at work are the sources of stress and mental problems which might be carried home (Byron, 2005in Heyman, 2006. In developing countries, parents are increasingly anxious for not being able to give much attention to their children because of their jobs. Such workers simply do not have enough time to take care of their children, and many of them may even be compelled to leave their children unattended at home (Heymann, 2006). Research has proven that there is a negative relationship between work-family conflicts and marriage satisfaction (Allen et al., 2000). More specifically, these work-family conflicts may take the forms of withdrawal from marriage, anger in marriage, negative interactions in marriage, a reduced capacity for adjustment in marriage, and a decreasing level of marriage quality (Hughes et al., 2004).
In this modern world, life pressure is becoming more intense, and shortage of quality time has become a commonplace. On the one hand, in order to build a healthy family relationship, time is of essential importance. On the other hand, allocating time for family purposes has become a challenge in itself. The result is a psychological distortion because couples find it increasingly difficult to make time to do meaningful activities together (Dally, 1996). A married couple no longer has a sufficient amount of time to do meaningful activities which can strengthen the relationships between themselves and with their children (Kinney, Dunn, & Hoffert, 2000, Tubss et al., 2005. As part of a day-to-day duty of female nurses, the concept of work shifts is applied as the basis on which nursing services are rendered to the clients. Work shift is defined as an arrangement of working time in a particular workplace based on certain parameters of time distribution. The shift system is a system of working time arrangement which can provide opportunity for employers to make the best use of all time available to perform operational activities (Muchinsky, 1997in Hestya et al., 2012. Riggio (in Hestya et al., 2012) defines a work shift as a work schedule in which each employee comes to a workplace on a rotational basis so that the employer's operational activities can be performed without interruption.
Nurses at mental hospitals are different from nurses at other types of hospital in various respects. Some mental hospital nurses may experience difficulties in communicating with their patients, and they must always maintain vigilance against any potential dangers or life-threatening situations posed by the patients due to their mental instability (Rahman, 2010). A study carried out by NIOSH (2008) reveals that nurses or any other health professionals have a greater potential for experiencing psychological problems or stress, which may result in burnouts, withdrawals from duties, and patient mistreatments. These might be caused by work overload, economic factors, and long working hours, which include shift works.
In the same vein, Nicolosi et al. (2004) found that quality time shortage and excessive stress at work may have a negative impact on sexual satisfaction for a married couple. Unfulfilled sexual needs stand out as a significant problem in a marriage life. Sexual satisfaction is an important factor in human emotional and mental health and an important criterion of a successful intimate relationship (L'Abate & Talmade, 1995in Bridgess et al., 2004. One of the strongest predictors of marriage stability and spousal relationship quality is sexual satisfaction achieved through the relationship (Asgharianji et al., 2015). In spite of the importance of this factor, not much research has been done to investigate the correlation between sexual satisfaction and marriage quality, especially amongst female nurses. Such lack of concern might be due to a misconception that, when a couple is married and thus can legally engage in sexual activities, sexuality is no longer considered as a phenomenon worthy of further investigation because it can no longer generate any significant problems in marriage (Christopher & Sprecher, 2000).
However, in reality, sexual behaviours are not only related to physical satisfaction, but also to emotional attachment and intimate relationship between a wife and a husband because sexual satisfaction greatly determines the general quality of the marriage itself. In order to investigate the variable of sexual satisfaction in the context of marriage, this research applies the social exchange theory (Lawrance & Byers, 1992in Stephenson & Meston, 2011. Sexual satisfaction can be measured using this social exchange theory, which maintains that every living individual constantly negotiates between rewards and costs. According to this theory, reward is associated with things that an individual gets, such as love, money, status, support, safety, and pleasure, while cost is associated with things that an individual spends, such as time, energy, and various kinds of sacrifices required for maintaining a relationship. This individual will always try to negotiate between what s/he gets and what s/he sacrifices, and problems arise when costs become more dominant than rewards in a sexual relationship (Lehmiller, 2014).
In terms of sexuality, such imbalance between costs and rewards is considered to take place when a sexual relationship can no longer guarantee sexual satisfaction, and the consequent result of which is that the individual might want to end the relationship and seek for another. The individual tends to search for other alternatives which can offer the reward which should otherwise have been provided by her/his spouse, while such attempts to search for other alternatives will lead to conflicts between the wife and the husband concerned. Such conflicts will most certainly affect their marriage quality and might end with a divorce or separation (Levinger, 1976;Lehmiller, 2014).
For the purpose of measuring sexual satisfaction, this research applies the Interpersonal Exchange Model of Sexual Satisfaction (IEMSS) theory. This theory divides sexual satisfaction into three dimensions (Lawrance & Byers, 1992in Stephenson & Meston, 2011. The first dimension is balance, which is the balance between sexual rewards and sexual costs. The second is comparison, which is a comparison between sexual reward-sexual cost balance and each partner's expectation in relation to the sexual reward and sexual cost. The third is equality, which is the equality between sexual rewards and sexual costs as experienced by each partner in the relationship. Ackerman (2002) views the concept of marriage from the interspecies perspective as a form of pairbonding. Pairbonding can be defined as a form of an attempt to build and maintain a dyadic relationship. A poor marriage quality will result in conflicts amongst family members, the worst case of which ends with divorce or separation. Amato and Marriot (2007) stated that marriage quality is a variable used to measure the relative strength or weakness of a marriage in terms of marriage happiness, interaction, misunderstanding, domestic problems, and potential for divorce. In a traditional form of marriage, in which wives stay at home and husbands work outside, marriages tend to be more stable than when both members of the couple have to work away from home. This is supported by the fact that an increase in the number of divorces has a positive correlation with an increase in the number of working wives (Poortman & Kaljmin, 2002).
Marriage quality has five dimensions, which are used in this research to measure the marriage quality of the respondents. The first dimension is marriage happiness, which measures a partner's perception of her/his marriage, both specifically and generally. The second is interaction in marriage, which measures cooperation between wife and husband in running their day-to-day family routine. The third is misunderstanding in marriage, which can be measured by examining the intensity of both verbal and physical conflicts experienced by the couple because of lack of understanding. The fourth is problem in marriage, which examines the characteristics and behaviours of each partner which have the potential for generating problems in the marriage. The fifth is potential for divorce, which identifies any tendency or desire in each partner to seek separation, divorce, or termination of their relationship.
According to another study (Conger, 1990;Ledreman, 2010), in spite of a turbulent relationship, good communication skills can play an important role in maintaining and improving marriage quality. A healthy interaction amongst family members also serves as a factor which determines the quality of a marriage (Matthews 1996). A couple with good communication skills tends to show a better marriage quality than a couple with poor communication skills. The quality of communication between partners becomes a determining factor in the survival of a marriage when the relationship is attacked by serious conflicts, such as financial or job-related problems (Lederman, 2010). Interaction between partners can be understood as a strategy with which a couple discuss and address external problems by applying good communication skills in a mutual way and not by projecting those problems to the other partner. In this way, good communication skills can help improve marriage quality (Banmen & Vogel,1985).
Another marriage-related problem (Bodenmann et al., 2007) arises when a partner experiences some external problems or stressful conditions at work and carries them home and projects it to other family members. Such behaviour introduces negative elements to the communication pattern in her/his family and reduces the quality of communication with her/his spouse at home. Karney and Bradbury (1995) in Bodenmann (2007) carried out a longitudinal study about the causes of divorce. One of their most important findings asserts that lack of communication skills is one of the most significant causes of divorce. Therefore, it can be surmised that nurses with high level of stress at work have to acquire good communication skills in order to ensure the survival of their marriages. Fowers (2001) describes communication skills consisting of four elements, which are applied in this research as the bases for measurement. The first dimension is nondefensive listening, which is defined as an attempt to listen without offering any counterargument, so that the partner can finish her/his statements without interruption; besides that, this also involves trying to understand what the partner is saying. The second is active listening, which is defined as an attempt to actively and nonverbally summarize, validate, and encourage the partner to express what s/he wants to say. The third is self-disclosure, which is defined as an attempt to express one's own feelings to the partner, so that everything that is expressed during the interaction is truly meaningful. The fourth is editing, which is defined as an attempt to manage the communication by showing politeness, sincerity, respect, and interest in what the partner is saying. Giving honest statements is not always the best strategy, but giving honest statements in wise ways is a better strategy for maintaining good communication (Gottman, 1994in Fowers, 2001.
Based on the above considerations, we have constructed this research question: "is there any influence of marriage communication skills and sexual satisfaction on the marriage quality of female nurses working at a mental hospital?" Our research hypothesis is that there is an influence of marriage communication skills and sexual satisfaction on the marriage quality of female nurses working at a mental hospital. The aim of this research is

Methods
Statistical Population and Sampling. Our research population consists of female nurses working at Dr. Radjiman Wediodiningrat Mental Hospital in Lawang, whose husbands also work. The total number of female nurses with working husbands at this hospital is 143. This research applies the convenience sampling method to collect data. Convenience sampling is a type of nonrandom sampling methods by which research subjects are selected according to a set of relevant criteria and researchers' accessibility (Etikan et al., 2015). Data were collected with the assistance of the head psychologist of Dr. Radjiman Wediodiningrat Mental Hospital in Lawang, who has the most convenient access to all subjects relevant to this research. The final number of research samples is 108.
Procedure and Questionnaires. By taking into account of all necessary data, situations, conditions, and aims of this research, we decided to use questionnaires as the most effective data collection method, as they can better reflect people's opinions, attitudes, and attentions. Three types of questionnaires are utilized in this research to investigate three relevant variables: marriage communication skills, sexual satisfaction, and marriage quality, each of which with its own set of predetermined indicators.
To construct the marriage communication skills scale, we develop our own measurement instrument based on Fowers' theory of four elements of communication skills (2001). Therefore, our scale also consists of these four dimensions: (1) non-defensive listening, which is an individual's ability to listen without making interruption or offering counterarguments; (2) active listening, which is an individual's ability to listen with full attention and to summarize what the partner says; (3) self-disclosure, which is an individual's ability to express her/his feelings during communication; and (4) editing, which is an individual's ability to manage language use.
To construct the sexual satisfaction scale, we also develop our own measurement instruments based on Lawrance and Byers' theory of three dimensions of sexual satisfaction (1992in Stephenson & Meston, 2011. Therefore, our scale also consists of these three main dimensions: (1) balance, which is the balance between the costs (sacrifice) borne and rewards (benefit) earned in a sexual relationship; (2)   To construct the marriage quality scale, we develop a measurement instrument based on the theory of five dimensions of marriage quality as proposed by Johnson et al. (1992). Therefore, our scale also consists of these four dimensions: (1) marriage happiness, (2) interaction in marriage, (3) misunderstanding in marriage, (4) problems in marriage, and (5) tendency to separate.
The validity of our three measurement instruments was tested by measuring the correlation between the items contained therein by performing factor analyses to identify the factor loading of each item as an indicator of construct validity. As the criterion for selecting items, we determine an item total correlation with a limitation of r ≥ 0.30. Our marriage communication skills scale originally consisted of 32 items; 8 items were omitted later, so only 24 items are rendered valid for the purpose of this research. Our sexual satisfaction scale consists of 15 items, all of which are valid. Our marriage quality scale consists of 24 items, all of which are also valid. The standard of factor loading was determined at > 0.35, and the factor loadings of all valid items in our three scales were also found to be at > 0.35, which indicates that all of those measurement instruments (and all items contained therein) can really perform an accurate measurement of the construct as intended by this research.
The reliability of our measurement instruments is measured using the Alpha Cronbach technique, and the results are as follows: (1) the α value of the marriage communication skills measurement instrument is 0.899; (2) the α value of the sexual satisfaction measurement instrument is 0.899; and (3) the α value of the marriage quality measurement instrument is 0.954. In accordance with the above Alpha Cronbach measurement results, our instruments for measuring marriage communication skills, sexual satisfaction, and marriage quality variables are considered as reliable because their α values are > 0.5. For the purpose of statistical measurements, this research applies the multiple regression technique.

Results and Discussion
Demographical Data. The majority of our research subjects are 31-35 years old, and they constitute 28% of the total samples. The inclusive criterion of our research subjects is 20-55 years old, so it can be said that there is no specific limitation in terms of age. 31% of the subjects had been married for less than five years at the time of our research, while the rest had been married for more than five years.
There is a great uniformity in the subjects' income range per month, with 86% earning less than five million rupiahs per month, 12% earning between five to ten million rupiahs per month, and only 2% earning more than ten million rupiahs per month. Such uniformity in monthly income can be obtained because all subjects work in the same institution. Most of the subjects' husbands work as private employees or civil servants.

Data Processing Results.
According to the results of previous assumption tests, which consist of a normality test and a multicollinearity test, our three research variables show a normal pattern of data distribution. The first assumption test is the Kolmogorov-Smirnov normality test, which is performed to measure the significance of all data sets which have been gathered using the three scales: (1)  The next assumption test is the multicollinearity test. Based on the results of this regression test, all independent variables show VIF values of < 10, which suggests an absence of any multicollinearity problems; in other words, it is clear that no very high linear correlation between independent variables has been identified. Therefore, the next calculations (in the form of regression calculations) can now be performed.
Based on the calculations of the correlation between variables (which are performed separately for each pair of variables), there is an influence between each variable X and each variable Y. The significance of the marriage communication skills variable is below 0.05, so it can be said that marriage communication skills influence marriage quality. The significance of the sexual satisfaction variable is also below 0.05, so it can be said that sexual satisfaction can also be used to predict the level of marriage quality.
The results of regression calculations also demonstrate that the marriage communication skills variable and the sexual satisfaction variable exert a reasonably strong influence on the marriage quality variable. According to their correlation coefficient (R square) values, marriage communication skills and sexual satisfaction exert 58.1% influence on marriage quality, while other factors contribute to the remaining 41.9%. The contribution of each variable can also be observed by using the R square change option in SSPS. The results show that sexual satisfaction has a greater capacity for predicting marriage quality (54.3%) than marriage communication skills do (3.8%).
As shown in the table below, the above calculations yield a significance of 0.000, which is a much lower value than 0.05. Because the significance is lower than 0.05, the zero hypothesis is rejected, which means that, in general, our independent variables can be said to influence our dependent variables, so the regression model can be applied to predict marriage quality. Thus, the above calculations have generated a regression equation, as shown below.
For all practical purposes, working in shifts often means working without a fixed time frame. Any individual who works in shifts must always be ready for a "tumbled" life, a reversal of the ordinary period of a human activity. For example, people who work in shifts might still be required to work on holidays or at night when other people are sleeping on their beds. This condition poses a greater challenge for working women who must also maintain a healthy relationship with their family members (Grosswald, 2004).
The results of our analysis demonstrate that there is a significant influence of marriage communication skills and sexual satisfaction on marriage quality. According to the resulting regression equation above, it can be concluded that both marriage communication skills and sexual satisfaction variables exert a positive influence on marriage quality. In other words, when marriage communication skills and sexual satisfaction increase, marriage quality can also be expected to increase.
In this research, the regression analysis is carried out as an attempt to measure the influence of the sexual satisfaction variable and the marriage communication skills variable on the marriage quality variable in a separate way. In the first process, the regression analysis is only performed to identify the influence of the sexual satisfaction variable on the marriage quality variable, which results in R square change = 0.543. Then, the marriage communication skills variable is added to the analysis in order to observe the extent to which the combination of both variables is able to predict the marriage quality variable, which results in R square change = 0.038. This model suggests that marriage quality can be 58.1% predicted by these two variables, with sexual satisfaction having a significantly higher predictive power (54.3%) than marriage communication skills (3.8%).
These findings suggest that sexual satisfaction is a very strong predictor of marriage quality. This is in line with Asgharianji et al. (2015) who maintain that lack of sexual satisfaction in a marriage may bring negative consequences to the relationship between a wife and a husband. Female nurses without a fixed working schedule, especially those whose husbands also work and who experience a high level of stress at their workplaces, tend to have a very limited amount of time to spend with their respective partners (Hestya et al., 2012;NIOSH, 2008). Sexual satisfaction is not only related to the fulfilment of physical needs, but also, and more importantly, to the development of affection between a wife and a husband (L'Abate & Talmade, 1995in Bridgess et al., 2004. This may be the reason why sexual satisfaction can serve as a very strong predictor of marriage quality. On the other hand, based on the results of our regression analysis, marriage communication skills only contribute 3.8% to marriage quality. Johnson et al. (1992) point out that, once an interpersonal relationship is established through marriage, marriage quality tends to be stable and will rarely fluctuate. Environmental pressures, which include stress at work, will only exert its influence on a married couple when both partners have not found the true meaning of their marriage, an event which is supposed to take place in the earliest stages of their marriage (Johnson et al., 1992). In relation to the demographical data gathered at the beginning of this research, 31% of the subjects had been married for less than five years at the time of this research, while 69% had been married for more than five years. Amato (2001) suggests that people constantly undergo changes during their marriage lives, and this process might cause conflicts. However, as time passes, many couples manage to find happiness or even new sources of pleasure at later stages of their marriage lives, and this correlates with the amount of time that they have spent together. Each time a couple find a new mutual source of pleasure, they will enjoy their relationship even more. This is related to the aspect of marriage communication skills which couples develop from time to time as they are constantly adjusting to each other. These adjustment strategies include the development of effective conflict settlement patterns each time job-related problems arise. According to our research findings, good communication skills still play an important role in improving the quality of a marriage, but their contribution seems to be undermined by the fact that couples already develop mutually agreed patterns of communication and conflict settlement. This argument may help explain why good communication skills only appear to make small contribution to the improvement of marriage quality.
A different conclusion can be drawn from other demographical data which show that 58% of the subjects were still less than 35 years old at the time of our research, which means that they were still at productive ages and sexually active. In accordance with the theory of social exchange which is applied in this research to measure sexual satisfaction, those subjects still had a great chance of earning rewards in the form of sexual pleasure from their respective partners, which would eventually contribute to their own sexual satisfaction. However, as time passes and their age advances, the need for sexual satisfaction will also fade, and both partners will develop and seek other alternative forms of rewards in order to maintain the quality of their marriages (Heiman et al., 2011).
Another type of demographical data which deserves further discussion is the subject's monthly incomes.
Previous studies have identified a number of negative consequences which may arise when wives have their own incomes. Wives with independent incomes might influence marriage quality because, on the husbands' perspective, working wives might be viewed as a challenge to their traditional role as breadwinners in the family. Wives with incomes higher than those of their husbands tend to exert more power in the family (Blood & Wolfe, 1972in Rogers, 1999.
On the other hand, working wives can also help improve their marriage quality because additional incomes from their jobs can help provide financial means for sustaining their families. Economic pressure is believed to have a great potential for destroying relationships and interactions amongst family members, including those between a wife and a husband (Voydanoff, 1988in Rogers, 1999. Conger (1990in Rogers, 1999 points out that economic hardships can lead to various threats to a relationship and produce unhealthy relationships. Hood (1983( in Rogers, 1999 specifically mentions that husbands with lower incomes can tolerate wives with incomes higher than themselves, providing that the husbands are allowed to share their wives' role as the principal breadwinners in the family.
Demographical data also suggest that 86% of the subjects earn less than 5 million rupiahs, 12% earn between 5 and 10 million rupiahs, and only 2% earn more than 10 million rupiahs. A comparison between these data and other research variables suggests that it is possible for working women to improve their marriage quality by building strong communication with their respective partners. The capacity for negotiating equality and distributing roles between a wife and a husband can serve as an important key to a better marriage quality.

Conclusion
Employers need to pay more attention to the mental wellbeing of their employees, especially the female ones. According to our research findings, marriage quality is influenced by sexual satisfaction and marriage communication skills. Challenges to marriage quality will be more difficult to deal with when the shift system is applied at their workplaces because such practices reduce the amount of time required to build interactions with family members. This situation can be aggravated by the fact that their husbands also work.
Work schedule must be reconsidered, so that the nurses may have an opportunity to balance between their jobs and their private lives at home. Dr. Radjiman Wediodiningrat Mental Hospital has taken steps to address this challenge by providing houses around the hospital area for most of its nurses. This policy has brought several benefits to the wellbeing of the female nurses, especially in terms of travel safety, because their living places are situated in the locality of their workplace. Besides that, this arrangement also reduces the travel time, so that the nurses can spend more time with their family.
In addition to our recommendation for employers, we would also suggest couples to proactively maintain their relationship by ensuring each other's sexual satisfaction because this factor plays a significant role in maintaining family stability and improving marriage quality. However, sexual satisfaction is not the only thing that matters in a marriage life. Couples also need to maintain productive interactions and improve their communication skills. Good communication skills may prove to be a great instrument for settling conflicts which may arise in various stages of a marriage life.