Cognitive Behavioral Therapy for Occupational Stress among the Intensive Care Unit Nurses.

BACKGROUND AND AIMS: Nurses working in the intensive care units (ICU) are faced with numerous stressors that can pose a serious threat to their self-efficacy and affect the quality of care. The aim of this study was to evaluate the effectiveness of Cognitive Behavioral Therapy (CBT) on the ICU nurses' occupational stress.
METHODS: This interventional study was conducted in a hospital in southeast of Iran. The participants included 120 nurses, who were randomly assigned into the control (n = 60) and intervention (n = 60) groups. In the pre-test, the occupational stress was assessed using Osipow questionnaire. Later, the intervention group attended the CBT course conducted in six 90 minute sessions. One month after the intervention, the post-test data were collected from both groups.
RESULTS: The means of occupational stress and its dimensions were not significant before the intervention between the intervention and control groups (P = 0.47). The means of occupational stress and its dimensions were moderately high at pretest for all nurses. In the post-test, the stress level and all its dimensions reduced from moderate-high to moderate-low (P < 0.001), except for the physical environment dimension that remained at the moderate-high level (P = 0.32).
CONCLUSION: The findings showed that CBT was effective on the nursing stress. Therefore, CBT training is suggested in in-service training programs for nurses. Copyright:

INTRODUCTION

Stress is considered as a positive and indispensable phenomenon of the human life, which can play an important role in the individual and social development of the individuals.[1] However, in the case of severe, persistent, and recurrent stress, and also when the individual lacks adequate supportive resources, it is considered as a negative phenomenon that can cause many physical diseases and mental disorders.[2] Today, the workplace is one of the most important sources of stress in every person’s life. Occupational stress is a type of emotional, cognitive, behavioral, and psychological response to harmful aspects of the job and workplace. Among different occupational groups, health workers, especially nurses, are at a higher risk of stress due to their mediating role of physician-patient care, long hours of presence in the hospital, patient care, and family support.[34] Several factors are involved in the nurses’ job stress. According to Asadi et al., occupational stress in nursing was associated with 5 factors of low income, job insecurity, lack of time to work, and poor physical conditions.[5] Kath et al. indicated that the occupational stress in nurses was related to their multiple and various roles, ambiguity in role and organizational constraints.[6]

According to the literature, nurses of the intensive care units (ICU) are faced with more stress, since they should deal with critically ill patients on ventilator, patient’s unstable consciousness, critical injections such as dopamine, continuous monitoring of vital signs, and prevention of bed ulcers compared to nurses working in public sectors.[78] Many of these problems are unavoidable in the ICU and nurses encounter these stressors every day.[9] One of the appropriate solutions is to increase the nurses’ mind and body strength so that they can maintain their balance in any situation, work with peace of mind and focus on the occupational environment and have a calm, high-quality and low-stress life environment.[10]

The organization can support its employees by providing Cognitive Behavioral Therapy (CBT) to deal with occupational stress. The nurses can be educated about the techniques and strategies to overcome their stress and reduce the adverse effects of the occupational stress.[11]

As a short-term, problem-focused and organized therapy, CBT aims at modifying inaccurate and irrational cognitions. One approach to stress treatment is to deal with the anxiety-inducing stimuli and situations. In other words, individuals can cope with their anxious feelings in all situations by making new associations.[12] In this regard, CBT can be offered individually or in groups. The group therapies are time and cost effective and have greater impact than individual therapies.[13] Numerous studies confirmed the efficacy of CBT in reducing stress,[14] anxiety, chronic pain, depression, insomnia[15] and complications of the post-traumatic stress disorder.[16]

Given that occupational stress in medical staff, including nurses, decreases their efficiency, increases the psychological and physical injuries, and causes dissatisfaction with services, an effective strategy should be employed to reduce the occupational stress and improve the nurses’ mental health.[2] Considering the fact that no study has ever investigated the impact of CBT on the nurses’ occupational stress, we decided to study the effect of CBT on the occupational stress among nurses working in the ICUs of Kerman City. In this regard, CBT can be used to take a small step toward improving the nurses’ health and performance.

METHODS

Study design and setting

This controlled quasi-experimental study was conducted using a pre-test and post-test design in a hospital in Kerman City, Southeastern Iran, from January to March 2019.

Participants

The study population included all the nurses working in the ICUs of Kerman Bahonar Hospital. Considering the calculated sample size (n = 176) using the Cochran formula, the information collected from a previous study,[17] error of 0.05, power of 0.8, d = 0.05, q = 0.5, P = 0.5, and z = 1,96, the sample size was calculated as 120 by NCSS software. The participants were selected using random sampling method and categorized into the intervention (n = 60) and control (n = 60) groups. Moreover, participants of the intervention group were classified into 3 groups of 20 members each.

The inclusion criteria for the nurses were working in the ICU, having at least a Bachelor’s degree, and having 6 months of clinical work experience. The exclusion criteria included having incomplete questionnaire and psychological problems (indicated by the nurse or the medical records). In this study, all the participants completed the study up to the end.

Intervention procedure

The CBT training program was held weekly in six 90-minute sessions for the three intervention groups. A review defined CBT as any intervention containing components of the behavioral and/or cognitive techniques: activity pacing, assertiveness or communication training, behavioral activation, biofeedback, cognitive or attentional distraction, cognitive restructuring, contingency management, goal setting, imagery, hypnosis, meditation, modeling, pleasant activity scheduling, problem-solving, relaxation training, and role playing. Furthermore, systematic desensitization or visualization homework was assigned after each session[18] [Table 1]. The educational intervention was presented by a Psychiatric Nurse, a psychologist, and 2 PhD nursing students using educational slides, lectures, group discussions, questions, and answers. During the study period, the control group attended no educational program. Table 1 shows the topics presented throughput the training sessions.[19]

Table 1

Contents of the cognitive behavioral therapy course

Session purpose	Agenda/content	Homework
Building alliance to the group	Perception of stress	“What is stress?”
Psycho-education	Psycho-education on stress, cognitive models, structure of the therapy	“What is group CBT”?
Motivate the Nurse
Socializing the Nurse
Goal setting	Collaboratively setting treatment goals	Problem list
Activating the nurse	The features of the concept	“The events that recently felt the stress”
Identifying mood and automatic thoughts	Dysfunctional thought record	“How to identify your moods and thoughts”
Testing automatic thoughts	Dysfunctional thought record	“How to balance your thoughts”
To enhance the ability to solve problems	It leads to the solution by using a problem-solving technique	Try the solutions to problems.
Set up an action plan towards the goal	Create an action plan to achieve the goal.	The execution of the action plan

Instruments and data collection process

The data was collected from the intervention and control groups before and one month after the CBT training using two questionnaires. The demographic questionnaire included information about the participants’ age, job experience, gender, marital status, education level and employment status.

The Osipow job stress standard questionnaire was first applied by Osipow et al. in 1987. The questionnaire includes 60 questions with 5 choices (ranging from never to very often). This questionnaire investigates the occupational stress in six aspects of the role workload (determines the individual’s status regarding the job requirements), role insufficiency (determines the balance between one’s skill, knowledge, as well as educational and experimental characteristics in comparison to the requirements of the job environment), role duality (determines one’s knowledge about priorities and expectations of the job environment), range of roles (determines the conflicts between conscience and job requirements), responsibility (determines the responsibility with regard to efficacy and other’s welfare), and physical environment (determines the unsuitable environments one is exposed to). A high score depicts a greater level of role stressor: low (10-19), low-moderate (20-29) moderate-high (30-39) and high (40-50). The total score of the occupational stress questionnaire is also divided into 4 levels of low (50-99), low-moderate (100-149), moderate-high (150-199), and high (200-250).[20]

The validity of this questionnaire was confirmed by Sharifian et al. and its reliability was determined as satisfactory using test-retest. Furthermore, its Cronbach’s alpha coefficient was reported as 0.89.[21]

Statistical analysis

Descriptive (percentage, mean, and standard deviation) and analytical statistics (independent samples t-test, and paired-samples t-test) were used to analyze the data. The Kolmogorov-Smirnov test was also run to assess normal distribution of the data. The level of significance was set at 5% and SPSS 20 was employed for data analysis.

RESULTS

Demographic information

The mean age of all participants was 33.56 ± 5.67 years, while it was 33.55 ± 6.35 and 33.58 ± 4.96 years for the intervention and control groups, respectively. The average work experience was 9.83 ± 6.26 years for all participants, 10 ± 6.37 and 9.66 ± 6.2 years for the intervention and control groups, respectively. According to the t-test, no significant difference was observed between the two groups in terms of age (P = 0.975) and work experience (P = 0.772). The majority of the participants in this study were female (66.9%), were married (62.4), and had Bachelor’s degree (66.8%). Considering employment, most of them were formally employed (15.9%). According to the results of the Pearson correlation, demographic variables were not significantly associated with the occupational stress (P < 0.05).

No significant difference was found between the intervention (193.58 ± 12.08) and control (195.13 ± 11.84) groups considering the mean of total occupational stress at the pretest (0.47). The total pretest stress was at the moderate-high level for both groups.

However, at the posttest, a statistical significant difference was found between the intervention (145. 86 ± 9. 36) and control (198.21 ± 12.26) groups in this regard (<0.001). In other words, CBT intervention had a significant effect on the occupational stress of the intervention group, so that occupational stress improved from “moderate-high” to “low-moderate” in this group. In addition, in the intervention group, means of the all occupational stress dimensions reduced significantly in the post-test. In other words, all the stress dimensions were at the moderate-high level in the pretest, but reduced to the low-moderate level in the posttest, except for the physical environment dimension which remained at the moderate-high level [Table 2].

Table 2

Comparison of the pre-test and post-test results between the intervention and control groups

Variables		Groups		P (between groups)
		Study (n=60)	Control (n=60)
Total stress	Before	193.58±12.08	195.13±11.84	0.47
	After	145.86±9.36	198.21±12.26	<0.001
	P (within group)	<0.001	0.74
Role workload	Before	36.86±3.89	37.36±3.36	0.45
	After	23±2.52	39.18±3.49	<0.001
	P (within group)	<0.001	0.052
Insufficiency of role	Before	31.40±3.28	31.38±3.16	0.97
	After	25.20±2.66	31.48±3.28	<0.001
	P (within group)	<0.001	0.15
Role duality	Before	31±4.76	31.15±4.77	0.86
	After	22.06±3.43	32.05±4.87	<0.001
	P (within group)	<0.001	0.058
Range of roles	Before	3.16±3.61	30.48±3.73	0.63
	After	20.73±3.32	30.66±3.82	<0.001
	P (within group)	<0.001	0.08
Responsibility	Before	31.66±3.35	31.90±3.42	0.70
	After	24.95±4.16	31.96±3.46	<0.001
	P (within group)	<0.001	0.32
Physical environment insufficiency of role	Before	32.48±3.89	32.85±3.50	0.58
	After	32.55±4.01	32.86±3.51	0.64
	P (within group)	0.32	0.32

Data were presented as mean±sd. Independent samples t-test, and paired-samples t-test were used., The level of significance was set at 5%.

DISCUSSION

The purpose of this study was to investigate the effectiveness of CBT on the occupational stress of nurses working in ICUs. The results showed that most nurses reported moderate to high levels of occupational stress in the pretest. In confirmation of our results, studies by Kwiatosz-Muc et al. in Poland, Tajvar et al. in Iran, and Jones et al. in France showed that occupational stress was at a moderate-high level among the ICU nurses[222324]. This level of stress can be due to lack of nursing staff, low salaries, heavy workload and responsibility of patient care, overnight stay, busy ward, limited and closed space of the ICU, alarm noises caused by the devices in the ward, lack of medication and equipment, and importance of prompt response to the emergency situations.[25] Unlike the present study, Mehrabian indicated that the level of stress was low in most nurses.[26] This discrepancy can be due to the fact that Mehrabian investigated the nurses of the public sector.

The results of this research also showed that after the CBT program, mean scores of the occupational stress and all its dimensions were significantly lower in the intervention group than the control group; the means reduced to the low-moderate level after the intervention. However, in the physical environment, the stress remained at the moderate-high level after the CBT. This difference can be justified by mentioning that standardization of the physical environment, including organizational infrastructure, support resources, and amenities is needed to improve the physical stress, and such a goal cannot be achieved by conducting a group psychological intervention.

Shariatkhah et al.,[27] Molla Jafar et al.,[28] and ShahAbadi et al. in 2010[29] stated that cognitive therapy had a positive impact on the nurses’ occupational stress and all its dimensions. Kim et al. in Korea also reported that group therapy intervention reduced the nurses’ occupational stress.[30] These findings can be justified by indicating that CBT uses different types of strategies, such as relaxing, imaging, etc., to decrease stress. It applies common cognitive-behavioral approaches, including cognitive reconstruction, education of coping, effectiveness, expressiveness, and anger management, which can be effective in reducing stress and its symptoms.

In CBT, nurses learn to refuse the ineffective strategies in managing the stressful situations and use the cognitive reconstruction techniques to interpret and understand the stressful events. Therefore, nurses with CBT skills can adapt better to stressful occupational situations.[27]

It seems that the current in-service training programs neither increased the nurses’ knowledge and attitude sufficiently, nor reduced their stress appropriately. This may be due to the lack of targeted training, lack of need assessing, and lack of conducting workshops. The results of some studies indicate that educational programs have a significant impact on stress control skills of nurses if they are based on needs, targeted, and in the form of workshops.[31] Therefore, considering the effectiveness of CBT training program on the nurses’ occupational stress, nurses are suggested to participate in the CBT group programs held through continuous education programs as short-term training courses or workshops. Further studies are also recommended to investigate the impact of CBT on other variables such as job burnout and productivity of nurses. Future researchers are also suggested to examine the nurses working in other parts of the hospital.

One of the limitations of this study was inconsistency of the working plan among the members of each group caused by the time and space constraints. Thus, further studies are recommended to address these limitations.

CONCLUSION

The purpose of this study was to investigate the effect of CBT on the occupational stress of nurses working in ICUs of a hospital in Southeast of Iran. Findings showed that CBT intervention had a positive effect on the nurses’ occupational stress and all its dimensions, except for the physical environment. Since stress and stressors are the integral part of the nursing profession, it is necessary to prevent from the psychological and behavioral effects of stress by holding in-service workshops and training courses for nurses.

Ethical approval

This research was approved by the Ethics Committee of Shiraz University of Medical Sciences (code of ethics: IR.SUMS.REC.1398.753). The participants were explained about the study goals and procedures. They were also ensured about the confidentiality and anonymity of the data as well as the voluntary participation in the study. Informed consent was obtained from all the participants included in the study. This study was carried out in accordance with the Code of Ethics of the World Medical Association (Declaration of Helsinki, 2010).

Declaration of participant consent

The authors certify that they have obtained all appropriate participant consent forms. In the form the participant(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The participants understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Vice Chancellor of Research in Shiraz University of Medical Sciences, Grant number: 97-01-89-18617.

Conflicts of interest

There are no conflicts of interest.