Authors
- Lai Fong Mok, Annie RN, RM, MN
- Chun Chau, Janita Pak RN, BN, MPhil, PhD
- Keung Chan, David Wing MN
- Ip, Wan Yim RN, RM, BN, MPhil, PhD
Abstract
Review question/objective: The objective of this review is to present the best available evidence for the effectiveness of cognitive behavioral (CB) interventions in reducing stress, preventing burnout, improving mood states, and reducing work absences among hospital nurses.
The specific review questions to be addressed are:
1. What is the effectiveness of CB interventions in comparison to usual care in reducing stress, preventing burnout, improving mood states, and reducing work absences among hospital nurses?
2. What is the effectiveness of CB interventions of different formats (for example, didactic teaching, workshop, role play) in reducing stress, preventing burnout, improving mood states, and reducing work absences among hospital nurses?
3. What is the effectiveness of CB interventions of different intensities (for example, different duration and frequency of sessions) in reducing stress, preventing burnout, improving mood states, and reducing work absences among hospital nurses?
Usual care is defined as either no intervention or general stress management interventions such as massage therapy, yoga, meditation, and mantra.
Background: Nursing is a stressful profession. The main causes of stress include an intense work environment, emotional burdens, a lack of organizational support, and dysfunctional relationships with co-workers.1 Many studies have indicated that work related stress is associated with physical and mental health problems including hypertension, ischemic heart disease, peptic ulcer, asthma, and depression.2-5 It has been estimated that 30% of all work-related disorders are linked to stress.6 Additionally, high levels of stress suppress the body's immune system. A study of 82 emergency (ER) nurses in Singapore reported that their stress levels were high and the IgA and lysozyme levels in their salivary glands were low, therefore indicating a suppressed immune system, when compared to 50 nurses in the general ward.7 Job stress also increases absenteeism which results in higher staff turnover and affects the quality and continuity of patient care.4 The monetary losses associated with stress amounts to 9.2 billion EUR in Europe, 1-1.2 billion EUR in the United Kingdom, and 6.6 billion USD in the United States (USA).8
Stress is defined by Selye as the "physiological response of an organism to any demand for change"9(p.533) and the consequence of the interaction between a stimulus and response.7 Selye's theory of stress and illness also differentiates between "eustress" and "distress". Eustress is a positive response to the environment and facilitates growth; however distress is a negative response that leads to physical and psychological maladaptation.10
In 2003, Mimura and Griffiths undertook a systematic review to assess the effectiveness of current approaches to workplace stress management for nurses.11 Seven randomized controlled trials (RCT) and three prospective cohort studies were identified and reviewed. The studies included 782 nurses working as mental health nurses, registered nurses, student nurses, or care assistants. Of those studies, three were conducted in the USA, two in the UK, two in Taiwan, and three in other European countries. Interventions involved education, role playing, relaxation, music, exercise, humor, and cognitive techniques. Stress levels were measured by the Perceived Stress Scale, Psychiatric Occupational Stress Scale, a modified version of the Nursing Stress Scale, DeVilliers Carson Leary Stress Scale, State Trait Anxiety Inventory, and Maslach Burnout Inventory. In four studies, significantly decreased levels of stress were observed after stress intervention. The mean difference was from -8.5 to 9. No meta-analysis was performed and the quality of research identified was weak. Programs that provided personal support were more effective than programs that used environmental management to reduce stress.31 Managing stress is important asif stress is not well managed, it can develop into burnout with emotional exhaustion, depersonalization, and reduced personal accomplishment.12, 13 Nurses may withdraw from their patients both emotionally and physically, furthermore they may become detached from their job and carry negative attitudes toward patients.13, 14 Their quality of care and service to patient may also suffer.
Numerous studies have indicated that cognitive behavioral therapy is effective in modifying dysfunctional cognitions and improving an individual's ability to deal with stressful events.15-17 Cognitive behavioral therapy is a type of psychotherapy that focuses on modifying dysfunctional cognitions and promoting education of appropriate behaviors for coping with stress and emergent situations.18-21
Cognitive Behavioral Therapy (CBT): In CBT, the person is encouraged to develop and apply adaptive conscious thought and problem solving. The person is taught to recognize and change pathological thinking at two levels of autonomous processing: automatic thoughts and schemas.22 Automatic thoughts are cognitions that appear rapidly in our mind while facing an incident. Unconsciously, people may be aware of the presence of automatic thoughts but do not subject them to rational analysis.22,23 Schemas are the principal beliefs that act as templates for information processing, thereby allowing humans to screen, filter, code, and assign environmental meaning to information.22-24 Previous studies indicated that people with depression or anxiety often experience maladaptive or distorted automatic thoughts.22,23 As a result, these thoughts lead to painful emotions and dysfunctional behavior. These individuals feel hopeless, have low self-esteem, and feel as though they are failures.22 They have automatic thoughts predicting danger, harm, loss of control, and are unable to manage threat. There are errors in their logic for automatic thoughts and cognitive errors in their pathological styles for information processing.22,23,25
Cognitive Behavioral Intervention Program: According to Mercer, the components of a CBT program include cognitive restructuring, problem focused coping, emotion focused coping, the systematic approach, and lifestyle changes.9 For cognitive restructuring, the Activating Event Beliefs Consequences (ABC) model can be used to help individuals understand the distortions and irrational beliefs that increase their stress.26 Individuals are taught to alter their belief system by rewriting their distorted thought into an adaptive coping statement in a daily record. Ultimately, individuals enhance their sense of control and reduce their overall stress level.9 Problem focused coping includes time management that prioritizes and breaks down larger tasks into smaller ones; assertive training to express thoughts effectively without offending others; and monitoring of stress intensity and intervening when individuals become overwhelmed by environmental stressors.9 Emotion focused coping includes diaphragmatic breathing or focusing on visual, auditory or tactile distractions while facing stressors, taking time outs by removing themselves from stressors or by doing other things, and systematic desensitization through the practice of relaxation techniques. In the systematic approach, individuals are taught to identify their stressors. They then generate strategies to change or modify their environment. If the stressor cannot be managed, individuals will also learn skills for managing the emotional impact.9 Finally, lifestyle changes include eating a healthy, well-balanced diet by reducing sugar intake, processed food and caffeine; regular physical activity; adequate sleep; and scheduling pleasant events. These changes are tailored to each individual. The cognitive behavioral stress management program is most often conducted in eight to 16 sessions.9
In 2010, Orly et al. conducted a randomized controlled study to evaluate the effectiveness of cognitive behavioral intervention (CBI) comprised of 16 meetings for cognitive intervention and stress reducing behavioral skills. The authors examined the effect of CBI on the nurses' sense of coherence (SOC), perceived stress, and mood states. A pre-post test was designed for two groups of 36 nurses. This study found that the CBI group had significantly decreased levels of stress and fatigue and significantly increased SOC and mood states. These finding suggest that CBT intervention can decrease stress and increase mood in nurses. The study limitations, however, were not testing the long term effects of CBI, the small sample size, and therefore, the lack of generalizability of the findings.18
Significance of the review: Reducing stress, preventing burnout, and improving mood states are essential to optimize the physical and mental health among nurses. The results of this systematic review will provide vital information for assisting nurses in dealing effectively with the high complexity of their nursing work and job demand.
A preliminary search of the Joanna Briggs Institute (JBI) Library of Systematic Reviews, Cochrane Library, MEDLINE, CINAHL, DARE and PROSPERO databases has already been performed. There is no systematic review report on this topic.
Article Content
Inclusion criteria
Types of participants
This review will consider studies that included nurses working in acute, rehabilitation, convalescent settings and community centers, regardless of gender or ethnicity. Nurses will include enrolled nurses, registered nurses, midwives, nursing officers, advanced practice nurses, and managers.
Types of intervention(s)/phenomena of interest
This review will include studies which apply CBT interventions which includes cognitive restructuring and behavioral stress management.9,26 Programs which are conducted by psychologists, trained healthcare workers or trained nurses, either in groups or individually one on one, will be considered. They may be delivered in either a role play format or through workshops and may be conducted in a one day session or in separate sessions ranging from eight hours to 16 hours.
Types of outcomes
The primary outcomes include stress reduction and improving physiological parameters.
Stress reduction is defined as decreasing levels of stress as measured by subjective methods like self-reported level of stress, for example Perceived Stress Scale27, Psychiatric Occupational Stress Scale28, Nursing Stress Scale29, DeVilliers Carson Leary Stress Scale30, State-Trait Anxiety Inventory (STAI)31. Physiological parameters are defined as a decrease in the blood pressure and pulse as measured by the participants.
The secondary outcomes of interests include burnout prevention, improving mood, and a reduction in sick days.
Burnout prevention is defined as decreasing burnout occurrence as measured by self-reported levels of emotional exhaustion and reduced senses of personal accomplishment, for example Maslach Burnout Inventory32. Mood is defined as the temporary state of the mind with regards to passion or feelings as measured by subjective methods such as self-reported state of mood for example Profile of Mood States33. A reduction in sick days is defined as reducing the number of sick days as measured by comparing the participant's number of sick days to the same period of the previous year.
Types of studies
This review will consider all randomized controlled trials (RCTs) examining the effectiveness of cognitive behavioral interventions. If there is an absence of RCTs, other research designs such as quasi-experimental designs, case control studies, pre- and post-studies, time series studies, and comparative studies will be included.
Search strategy
Using a three-step approach, the search strategy aims to obtain both published and unpublished studies in English and Chinese, beginning in 1960, when CBT was first employed. The first step will be an initial search of the Medline and CINAHL databases to identify keywords used in titles or abstracts. The second step will be an extensive search of all the databases to identify potential articles that fit the review's inclusion criteria by identifying keywords, index terms, and matching subjects. The third step will be a manual search of other study sources or relevant source materials listed below, not included in the search strategies. It will include a manual search of relevant conference proceedings and postgraduate and doctoral dissertations. Online searches of databases and websites such as Google Scholar will also be included to identify other studies related to the area of interest. Additionally, the reference lists and bibliographies of all retrieved articles will be screened for relevant studies.
Electronic databases including MEDLINE, CINAHL Plus, EMBASE, PsycArticle, PsycINFO, Cochrane Central Register of Controlled Trials, SCOPUS, ProQuest (Dissertation), ISI Web of Science, Academic OneFile, Bandolier-Evidence Based Health Care, Scirus.com, and Centre for Reviews and Dissemination (CRD) will be searched from the databases 1960 through January 2014.
Electronic databases to be searched for primary publications written in Chinese include: WanFang Data, China Journal Net, Chinese Biomedical Literature Database, Chinese Medical Current Contents, Hong Kong Index to Chinese Periodical Literature, Chinese Electronic Periodical Services, Chinese Electronic Theses & Dissertations Service, and Taiwan Electronic Periodical Services. The Chinese search terms will be based on the terminology used in Taiwan and China.
The search for unpublished studies or grey literature will include: Dissertation Abstracts International, Netting the Evidence, Digital Dissertations, Index to Theses, Lancashire Care Library and Information Service, Grey Literature Report (via New York Academy of Medicine), NLM Gateway, the Networked Digital Library of Theses and Dissertations (NDLTD), Academic Archive Online, Althealth Watch, and the Agency of Healthcare Research and Quality (AHRQ).
The initial search terms will be:
* cognitive behavioral* therapy or CBT
* stress* and stress management*
* nurses*
* mood
* burnout*
For the search strategy for MEDLINE, please refer to Appendix I.
The initial Chinese keywords to be searched will include:
Assessment of methodological quality
The methodology quality of the eligible studies will be assessed using the Joanna Briggs Institute (JBI) Meta-analysis of Statistics Assessment and Review Instrument (MAStARI).34 Critical appraisal checklists will be used for Randomized Control Trial or pseudo-random samples (Appendix II). Two reviewers will independently assess the methodological quality of the eligible studies. Disagreements between the reviewers will be resolved through discussion or by consulting a third reviewer.
Data collection
Data will be extracted from studies using a standardized data extraction tool from JBI-MAStARI (Appendix V). Two reviewers will independently extract data to ensure data accuracy. Discrepancies between the reviewers will be resolved through discussion. The reviewers will extract information related to the research questions and outcomes. The information will include all study method details, settings, interventions, and population characteristics. If the data is reported as aggregated, combined, or missing, the authors of the publications will be contacted to provide the raw data or to seek their assistance.
Data synthesis
All results will be subjected to double data entry to minimize the risk of errors. For continuous data collected using different scales, the standardized mean differences and their 95% confidence intervals will be calculated, while for continuous data that are collected using the same scale, the mean difference and 95% confidence interval will be calculated for each included study and used as the summary measure of effect. For dichotomous data, relative risk, the odds ratio, and their 95% confidence intervals will be calculated. Clinical heterogeneity of the studies will be assessed by considering the settings, populations, interventions, and outcome measures. If appropriate, quantitative results will be combined into a meta-analysis using the JBI-MAStARI. The statistical heterogeneity of the combined studies will be tested using chi-square tests. A fixed effect model will be applied for pooling if there is no evidence of clinical or statistical heterogeneity between studies, while a random effect model will be used in the case of statistical heterogeneity in the absence of clinical heterogeneity. If statistical pooling of the result is not possible, the finding will be presented in narrative form with tables and figures to aid in data presentation where appropriate. A funnel plot will be used to examine asymmetry to determine whether the review is subject to publication bias. If there is asymmetry, reasons other than publication bias will also be considered, such as language bias. A sensitivity analysis assessing the impact of unpublished studies and studies with a high risk of bias will also be performed to address heterogeneity if appropriate.
If possible, subgroup analysis with the available data will be undertaken to determine the effectiveness of CB interventions on stress reduction in subjects of different gender, age, and ethnicity.
Conflicts of interest
The reviewers of this systematic review do not have any type of conflict of interest.
Acknowledgements
None
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Appendix I
Searching strategy for MEDLINE
1. exp. Behavior Therapy, Cognitive
2. exp. Stress, Psychological
3. stress management. mp
4. stress reduction. mp
5. mood. mp
6. exp. Affect
7. exp. Burnout, professional
8. 2 or 3 or 4 or 5 or 6 or 7
9. nurs*
10. 8 and 9
11. limit 10 to (yr= "1960-2012")
12. from 11 [mp=title, original title, abstract, name of substance word, subject heading word] [Context Link]
Appendix II
MAStARI appraisal instrument for randomized controlled trial/pseudo-randomized trial
Reviewer _________________ Date _____________ Record No. _____________
Article _______________________________________________________________
_______________________________________________________________
Comments (including reasons for exclusion)
________________________________________________________________________________________________________________________________________________________________________________________________________________________________ [Context Link]
Appendix III
JBI data extraction form for experimental/observational studies
Study results
Keywords: cognitive behavioural therapy or CBT; stress and stress management; mood; burnout; nurses