Abstract
BACKGROUND:
Nurses working in hospitals can suffer from occupational stress due to high workloads and low job and/or personal resources. This can lead to work-related stress, exhaustion, health problems, and low quality of care.
OBJECTIVE:
The aim of the study was to evaluate the effectiveness of work-related self-care skill training for nurses.
METHODS:
A pilot study was conducted with 94 nurses in hospital departments in Germany. Nurses were either assigned to the intervention group that received competence training or to a waitlist control group. The intervention took place in groups over a period of 12 weeks. Training content included i.e. work-related stress management training, problem-solving techniques, and solution-focused counselling. The outcomes studied were changes in work-related stress, emotional exhaustion, emotion regulation, and job satisfaction. Three follow-up assessments were arranged.
RESULTS:
Nurses in the IG achieved a decrease in perceived job stress and emotional exhaustion as well as improvements with regard to enhanced emotion regulation skills. The intervention was evaluated with high satisfaction scores.
CONCLUSIONS:
This study showed first indications that training of mental health self-care skills for junior nurses could be a supportive approach for nurses starting work in hospital departments. However, replication studies are needed to verify the results.
Introduction
Starting the first job after nurse education is associated with very intense job demands and emotional challenges. Working as a nurse in the hospital setting is characterized by a need to deal with long and irregular work hours, pain, emotional drain, conflicts, as well as caring for patients and providing support to families. These new nurses often have limited supervisory support [1]. The work demands put junior nurses at risk to stress-related strain. Worries about long-term mental health status and work ability are increased if there is low perceived feedback on individual performance [2–4].
Nurses have been experiencing increased stress related to factors such as staffing shortages, in-creasingly complex patients, corporate financial constraints, and technology innovations. Stress can affect attention and memory. Disruption in attention increase the risk of serious negative patient consequences such as medication errors, failure to recognize serious or life-threatening signs, and other essential safety concerns [1].
In summary, it can be said that the working environment, the requirements, and the associated job demands on nurses and caregivers are well analysed. However, very little research has been done on training for psychosocial skills to help nurses cope with work demands and challenges in the early years of their clinical work. Junior nurses are vulnerable for mental health issues (i.e. symptoms of anxiety, depression) [5]. Practical mental health promotion interventions are needed, including support groups, coaching, and the teaching of resilience and stress management skills. The main objectives of such health interventions are to improve and support the individual and team skills of caregivers as well as coping strategies for coping with the daily work demands, different work situations, and the balance between areas of life. The effectiveness and success of mental health promotion programs have been demonstrated in various research evaluations. Research studies on stress management interventions have shown improving the individual coping skills of employees leads to less stress in the workplace, higher job satisfaction and better job performance, and improves the level of anger and depressive symptoms among employees [6–8].
As mentioned above, the working context of nurses often requires them to deal with serious problems. Such situations are often accompanied by strong negative emotions and require effective coping strategies to regulate these emotions. However, in research on mental health interventions for health professionals, this focus on emotion regulation remains largely untargeted.
Established theoretical models, such as the Laza-rus’s transactional model of stress [9], are included in many concepts of mental health promotion interventions. The Lazarus’s transactional model of stress postulates two coping strategies: 1) problem-focused coping and 2) emotion-focused coping. Problem-focused coping is used to actively influence a stress situation positively through cognitive or behavioral efforts. Coping with everyday work problems has been successful in reducing mental health and physical health problems [10, 11]. Emotion-focused coping is primarily used to deal with demanding emotions such as anger, frustration, disappointment, and sadness in relation to the specific situation [12].
No study was found that focuses on psychosocial skill training/ mental health promotion for young nurses starting their careers in hospital departments. However, it is very important to support the participants in coping with the daily demands and challenges. For them, many new demands and activities in a hospital department can contribute to being overwhelmed, and to developing a feeling of role confusion. Another common complaint is the lack of social support, communication, and sharing of experiences and feedback among nurses. Nurses’ training generally focuses only on the acquisition of clinical skills, while formal training focuses little or not at all on the development of psychosocial coping skills or self-care.
This innovative training of psychosocial skills for young nurses can help to bridge the gap between the high demands of work and the needs of young nurses, while providing opportunities to develop professional skills. This goal is the reason for why we initiated the pilot program for young nurses starting careers in hospital departments.
Aim of this study
The aim of this exploratory study was to find out whether a training program for development of psychosocial skills of nurses working in hospital departments improves individually perceived work stress and emotional exhaustion. As a secondary objective, we investigated how training influences the job satisfaction of nurses.
Main research hypotheses: Nurses in the intervention group will score significantly lower in perceived work stress and emotional exhaustion after the training compared to those in the control group (CG). Nurses in the intervention group will score significantly higher in emotion regulation skills after training compared to the nurses in the CG group.
Methods
Study design
This innovative pilot study for nurses was designed as a 2-arm randomized controlled trial. Junior nurses working in hospital departments in Germany were randomized into two groups (intervention group and waitlist control group).
Recruitment and participants
A total of 120 nurses recruited from various hos-pital departments in Germany were potential participants in the pilot study. They were invited by e-mail and/or direct communication to participate voluntarily. Of the total, 98 nurses wanted to participate, proved eligible to participate, and were included in the randomization. Inclusion criteria were: (1) regular access to the Internet, (2) full-time employment in a clinic, (3) a maximum of two years of work experience (junior nurse), (4) availability and willingness to participate during the 36 weeks, (5) agree to complete the questionnaires, (6) no previous knowledge or experience with mental health promotion training.
Every participant gave written informed consent and attended an introductory session where each person had the opportunity to individually ask questions. The total sample consisted of 94 German speaking, employed junior nurses (Fig. 1).
Randomization
After answering the baseline questionnaire (t0) participants were randomized with the ratio 50% : 50% to the two study groups (IG or CG). The randomization process was accomplished with a computer generated list of numbers. This list was created by an independent research assistant; another assistant was blinded to the list, securing covered distribution to research conditions.
Intervention
The intervention group was offered psychosocial competence training combined with cognitive behavioral and solution-focused counselling. The content of the training was specifically designed to meet the needs of junior nurses. The main focus was on current work situations and the problems of junior nurses, coping strategies, resilience and self-efficacy training, and the development of a support system among colleagues.
We structured four training groups. Two qualified psychotherapists conducted the training sessions. Both psychotherapists were registered and accredited as psychotherapists. They had training in cognitive behavioral therapy, systemic therapy, and solution focused brief therapy.
The pilot intervention was based on Lazarus’s transactional model of stress, including strategies for coping with work stressors: problem-coping and emotion-oriented coping [9]. The intervention contained elements of the cognitive behavioral therapy approach and the solution focused approach. There is considerable evidence of the effectiveness of cognitive behavioral therapy (CBT) in managing mental health problems [13]. The solution-focused counselling approach is based on solution-focused therapy by Steve de Shazer and Insoo Kim Berg [14] and has recently gained an increased popularity among a wide range of professionals in various fields. It has been established in various healthcare settings and has shown positive effects in reducing stress-related responses [15, 16].
The training consisted of 12 weekly sessions of 1.5 hours. Training sessions included theoretical input, watching videos, oral group discussions, experiential exercises, and home assignments.
An overview and description of the training sessions follows.
1. Unit Introduction: opening remarks, psycho-educational information & data, and discussion on the theme of working as a nurse in hospital
2./3. Unit Module on diverse problem-solving techniques: work-related problems and strategies to solve problems in the working context
4./5. Unit Module on emotion regulation techniques: cognitive strategies and relaxation techniques (muscle and breath relaxation, acceptance and tolerance of emotions, and effective self-support)
6./7. Unit Module on conflict management at work: conflict types and conflict handling in the hospital setting
8. Unit Module on planning for the future: looking for supervision and feedback on one’s own job performance
9. Unit Module on communication for nurses: how to improve communication in the hospital setting
10. Unit Module on organizational hospital culture: hospital culture, how to report mistakes to supervisors, and dealing with mistakes
11. Unit Module on social support: how to use social support in the hospital, how to speak up to supervisors, handling difficult work situations
12. Unit Overall training evaluation by the participating nurses
Module: Psycho-educational information
During the first session, the nurses received psy-cho-educational information about stress based on Lazarus’ transactional model of stress [9] and basic information on stress. This session was designed to prepare nurses with general knowledge of coping methods (emotion-focused and problem-focused coping strategies) and more specific coping strategies for work-related problematic situations. Subsequently, the nurses identified personal goals, work-related stressors, and motivation for training participation.
Module on problem solving techniques
In sessions 2 and 3, the nurses worked on problem-solving techniques. This module was based on sol-ution-focused therapy [14]. The participants learned a systematic six-step problem-solving method that can be applied to an individual’s problems. Typical scenarios for work-related stress in hospitals were presented.
Module on techniques of emotion regulation
The nurses worked on modules for emotion control and emotion regulation. Techniques include muscle and breath relaxation, acceptance and tolerance of emotions, and effective self-support. The techniques were presented using examples of emotional reactions related to the typical work context.
Module for planning for the future
The participants were asked to develop a plan for the future. They were also asked to strengthen something important in their lives and to imagine life after completion of the training modules.
The CG group was asked to complete all surveys. The CG group received no intervention on mental health and did not undertake anything comparable to the intervention, e.g. any other training in psychosocial skills, counselling or therapy.
Assessment procedure
All nurses were asked to complete an online survey before the randomization process (T0, baseline assessment). Results were evaluated after the intervention (T1, 12 weeks after baseline assessment (BA), after 24 weeks (T2), and after 36 weeks (T3). All measurements were conducted as self-reports using a secure and widely used external online survey collection service. Links to the surveys were sent by e-mail directly to the nurses.
Measurements
The outcome variables included Nurses’ perceived stress, Nurses’ emotional exhaustion, Nurses’ emotion regulation skills, and Nurses’ job satisfaction.
These outcome measures were rated by using the Perceived Stress Questionnaire (PSQ), Copenhagen Psychosocial Questionnaire (COPSOQ), Maslach Burnout Inventory (MBI), and Emotion Regulation Skills Questionnaire (ERSQ-27).
Primary outcome measure
The main outcome was the level of perceived stress measured by the Perceived Stress Questionnaire (PSQ) [17]. The scale includes a number of direct queries about current levels of experienced stress, feelings, and thoughts during the last month. As this scale was developed on the Lazarus’s transactional model of stress, it fits well with the theoretical basis of the study intervention. All items of the PSQ can be answered with a 4-point rating scale (1 = almost never, 2 = sometimes, 3 = often, and 4 = usually) and all answers refer to the time period of the last month. Higher scores indicate a higher stress level as perceived by the participant [18]. Cronbach alphas for the PSQ have been reported to range from α = 0.75 to 0.90 [17] and was α = 0.81 at baseline analysis in this study.
Secondary outcome measures
Work-related mental health
We assessed work-related mental health emotional exhaustion by using the subscale of the Maslach Burnout Inventory (MBI-EE) (5 items; range 1-6; α = 0.86). Emotional exhaustion is defined as a feeling of being emotionally overextended and describes a chronic state of physical and emotional depletion resulting from excessive job and/or personal demands and continuous job related stress [19, 20].
Psychosocial skills
We used the Emotion Regulation Skills Questionnaire (ERSQ-27) to assess emotion regulation in terms of comprehension (-C), acceptance (-A), and self-support (-SS) (9 items; range 0–4; α = 0.84, 0.82, 0.81) [21].
Other measures
A survey was conducted to assess the satisfaction of the nursing staff with the training. The survey included questions on self-perceived training outcome and training design (e.g. practice transfer of skills and techniques learned). Nurses were asked to respond on a scale of 1 (‘totally disagree’) to 5 (‘totally agree’). In addition, nurses were asked to give a grade as an overall course evaluation (1-very dissatisfied to 5-very satisfied).
Statistics
At the beginning, descriptive analyses were carried out for the baseline measurement. Using t-tests and chi-square tests, it was checked whether IG and CG differed in the mean values of the socio-demographic factors and the outcome measures (e.g. job satisfaction). In addition, the group samples were analyzed according to drop-outs. The normal distribution was checked with the Shapiro-Wilk test. The outcome measurements (perceived stress, job satisfaction etc.) were assessed at baseline and at three follow-up points in time for both groups with t-tests and ANCOVA. Cohen’s d with 95% confidence intervals (CIs) was calculated. According to Cohen [22], the following standardized effect sizes were considered: d = 0.2 was considered a small effect, d = 0.5 a medium effect, and d = 0.8 a large effect [22]. In addition, the p-values shown were statistically corrected for multiple comparisons. A two-tailed P < 0.05 was considered statistically significant. IBM SPSS Statistics Version 23.0 was used to perform the analyses.
Sample size
Since the current evidence base for work-related self-care skill training for nurses is limited, we expected little impact. Sample size estimation and power analysis showed that a sample size of 70 in both groups yields a power of at least 80% to detect standardized mean differences above 0.5 on a normally distributed variable (based on an alpha of.05; sample size calculation for t-tests). However, these sample size considerations could not be met; it was not possible to reach the number of nurses participating. Consequently, this study should be interpreted as a feasibility study, which will raise awareness and interest in further research in this area.
Results
Sociodemographic data
The demographic variables for all study participants are shown in Table 1. 78% of the nursing staff in the intervention group were women (n = 36); in the control group 71% were women (n = 33). The average age for all participants was 23 years (SD = 2.5). All nurses were full-time employees; their average work experience in hospital departments was 1.1 years (SD = 1.3). Baseline data on socio-demographic differences indicated only small, insignificant differences between intervention and control group (P > .05). Regarding the sociodemographic data, there were no significant differences between dropouts and those nurses who participated in all three measurements.
Baseline characteristics of the study participating nurses
Baseline characteristics of the study participating nurses
There was an overall drop-out rate (from randomization to analysis) of 12%. 10 participants decided to terminate the study (reasons included illness, non-appearance of participants) and did not answer the questionnaires.
Overall, four of the 94 participants at T1, 6/94 of participants at T2 and 4/94 of participants at T3 did not provide all follow-up data on the results. The participants who did not provide all follow-up data did not differ in any meaningful way, either in the primary outcome or in other baseline outcomes (P > 0.05), from those who provided data.
Outcome analyses
As shown in Table 2, a significant effect indicated that lower scores for perceived stress were present for the IG at T1 (F = 16.62, P < 0.001), T2 (F = 12.02, P < 0.001) and T3 (F = 9.42, P < 0.01). Large to Medium between-group effect sizes were observed at T1 (d = 1.0), T2 (d = 0.7) and T3 (d = 0.6).
As shown in Table 2, statistically significant positive improvements were found in emotional exhaustion and some emotion regulation skills (P <0.05) with small to medium effect sizes (d = 0.3–0.5). Job satisfaction showed no significant changes between baseline and follow-ups (P > 0.05).
ANCOVA analyses results
ANCOVA analyses results
IG-intervention group; CG-comparison group; n.s.-non significance.
The evaluation results show an overall training satisfaction score of M = 4.85. Satisfaction with the training design was scored with M = 4.51. Training atmosphere achieved high rates (M = 4.25). Recommendation of the program was M = 4.69.
Discussion
The main focus of this pilot study was to evaluate the effectiveness of psychosocial skills training for junior nurses working in hospital departments. To this end, a two-arm, controlled randomized trial was conducted. The results indicate that the pilot training has shown initial evidence of a reduction in the level of stress and emotional exhaustion of nurses and an improvement in the nurses’ ability to regulate emotions. An exclusive feature in the present intervention study were the multidimensional, innovative training elements (e.g. counselling combined with stress management training).
As far as we know, this was the first randomized controlled trial on the training of psychosocial skills of junior nurses working in hospital departments. Previous randomized controlled trials evaluated psychosocial skill training and mental health promotion programs conducted in other types of work environments.
Equivalent research studies on this topic confirmed mixed between-group effects for stress reduction at follow-up tests, ranging from non-significant to moderate effect sizes. Ruotsalainen et al. specified in their review that there is little evidence of low quality for intervention studies that include cognitive-behavioral training as well as mental and physical relaxation to reduce work stress more than no intervention, but not more than alternative interventions [23, 24]. However, comparison is somewhat limited because it is a multi-component work-related self-care training combining elements of counselling and cognitive behavioral training. The main focus was on the actual work situation of the nurses, the problems, coping strategies, support between colleagues, and goals for the future.
The long-term reduction in perceived work stress after such training can be explained by the active and continuous practice of coping skills, improved regulation of conflicts and emotions, as well as better communication skills [25]. In addition, training competencies in mental health can support the resilience of nurses by developing skills and self-confidence. These insights can lead to behavioral changes that may also affect the quality of patient care [26]. Moreover, significant medium to large between-group effects were found for emotional exhaustion, anxiety, and emotion regulation competencies.
Previous studies that focused on these outcome parameters showed comparable results. For example, mindfulness training interventions for nurses reported improvements in emotional exhaustion and perceived stress at work [27, 28]. In addition, a comparable integrative self-care program for healthcare workers was conducted and evaluated, which showed significant effects on mental stress, fatigue, and stress perception [29].
The current study result did not show any significant improvements in the job satisfaction of nursing staff after participation in the training. This result was unexpected. However, previous studies verified this finding, which showed no or only very small effects of mental health promotion interventions on the perception of job satisfaction among employees [24, 30–32]. It can be assumed that the training content was not directly aimed at improving the job satisfaction of nurses.
Practical implications
The training of psychosocial skills for nurses is feasible. A plan for nurses to learn protective coping techniques and skills integrated in the work process could be a future benefit for hospitals. The participating nurses reported a certain degree of awareness and reflection regarding the stressful and challenging nature of daily work demands for the role of a professional nurse. The transfer of this training concept to other hospitals or medical disciplines seems possible. The training is adaptable, cost-effective, and could easily be integrated into training settings without enormous financial or organizational effort.
Strength and limitations
This study evaluates an innovative training of psychosocial skills for young nurses working in hospital departments. The strength of this study is the randomized, controlled study design. The number of follow-up examinations can be considered satisfactory for research on workplace intervention.
A limitation of this pilot study is its small sample size, which limits general conclusions and the external validity of the study results. At the beginning of the study a power calculation was carried out. However, we could not achieve the appropriate sample size in this pilot study We tried to get the highest number of nurse participants. Therefore, this study should be considered a pilot study, raising interest in this topic and in further research.
The follow-up measurements included three follow-ups over a period of only 36 weeks; therefore, our ability to measure the long-term effect of the intervention is limited. A combination of varied self-reporting measurements with physiological and other objective performance assessment measurements would provide valuable results and implications.
There is a potential for positive bias within the study group because the participants were motivated to learn new skills and practice coping techniques. Furthermore, there could be a potential bias in the results because just being in a group of people with similar working conditions might have played an important role in the results.
Conclusion
This study provides initial evidence that psychosocial skills training could promote mental health for junior nurses. Overall, the participating nurses were very satisfied with this intervention. Further studies are needed to validate the effectiveness of the mental health training for (junior) nurses. The results show first indications that this training could be a valuable support not only for nurses but also the health sector in general. A training program for psychosocial skills such as this one is generally adaptable and could easily be integrated into several hospital departments. The training we are presenting is practical and feasible.
Conflict of interest
None to report.