The effectiveness of cognitive behavioral interventions in reducing stress among nurses working in hospitals: a systematic review protocol

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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.

Review question/objective

The specific review questions to be addressed are:

Review question/objective

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?

Review question/objective

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?

Review question/objective

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?

Review question/objective

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

Background

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

Background

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.

Background

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

Cognitive Behavioral Intervention Program

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.

Significance of the review

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.

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