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   Table of Contents      
ORIGINAL ARTICLE
Year : 2022  |  Volume : 27  |  Issue : 5  |  Page : 377-384

Comparing the effect of resilience skills training and metacognitive therapy on job stress in nurses: An experimental study


1 Nursing and Midwifery College, Birjand University of Medical Sciences, Birjand, Iran
2 Nursing and Midwifery College, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission14-Feb-2021
Date of Decision25-Dec-2021
Date of Acceptance28-Jun-2022
Date of Web Publication14-Sep-2022

Correspondence Address:
Gholamhossein Mahmoudirad
Nursing and Midwifery College, Birjand University of Medical Sciences, Ayatollah Ghaffari Avenue, Birjand, P. O. Box: 9717853577
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijnmr.ijnmr_59_21

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  Abstract 


Background: Nursing is one of the stressful professions. The work-related stressful factors have affected the physical and mental health of nurses seriously. This study aimed to compare the effect of resilience skills training and metacognitive therapy on nurses' job stress. Materials and Methods: This experimental study was conducted on 54 nurses working in intensive care units and the emergency department of Valiasr Hospital, Birjand, Iran, in 2018. Selected participants were allocated via permuted block randomization into three groups: resilience skills training, metacognitive therapy, and control (n = 18 for each group). Both resilience and metacognitive therapy programs were held in eight sessions of 45-mintraining classes twice a week. The control group received no intervention. The data were collected using a demographic characteristics form and the Expanded Nursing Stress Scale (ENSS) before, immediately after, and one month after the intervention. The data were analyzed using Chi-square, Fisher's exact test, Analysis of Variance (ANOVA), and repeated measures ANOVA in the Statistical Package for Social Science (SPSS) software. Results: Job stress significantly decreased in both resilience (F2,51 = 123.5, p < 0.001) and metacognitive therapy (F2,51= 29.2, p = 0.002) groups over time. However, this decrease was not significantly different between the two groups (p > 0.05). Also, the control group's job stress mean score increased over time (F2,51 = 9.35, p < 0.001). Conclusions: The findings suggest that both resilience skills training and metacognitive therapy can reduce the job stress of emergency and intensive care nurses. Therefore, it is recommended that both programs be taken into account by managers to reduce nurses' job stress.

Keywords: Metacognition, nurses, occupational stress, resilience, psychological


How to cite this article:
Hasani H, Zarei B, Danaei Z, Mahmoudirad G. Comparing the effect of resilience skills training and metacognitive therapy on job stress in nurses: An experimental study. Iranian J Nursing Midwifery Res 2022;27:377-84

How to cite this URL:
Hasani H, Zarei B, Danaei Z, Mahmoudirad G. Comparing the effect of resilience skills training and metacognitive therapy on job stress in nurses: An experimental study. Iranian J Nursing Midwifery Res [serial online] 2022 [cited 2022 Sep 29];27:377-84. Available from: https://www.ijnmrjournal.net/text.asp?2022/27/5/377/356046




  Introduction Top


Workplace situations are among the most stressful situations that can harm employees physically or psychologically.[1] Nurses are at the frontline of a health care setting. Thus, they are prone to work-related stress. The nursing profession is complicated, laborious, and has high demands. These demands and other work responsibilities are the main reasons for job stress in nurses.[2] In Iran, the overall prevalence of job stress was estimated to be 60% among nurses.[3] It should be noted that nurses working in intensive care units and Emergency Departments (EDs) may be more likely to tolerate stress. Because EDs are highly dynamic work environments with a high frequency of patients, intensive care units are complex technology-intense, and patients are seriously ill.[4],[5],[6] A previous study has shown that stress can significantly reduce nurses' efficiency in patient care provision.[7] Outcomes of job stress in nurses include psychosomatic disorders, poor mental health, alcohol and drug abuse, absenteeism, fatigue, abandonment, work accidents, impaired ability to provide medical care, and reduced concentration, attention, and memory.[8]

Given the high prevalence of job stress among nurses and its negative effects, it is important to employ strategies to reduce their stress. Alongside this, Meta-Cognitive Therapy (MCT) has gained increasing popularity as a treatment for different psychological complaints such as stress.[9] Historically speaking, Felavell (1979) was the first one to coin the term “metacognition” to denote the process of “thinking about thinking” as well as our knowledge of what we know and what we do not.[9],[10],[11] The theoretical roots of MCT can be traced to the self-regulatory executive function model,[10],[12] which maintains that psychopathology comes to the fore in response to a perseverative thinking style known as the Cognitive Attentional Syndrome (CAS). The CAS, in turn, comprises dysfunctional coping strategies utilized by someone to manage distressful feelings and thoughts, including worry, avoidance, threat monitoring, rumination, strategies to control thought, and reassurance seeking. In the course of MCT, the therapist identifies and attempts to modify metacognitive beliefs and processes associated with the CAS.[13] The metacognitive approach provides individuals with strategies whereby people can free themselves from the mechanisms that result in maladaptive self-control. It also helps them be prepared to encounter threats and injury via flexible emotional training.[9] The literature suggests the efficacy of MCT in mental disorders and symptoms of psychological complaints.[14] De Dominicis et al.[15] (2021) suggest that MCT can be a sustainable and promising program for work-related stress of individuals suffering from chronic work-related stress. They argued that large-scaleRandomized Control Trials (RCTs) needed to be performed to determine the effect of MCT on stress to develop an organized, cost-effective method to help the workforce. Another coping strategy that helps an individual cope with stressful situations is resilience.[16] Resilience denotes an ability to adapt to adversity adaptability and as a form of strength or flexibility in the face of a stressor.[17],[18] A high level of resilience acts as a protective factor, whereas a lower level of resilience increases vulnerability to developing pathological outcomes of adverse environmental events.[19] Ramalisa et al.[20] (2018) argued that nurses need to skillfully develop resilience to deal with challenging circumstances and handle unpleasant feelings and situations. In this line, Hezaveh et al.[21] (2020) found that the resilience program employed in their study was conducive to improving the psychological empowerment of intensive care unit nurses. In Iran, a study by Mirzaeirad et al.[22] (2019) showed that resilience skills training reduces stress in nursing staff. Previous research has suggested that resilience can be incorporated into nursing education to empower nurses.[23],[24]

Some interventions have been designed and used to reduce nurses' work stress in recent years. However, work stress remains an important concern in nursing that affects individuals and organizations.[25] To compare the two programs of resilience and MCT in Iran, we can refer to previous studies by Zamirinejad et al.[26] (2013) on depression of female students and Hasani et al.[27] (2020) on the anxiety of nurses. There was no significant difference between the two groups in the first study, but in the second study, the resilience group showed better results.[26],[27] Nevertheless, there is no research, as yet, to compare the effects of these two programs on the work stress of Iranian nurses. This study had two aims: (1) to examine whether resilience skills training and MCT can improve the job stress of nurses working in intensive care units and emergency departments and (2) to compare the effect of these two programs on the job stress of nurses.


  Materials and Methods Top


This experimental study with a pretest/post-test/follow-up design was performed with nurses working in the ED and intensive care units Newborn Intensive Care Unit (NICU), Pediatric Intensive Care Unit (PICU), and Intensive Care Unit (ICU)) of in Valiasr Hospital, Birjand City, Iran in 2018–2019. The required sample size was estimated to be 18 subjects per group according to a similar previous study,[28] with a confidence level of 95% and power of 90% with an attrition rate of 15%, the sample size increased to 21 subjects per group. Out of 120 nurses working in the units under study, 90 nurses at ED and intensive care units were eligible to participate, of whom 63 nurses were selected through convenience sampling. Inclusion criteria comprised willingness to participate in the study; a minimum of 1 year of work experience; nonuse of neurologic medications in the past 1 month; days off for a maximum of 2 weeks in the previous month; no history of psychiatric or physical illness; lack of a second job; and no severe stress experienced in the past 6 months (e.g., severe accident, death of a relative, or separation from the spouse). Nurses were excluded if they met any of the following criteria: absence for at least two sessions from the training classes; leave from work; work shift changed from intensive care ward and ED to other wards/departments, and simultaneous participation in other stress management workshops. Afterward, the study scales were completed for all the participants through interviews by the main researcher (first author). The participants were subsequently allocated to resilience, MCT, and control groups via permuted block randomization (1:1:1) [Figure 1].
Figure 1: Consort of the study

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The resilience group received resilience skills training presented by the researcher (third author) in eight 45-min sessions held twice weekly from November 2018 to January 2019. The training protocol was derived from Nan Henderson's Resiliency Training Program, developed in 1996 to create safe schools in the United States.[29] The resilience skills training package consisted of self-confidence reinforcement, management of emotions and feelings, coping with stress, anger management, effective communication, problem-solving, decision-making, purposeful, planning to achieve goals, and foresight.[22],[29],[30] The sessions were held in the conference center of Valiasr Hospital. The contents of the sessions are summarized in [Table 1].
Table 1: A summary of resilience sessions

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Similarly, the MCT group received eight 45-min sessions of MCT training based on Wells' metacognitive model[13] held every week. In this program, the training provided in the previous session was first reviewed, and new training was subsequently delivered. Moreover, the questions were answered at the end of each session. Each training session was reiterated once more during the week to allow for the participation of those who could not attend the main session for any reason, including the working shift. The control group did not receive any intervention. The contents of the MCT sessions were based on Wells' guidelines on generalized anxiety disorder, where all individual treatments were performed for group members. The pieces of training were delivered through discussion, lecture, problem-solving, and question and answer. The sessions were held in the conference center of Valiasr Hospital. The contents of the sessions are summarized in [Table 2]. To minimize biases, the intervention implementation and data collecting were performed by two different researchers (third author and first author). Also, the data collector was blinded to the group assignment. In both programs, a separate pamphlet was prepared for each skill. These contents were collected upon reviewing the related sources and studies and approved by six nursing faculty members. The control group received no intervention. However, after completing the intervention, an educational package including contents on resilience and MCT was presented to them.
Table 2: A summary of Wells' MCT* sessions

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The study scales were completed for the participants in the two groups immediately and one month after the intervention through interviews. The data were collected using a demographic form and the Expanded Nursing Stress Scale (ENSS). The items of the demographic form were age, gender, marital status, education, employment type, work shift, work experience, overtime work condition, and domicile. The ENSS was developed by Gray–Toft and Anderson (1981) and is the first tool designed to measure nursing stress rather than generalized job stress.[31] In 2000, French et al.[32] revised it to include stressful situations not included in the nursing stress scale. The final version comprised 57 items rated on a 5-point Likert scale from 1 = never stressful to 4 = extremely stressful and 0 = does not apply. It consists of nine subscales: potentially stressful situations related to death and dying (7 items with a score range of 0–28), inadequate preparation (3 items with a score range of 0–12), uncertainty about treatment (9 items with a score range of 0–36), workload (9 questions items with a score range of 0–36), conflict with physicians (5 items with a score range of 0–20), problems with supervisors (7 items with a score range of 0–28), problems with colleagues (6 items with a score range of 0–24), patients and their families (8 items with a score range of 0–32), and discrimination (3 items with a score range of 0–12). The total score of ENSS ranges from 0 to 228. Higher scores represent more stress. No specific cut-off scores for this scale and subscales have been defined in previous studies.[33] In Iran, previous research on nurses confirmed the validity of the ENSS and reported a desirable reliability coefficient, with a Cronbach's alpha of 0.96.[34] In the present study, the alpha coefficient for the ENSS was 0.81.

The data were analyzed using the statistical package for social science (SPSS) software version 19 (SPSS Inc. Chicago, IL, USA) at a significance level of 0.05. The descriptive statistics, including mean, standard deviation, and frequency, were used to describe the participants' demographic characteristics and their responses to study measures. Given the normal distribution of the data, statistical analysis was performed using one-way ANOVA, Tukey's posthoc test, analysis of variance with repeated measures, Bonferroni posthoc test, Chi-square, or Fisher's exact test.

Ethical consideration

The study was approved by the Ethics Committee of Birjand University of Medical Sciences (BUMS), Birjand, Iran (code: IR.BUMS.REC.1397.193). The study objectives and confidentiality of data management were explained to all participants, and their informed consent was obtained.


  Results Top


Out of 63 nurses participating in the research, three participants were excluded from each group (lack of willingness to continue the research). Finally, 54 participants entered the final analysis (18 for each group). The age means (SD) of the nurses in the resilience, MCT, and control groups were 31.6 (5.4), 31 (5.90), and 31.50 (6) years, respectively. There was no statistically significant difference in the age means between the three groups (F2,51 = 0.06, p = 0.94). Tenure mean (SD) values were not significantly different (F2,51 = 0.05, p = 0.95) across the resilience group (7.50 (6.40) years), the MCT group (7.40 (2.90) years), and the control group (7.50 (1.10) years). There was no significant difference between the three groups in terms of gender, marital status, education, working shift, employment status, ward/department, and housing status (p > 0.05) [Table 3].
Table 3: Comparison of demographic characteristics of nurses in the study groups

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According to [Table 4], statistical analysis revealed that the mean job stress scores had a significant difference between the three groups in the three-time points (p < 0.001). Tukey's posthoc test showed that the stress means score before intervention in the resilience training group was significantly higher than that of the control group (F2,51 = 4.27, p = 0.02). At the same time, it was significantly lower immediately after the intervention in the resilience than in the control group (F2,51 = 6.35, p = 0.002). One month after the intervention, the mean stress scores in the resilience and MCT groups were significantly lower than in the control group (F2,51 = 15.40, p < 0.001).
Table 4: Comparison of the mean scores of job stress before, immediately after, and one month after the intervention in the study groups

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The results showed that the job stress means score decreased in both the resilience and MCT groups over time (p < 0.001), whereas the job stress means score increased in the control group over time (F2,51 = 9.35, p < 0.001). The results of the Bonferroni posthoc test showed that in both resilience and MCT groups, the job stress means score decreased significantly immediately and one month after the intervention compared to before the intervention and one month after the intervention compared to before and immediately. In the control group, the job stress mean score was significantly increased immediately and one month after the intervention compared to the baseline (p < 0.05). [Table 4]

A comparison of mean score changes of job stress in the three groups showed that the scores before and immediately after the intervention and before and one month after the intervention were significantly higher in nurses of the resilience and MCT training groups than the control group (p < 0.001). Also, mean changes in job stress scores were significantly higher in nurses in the MCT compared to the resilience and control groups immediately after intervention and 1 month later (p < 0.001) [Table 5].
Table 5: Comparison of mean score changes of job stress before, immediately after, and one month after intervention in the study groups

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  Discussion Top


This study aimed to compare the effect of resilience skills training and MCT on the job stress of nurses working in ED and intensive care units. The results showed that the mean score of job stress in the resilience group decreased significantly over time. This finding is consistent with the studies of Babanataj et al.[35] (2019) and Mistretta et al.[36] (2018). They reported that resilience training was effective in reducing the stress of nurses working in ICU and health care workers, respectively. A review of research regarding resilience training in an organizational context carried out by Scheuch et al.[37] (2021) revealed that resilience skills training could alter employees' resilience positively.

Furthermore, some evidence from previous research indicated that stress and resilience are correlated negatively.[38] According to McGowan and Murray (2016),[39] individual resilience skills warrant that nurses are successful in their profession and can support themselves in difficult and challenging working conditions. Because resilience can increase positive emotions and decrease negative emotions and feelings,[40] thereby making it easier to cope with difficult living conditions and improve the ability to overcome problems, consequently reducing stress.[40],[41] Werneburg et al.[42] (2018) concluded that increasing one's resilience level and tolerance threshold by shifting perceptions of what is considered stressful can foster one's ability to become aware of reactive stress responses and provide potential choices in their response. Furthermore, establishing resilience by creating psychological acceptance reduces workplace-related stress.[43]

Our results showed that the mean score of job stress decreased significantly over time in the MCT group. Although no research could be found to directly assess the impact of a metacognitive program on nurses' job stress, the results of the following studies can be interesting. Rochat et al.[44] (2018) assessed the efficacy of single-case studies of MCT in a meta-analytic review, reporting that these studies support the therapeutic efficacy of MCT for anxiety, depression, and other psychopathological symptoms. Fisher et al.[45] (2019) found that a brief MCT program could improve emotional distress in adult cancer survivors.

A study by Pournamdarian et al.[46] (2013) indicated a significant positive relationship between stress and all dimensions of metacognitive beliefs. In fact, one of the variables that can play a significant role in perceived stress is metacognition. Most metacognitive theorists believe that when armed with a metacognitive weapon, an individual can easily improve performance by reducing the severity and levels of perceived stress from different situations.[47]

According to the results, the mean score of total job stress increased significantly in the control group over time. This result may be attributed to the repetition of the response to the stress scale in the three-point times. Furthermore, the nature of the stress scale and the internal challenges posed by thinking about its items make it possible to expect such outcomes. It can also be explained that since no intervention was performed for the control group, workplace stressors existed as in the past and made a significant impact over time.

To the best of our knowledge, this is the first study to compare the effect of resilience and MCT training on job stress in nurses working in intensive care units and EDs. We hope that the present study's findings generate new outlooks in the creation and development of job stress reduction interventions for nursing managers and researchers.

The study has some limitations. Therefore, caution should be exercised when generalizing the results to other nursing populations. First, only nurses working in intensive care wards and the EDs participated in the present study. Second, the participants were selected from only one hospital. Therefore, the dissemination of information between the groups may have occurred. Future studies can investigate the impact of these two approaches presented in the present study on other factors such as anxiety, emotional exhaustion, and burnout in nurses.


  Conclusion Top


The findings suggest that both resilience and MCT training programs can alleviate the job stress of intensive care units' and EDs' nurses. The study results highlight possible directions for future research and offer useful insights for job stress reduction programs in health care settings. Nursing managers and policy-makers can implement these two programs alone or as tailored, effective, and low-cost programs for nurses. Also, the results of this study can prepare helpful data for investigators to carry out evidence syntheses, such as meta-analysis concerning the effects of resilience and MCT training on the job stress of nurses.

Acknowledgements

This article is extracted from a master's thesis at BUMS (grant no = 455652). We want to thank all nurses who participated in the study.

Financial support and sponsorship

Birjand University of Medical Sciences (BUMS)

Conflicts of interest

Nothing to declare.



 
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