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Applied Nursing Research 25 (2012) 152–157www.elsevier.com/locate/apnr

Are cognitive–behavioral interventions effective in reducing occupationalstress among nurses?

Sarid Orly, PhDa,⁎, Berger Rivka, MDb,Eckshtein Rivka, MMedScc, Segal-Engelchin Dorit, PhDa

aDepartment of Social Work, Ben-Gurion University of the Negev, Beer-Sheva 84105, IsraelbInternal Medicine C Ward, Soroka Medical Center, Beer-Sheva, Israel

cOutpatient clinics, Soroka Medical Center, Beer-Sheva, Israel

Received 1 May 2010; revised 12 January 2011; accepted 17 January 2011

Abstract Despite the growing evidence regarding the effectiveness of cognitive–behavioral interventions in

⁎ Correspondingities and Social Scienc84105, Israel. Tel.: +9

E-mail address: o

0897-1897/$ – see frodoi:10.1016/j.apnr.201

reducing occupational stress, very few studies have examined its effectiveness among nurses. Thisstudy investigated the impact of a cognitive–behavioral (CB) course on the nurses' well-being. Thestudy compared the sense of coherence (SOC), perceived stress (PSS), and mood states of 20 nurseswho had participated in the CB course to that of 16 control participants using a pre–post test design.At baseline (t1), no significant differences were found between the two groups in SOC, PSS, andmood states. The effects within each group controlling for t1 were examined by analysis ofcovariance. At t2, a significant increase in SOC and the mood state of vigor and a significantdecrease in PSS and fatigue were found only among participants in the CB course. The results arediscussed in relation to the conceptual framework of stress and coping theory.

© 2012 Elsevier Inc. All rights reserved.

1. Introduction

Health care professionals are prone to continuous stress aspart of their occupational demands. Occupational stress isdefined as a response to chronic job-related stress,characterized by physical and emotional exhaustion(Maslach & Jackson, 1996; Onder & Basim, 2008) andstress-related disorders. This definition conceptualizes stressas a dependent variable. Other studies looked at occupationalstress as an independent variable. As such, it is defined byjob characteristics, such as workload and work setting.Increased workload (Happell, 2008), intensive contact withdistressed or dependent people, and work in departmentssuch as intensive care and oncology (Casado et al., 2008;McGrath, Reid, & Boore, 2003; Medland, Howard-Ruben,& Whitaker, 2004) are associated with occupational stress.

author. Social Work Department, Faculty of Human-es, Ben-Gurion University of the Negev, Beer-Sheva72 8 647 2337; fax: +972 8 647 2933.rlysa@bgu.ac.il (S. Orly).

nt matter © 2012 Elsevier Inc. All rights reserved.1.01.004

Among the health professions, nursing is considered aparticularly stressful and emotionally demanding job(Grossman & Wheeler, 1999; Jones & Johnston, 2000).The nurses' stressful work situations may cause excessivepsychophysiological responses, mental distress, mood dis-turbances (Healy & McKay, 2008; Piko, 2006), and burnout(Demerouti, Bakker, Nachreiner, & Schaufeli, 2000) andmay also adversely affect the nurses' job performance(Hirokawa, Yagi, & Miyata, 2002) and productivity (Uğur,Acuner, Göktaş, & Şenoğlu, 2007).

Previous studies showed that a number of personalityresources mitigate the effect of occupational stress on nurses'mental health. Among these resources are personalitydispositions such as hardiness (Judkins, Furlow, & Ken-dricks, 2007; Lambert, Lambert, Petrini, Li, & Zhang, 2007)and coping strategies. Coping strategies that have been foundto improve nurses' mental health included practice of self-control, positive reappraisal, escape–avoidance coping, anddistancing (Chang et al., 2006; Lambert et al., 2007). Nurseswho used the above-mentioned coping strategies felt lessanxious and depressed and reported coping better with job-related stressors and increased levels of well-being compared

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with their counterparts (Lee, Song, Cho, Lee, & Daly, 2003).However, results of other studies were equivocal and showedthat avoidance and distraction coping strategies could bluntemotional responses and cause burnout in the long run(Deary, Watson & Hogston, 2003; Mojoyinola, 2008).

One of the personality dispositions associated withreduction of stress is sense of coherence (SOC, Antonovsky,1987). SOC portrays the degree to which a person perceivesthe world and the inevitable stressful events he or sheencounters as comprehensible, manageable, and meaningfulchallenges worth overcoming. Such orientation enablesefficient recruitment of available resources to cope with avariety of demanding situations. High SOC facilitatesflexibility and an increased ability to effectively choose theadequate resources for coping with a specific situation.Indeed, negative relationships between SOC and levels ofanxiety in stressful situations were previously documented(Berger, Sarid, Hurvitz, & Anson, 2009; Carmel &Bernstein, 1990; Chumbler, Rittman, Van Puymbroeck,Vogel, & Qnin, 2004; Heiman, 2004), as well as a negativerelationship between SOC and burnout (Cilliers, 2003).From the above, we can see that emotionally drainingexperiences can cause a psychophysiological burden on anindividual. The prolonged cost of this load is reflected by“wear and tear,” so that over time, the individual graduallyloses the ability to adequately cope with threatening andunpredictable stimulus (Romero, Dickens & Cyr, 2009).

The above findings suggest that nurses' work stress maypose a major challenge for the individual nurse and for thehealth care organization given that nurses' occupationalstress may hamper their productivity (Uğur et al., 2007).Thus, it is possible that when the personnel experience alesser amount of stress, their work will be more productive.Therefore, health care organizations may benefit fromaddressing nurses' well-being. To date, two major types ofintervention aimed at reducing nurses' occupational stresshave been studied. One type of intervention focuses onchanges in organizational culture, management, practices,workforce deployment, and work design to reduce nurses'negative reactions to work stress (Hall, Doran, & Pink, 2008;Ho, Chang, Shih, & Liang, 2009). The second type focuseson individual or group interventions designed to reducenurses' occupational stress bymeans of educational programsand cognitive–behavioral interventions (CBIs). Findingsfrom recent studies show that CBIs are more effective thanorganizational changes in enhancing nurses' ability tomanage stress (Clegg, 2001; Mimura & Griffith, 2003).

The behavioral component of CBI focuses on physicalelements that emphasize relaxation through breathingexercises, autogenic training, and/or progressive muscletraining (Jacobson, 1938). This aims to modify psychophys-iological reactions in the body and thus to reduce theexcitatory effect of stressful situations (Davis, McKay, &Eshelman, 2000; Norris & Fahrion, 1993; Sandi & Pinelo-Nava, 2007). Another component of CBI focuses oncognitive elements aimed at gaining a more balanced

perspective of events (Ellis & Harper, 1975); this includesprovision of information regarding potential reactions tostressors, challenging existing assumptions, learning alter-native interpretations of events, acquiring problem-solvingskills, and developing assertive abilities. Learning andpracticing rational ways of thinking intend to manageanxiety-producing situations by using cognitive restructuringtechniques to intervene on the interpretation of stressfulsituations (Bryant, Moulds, & Nixon, 2003).

Despite the growing evidence regarding the effectivenessof CBI in reducing occupational stress, very few studies haveexamined its effectiveness among nurses in the last decade(see, for example, Cohen-Katz, Wiley, Capuano, Baker, &Shapiro, 2004; Mackenzie, Poulin, & Seidman-Carlson,2006). Furthermore, to the best of our knowledge, no studyin Israel has examined the impact of CBI among nurses intheir workplace. The purpose of this study was to investigatethe effect of CBI on nurses' SOC, perceived stress (PSS), andmood states. To augment the scientific literature in this area,this study focuses on moods as a factor that can influencepersonality resources. We expected to find higher SOC levelsand lesser PSS and negative mood states among nurses in theCBI group compared with nurses in the control group.

2. Methods

The study was conducted in a major regional hospital inthe southern part of Israel. A pre–post test design, withcontrol, was chosen to meet the aims of study. The sampleincluded 36 registered nurses and consisted of two groups. Astudy group, which participated in a CBI course (n = 20), anda control group matched by age, education, marital status,and hospital department (n = 16). The rational for the samplesize was based on the literature on group interventions,indicating that small groups consisting of 15–20 individualsare suitable for psychosocial interventions (see, for example,the review by Sims, 1977).

Nurses in the sample were recruited from several hospitaldepartments using the snowball sampling according to thefollowing criteria: they had at least 5 years of experience innursing and fulfilled both clinical and administrative nursingroles. The latter criterion was based on the assumption thatdual roles lead to increased role strain. The age range of thenurses was 28–60 years (M = 50.6, SD = 10.7), 83% weremarried, 8.3% were single, and 8.7% were divorced. About40% of the nurses were born in Israeli, 42% were born in theformer Soviet Union, and 18% were of Asia–Africa origin.More than 75% of the nurses had an academic degree innursing, and most (98%) rated their economic status as good.

2.1. Procedure

Data were collected at two measuring points: at thebeginning of the study (t1) and 4 months later upon thecompletion of the study (t2). Between these two measuringpoints, the study group participated in a CBI course

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composed of 16 meetings and in five seminars, in whichnursing job-related issues such as responsibility andunpredictability at work, amount of control over work,support at work and outside of work, roles demands, andpossible role conflicts were discussed. Each seminar lasted3 hours.

The CBI course provided theoretical and practicalcognitive–behavioral (CB) concepts (Ellis & Harper,1975; Meichenbaum, 1985). The CBI that was used in thisstudy was based on a variety of CB principles andtechniques and not on a particular theory. The rationale forthe above is that the use of several techniques exposesnurses to a variety of coping strategies, thereby allowingthem to choose the strategies that are most effective forthem. Four-hour meetings took place once a week (wholeCBI course was composed of 64 hours). Behavioralinterventions included teaching and practicing of breathingtechniques and progressive muscle training (Jacobson,1938). Relaxation skills were taught during the 10 meetings.Cognitive elements covered within the meetings includedprovision of information regarding potential reactions tostressors (2 meetings), identification of irrational ways ofthinking (6 meetings), skills for modifying negative ways ofthinking (7 meetings), and acquiring problem-solving skills(10 meetings). Participants were taught to question theirself-defeating thoughts by examining evidence, practicingthe above strategies to reduce psychophysiological aspectsof stress, and rehearsing skills they acquired. Each meetingstarted with a theoretical presentation followed by practiceof the relevant skill(s). The last half hour of each meetingwas devoted to the participants' reflections on the newlyacquired skill.

Nurses in the control group were matched by age,education, marital status, and hospital department. Nurses inthe control group, like the nurses in the study group, hadparticipated in the five seminars mentioned above and didnot receive any additional intervention.

The study was conducted in accordance with theethical standards of the regional ethics committee. Allparticipants provided informed consent, were told thattheir participation in the study was voluntary, andparticipated throughout the study.

2.2. The scales

Based on the findings from the studies described above,the scales were chosen for measuring stress reactions,personality resources, and moods. Data were collected atthe two measuring points (t1 and t2) using a self-administered structured questionnaire.

2.2.1. Personality resourcesThe SOC (13 items, short form; Antonovsky, 1987) was

administered at the two measuring points. The Hebrewversion of the scale was validated by Carmel and Bernstein(1990). Respondents were asked to report, on a 7-pointLikert scale, the degree to which each of the 13 statements

represented their attitudes. Cronbach's alpha was between.75 (t1, study group) and .76 (t2, control group). One scorewas thus calculated in which higher scores indicated astronger SOC.

2.2.2. Transitory mood variables

1. The Perceived Stress Scale (PSS; Cohen, Kamarck, &Mermelstein 1983) measured the degree to whichsituations in one's life are appraised as stressful. Thescale was translated and adopted for Hebrew by Drory(1989). Fourteen items were designed to test howunpredictable, uncontrollable, and overloaded respon-dents found their lives during the previous month.Respondents were asked to indicate how often theyexperienced each item on a 5-point Likert scale,ranging from 0 (never) to 4 (very often). In this study,internal consistency (Cronbach's alpha) ranged be-tween .74 (t1, for both groups) and .75 (t2, controlgroup). Similar results were reported among Israeliparticipants (Lev-Wiesel, 1999). One score wascalculated by adding the 14 items; a higher scorereflects a higher level of PSS.

2. The Profile of Mood States (POMS; McNair, Lorr, &Droppleman, 1971) consists of 58 items that measuretension–anxiety (9 items), depression–dejection (15items), anger–hostility (12 items), vigor (8 items), andfatigue and confusion (7 items each). Participants wereasked to indicate to what extent they felt each itemdescribed their current mood on a 5-point Likert scale.The Hebrew version of the instrument was validatedby Hoffman, Bar-Eli, and Tenenbaum (1999). ThePOMS was administered at t1 and after the course wascompleted at t2. Internal consistencies (Cronbach'salpha) for the study group and the control group rangedfrom .65 (confusion at t1) to .80 (anger, t1) and from.70 (tension–anxiety, t2) to .87 (anger, t2), which weresimilar to what has been reported by McNair et al.(1971). At t1 and at t2, participants were asked to referto their mood during the past week.

3. Sociodemographic information: The sociodemo-graphic questions asked about age, place of birth,level of education, and marital status.

2.3. Mode of analysis

Chi-square tests were carried out to examine differencesbetween the two groups on the categorical demographicvariables. Descriptive statistics was conducted to examinemeans and standard deviations of psychological measures atbaseline. T tests were conducted at baseline (t1) to examinedifferences in psychological variables between the studygroup and the control group. Univariate analysis ofcovariance (ANCOVA) was used to test group effects onthe personality variables and transitory mood states. Wedefined the values of SOC, PSS, and all POMS subscales att1 as the covariates.

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3. Results

The study and the control groups were matched by age,education, marital status, and hospital department. Chi-square tests, carried out to examine differences between thetwo groups on the categorical demographic variables (e.g.,education, marital status, place of birth, and hospitaldepartment), revealed no significant differences.

Mean values, standard deviations, and t tests wereconducted for all psychological variables at baseline (t1).No statistically significant differences of SOC mean valueswere found between the study group and the control group(M = 70.83, SD = 7.67 vs.M = 72.07, SD = 8.9), t(29) = −0.4,ns. No statistically significant differences of PSSmean valueswere found between the study group and the control group(M = 25.4, SD = 3.70 vs.M = 23.6, SD = 4.6), t(33) = 1.8, ns.No statistically significant differences of POMS tensionmean values were found between the study group and thecontrol group (M = 5.8, SD = 2.68 vs. M = 5.68, SD = 2.77),t(34) = 0.17, ns. No statistically significant differences ofPOMS depressionmean values were found between the studygroup and the control group (M = 4.0, SD = 4.6 vs. M = 2.5,SD = 3.9), t(33) = 1.0, ns. No statistically significantdifferences of POMS anger mean values were found betweenthe study group and the control group (M = 5.6, SD = 3.28 vs.M = 7.2, SD = 11.7), t(33) = −0.5, ns. No statisticallysignificant differences of POMS vigor mean values werefound between the study group and the control group (M = 23,SD = 5.11 vs. M = 23.3, SD = 4.17), t(31) = −0.18, ns. Nostatistically significant differences of POMS fatigue meanvalues were found between the study group and the controlgroup (M = 7.4, SD = 5.12 vs. M = 7.4, SD = 5.12), t(32) =1.4, ns. No statistically significant differences of POMSconfusion mean values were found between the study groupand the control group (M = 5.9, SD = 2.4 vs. M = 5.1 SD =2.3), t(33) = 0.94, ns.

ANCOVA was conducted to detect the effect of groupon psychological measures. The effects within each group,controlling for t1, are presented in Table 1. Table 1 alsopresents the means and standard deviations for eachgroup at t2.

Table 1Changes in SOC, PSS, and POMS subscales between t1 and t2: ANCOVAa

testing for group effect (means, standard errors, F)

Scale Study group,M (SD)

Control group,M (SD)

df F (p)(group)

SOC: t2 75.05 (6.7) 69.61 (7.64) 1 10.44⁎

PSS: t2 21.95 (4.63) 23.84 (5.25) 1 6.97⁎

Tension: t2 6.84 (3.11) 5.68 (1.70) 1 0.22 (ns)Depression: t2 4.22 (5.27) 2.64 (3.15) 1 0.31 (ns)Anger: t2 4.0 (2.62) 3.35 (2.43) 1 0.43 (ns)Vigor: t2 25.10 (4.33) 22.20 (3.64) 1 4.30⁎

Fatigue: t2 2.71 (0.70) 0.03 (0.85) 1 5.65⁎

Confusion: t2 5.57 (2.11) 5.53 (1.76) 1 0.05 (ns)a Scores of t2 controlling for t1.⁎ p b .05.

As shown in Table 1, only in the CBI study group,statistically significant changes were detected in four of thepsychological measures at t2: A statistically significantdifference in SOC and vigor has been observed in t2. TheSOC mean value of the study group was 75.05 and 25.10 ofvigor, indicating an increase in t2 in comparison with t1.Only in the study group, PSS and fatigue significantlydecreased at t2. The study mean group of PSS was 21.95 and2.71 of fatigue, indicating a decrease in t2 in comparisonwith t1. No such changes were observed in the control group.No statistically significant changes were detected in fourPOMS subscales: tension, depression, anger, and confusion.

4. Discussion

The present study investigated the effects of CBI groupintervention upon nurses' perceived SOC, PSS, and moodstates in comparison with a control group. Results showedthat only nurses who had participated in the CBI course hadhigher SOC, more vigor, less PSS, and less fatigue uponcompletion of the study. These findings are congruent withprevious findings showing that among participants in the CBcourses, the SOC increased and negative mood statesdecreased upon completion of the course (Berger et al.,2009; Sarid, Segal-Engelchin, & Bitan, 2008). Higher SOCvalues are reported in the literature as an indication of theability to choose the appropriate resources for coping with aspecific situation and were related with an increase in self-reported well-being. Given these findings, it seems reason-able to assume that nurses in the CBI group who reportedhigher values of SOC upon completion of the course felt thatthey were better able to cope with work-related stresses.

Other findings in this study showed that nurses whoparticipated in the CBI group reported a higher degree ofvigor and a lesser degree of PSS and fatigue uponcompletion of the course. These results are comparable toprevious findings showing the positive effect of CBI withregard to the vigor transitory mood (Sarid, Anson, Schwartz,& Yaari, 2008) and reducing PSS level (Berger et al., 2009).High levels of vigor were related with the down-regulation ofthe sympathetic adrenal system. Specifically, increasedvalues of vigor were associated with lower levels of cortisol,a key stress hormone related to a range of pathologies (Sarid,Anson, et al., 2008). The behavioral component of CBI,breathing exercises and relaxation techniques, assist inshifting attention from excessive arousal to regulatoryprocesses (Sarid & Huss, 2010). It could very well be thatthe CBI course increased the nurses' ability to modifypsychophysiological excitatory reactions related to workstressors. That is, it may be that the recurrent training of CBskills contributed to the reduction of PSS and to the increasedlevels of vigor in the second measuring point.

CBI focused on cognitive elements by providing infor-mation about possible reactions to stress. Participants learn torefute dysfunctional way of thinking to manage anxiety-

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producing situations and use cognitive restructuring techni-ques to intervene on the interpretation and thus perceptions ofstressful events (Bamber, 2006). The cognitive componentfocused on the recurrent modulation of disturbing narrativesand memories as the nurses described them. The nurseslearned to shift from physical overexcitation to physicalrelaxation and to alter disturbing perceptions at work bymodifying their interpretations. We assume that through therecurrent practice and implementation of these techniques,the nurses gained CB skills that enabled them to perceivestressful events at work in a more balanced perspective. This,in turn, may have enabled them better coping and adjustmentto stressful work situations, resulting in their increased levelsof SOC and decreased levels of PSS and fatigue. It is possibleto assume that by reducing the nurses' psychophysiologicalstress and acquiring skills to cope with future stress, nursesmay counteract burnout.

In conclusion, we assume that the practice of CBI reducedstress reactions and facilitated cognitive restructuring ofstressful work situations. CBI seemed to modify theexcitatory reaction typical to adrenal–sympathetic response.Reduction of the emotional response was conducted byshifting the attention from the stress-related situation andeliciting alternative ways of interpretations of these situa-tions. Thus, by altering cognitions, it is assumed that nurseswere able to face work-related stress with alternative ways ofthinking. However, it is possible that the dependentvariables, such as depressive mood and anger, were lessprone to the CBI. Possibly, more practice is needed to alterthese moods. In addition, it may be that different practices,such as sport activities, are more effective in alteringdepression and regulating anger.

The results of this study need to be considered with regardto its limitations. First, owing to the small sample size, it isdifficult to generalize the effectiveness of CBI. Despite thesmall sample size, however, the preliminary results clearlyrevealed that the CBI had beneficial effects on the nurses'well-being. Future studies are called to examine the effect ofCBI in larger samples of nurses and other health profes-sionals. Second, the changes observed in the CBI group canbe related to group setting itself, number of meetings, andsocial support. In the CBI group, participants met frequentlyand possibly had more peer support than participants in thecontrol group. However, findings from another studyshowed that the type of intervention, for example, CBgroup versus support peer group, and not the group settingwas linked with the increased well-being of the participants.Only participants in the CBI group showed improvement intheir psychological indices (Sarid, Segal-Engelchin, et al.,2008). Third, it is important to note that although the changesin SOC, PSS, and mood stated may occur spontaneously, it ismore plausible to assume that the acquisition of CB skillswithin the course meetings along with spontaneous practiceof the skills during the program process over the 4-monthtime, as reported by the study group, accounts for thechanges in the second time measurement. We recommend

future research to monitor homework practice and investi-gate the possible long-term impacts of these practices on thenurses' well-being.

Implications of this study point to the important roleclinical researchers have in examining the positive psycho-logical effects of CBI on clinicians, such as nurses. CBIcould enhance the regulation of emotional and cognitivestress symptoms within the work setting. Further research isrequired to investigate the long-term effects of the CB groupinterventions upon nurses and other health professionals.

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