2020 Volume 2 Issue 1
Objectives: To preliminarily determine the effects of an Internet-based cognitive behavioral therapy program for the stress management of new graduate nurses on improving depressive symptoms and other psychological outcomes using a pre-post experimental design. Methods: A 6-week, six-lesson Internet-based cognitive behavioral therapy program was developed through an extensive interviewing of nurses. The program utilized major cognitive behavioral therapy skills (self-monitoring, cognitive restructuring, assertiveness, problem-solving, and relaxation). We administered the Internet-based cognitive behavioral therapy program to participants who were at 5 months after starting their job. At baseline and post-intervention, we measured the primary outcome of depressive symptoms along with the secondary outcomes of psychological distress, dysfunctional attitude, and knowledge of and self-efficacy for the components of cognitive behavioral therapy. Results: Twenty-three new graduate nurses were recruited, although only 21 actually took part in the program. Twelve (57%) participants completed all six lessons, and about one-third of participants completed less than three lessons. At post-intervention, only 12 of the 21 participants had completed the post-intervention survey. The program failed to show significant intervention effects on depressive symptoms, psychological distress, and dysfunctional attitude, but it did show significant or marginally significant improvements in knowledge of and self-efficacy for most cognitive behavioral therapy components. Conclusions: The relatively low intensity of the program may explain the null findings. This suggests a need for further improvement of the content and mode of delivery. Nevertheless, the program was able to improve knowledge of and self-efficacy for most cognitive behavioral therapy components.
The working environment for nurses is stressful1), so they tend to be depressed2,3). Especially, it has been reported that new graduate nurses have more symptoms of depression than experienced ones4,5,6). When new graduate nurses enter a workplace, they face numerous stressful situations, such as an unfamiliar environment, new knowledge and skill requirements, and interpersonal problems with colleagues, all of which can cause sensory overload and lead to self-defeating thinking and feelings4,7). Additionally, new graduate nurses often face “reality shock” — a dilemma between the idealistic values learned in nursing schools and the organizational values of the workplace4,7,8). All of these factors may be responsible for the greater prevalence of depressive symptoms4,5,6). Depression can lead to poor physical health9) and quality of life10), absenteeism11), intention to leave11), and poor quality of care they provide12). This suggests that stress management programs specifically targeting new graduate nurses are necessary.
As for general workers’ stress management, it was reported in a meta-analytic review that depressive symptoms were significantly improved by cognitive behavioral therapy (CBT) interventions13). Also, according to two meta-analyses, CBT- and relaxation-based approaches were effective in reducing work-related stress among workers14,15). The estimated effects (Cohen’s d) of CBT were 0.68–1.16, and those of relaxation were 0.35–0.5014,15). In the nursing setting, a Cochrane review reported that CBT and relaxation significantly improved occupational stress and depressive symptoms among nurses when those were applied as stress management interventions compared to no intervention (standardized mean difference [SMD]=−0.34 and −0.59, respectively, at 6 months follow-up)2). On the other hand, only a limited number of studies on stress management have targeted new graduate nurses. Brunero, Cowan, and Fairbrother (2008) conducted a CBT workshop with 18 new graduate nurses and evaluated the effect of CBT on stress reduction using a pre-post study16). Specifically, they measured nurses’ stress level using the Nurse Stress Scale (NSS) at baseline and at 6 weeks after workshop attendance. They found that the total NSS score did not significantly decrease (p=0.10), but the subscale scores “nurse-doctor conflict” (p=0.03), “death and dying” (p=0.01), and “nurse-nurse conflict” (p=0.02) showed statistically significant improvement at follow-up. Their results support the use of CBT for stress management among new graduate nurses. Notably, however, they did not use a control group or report the effect sizes of their findings. Overall, the amount and quality of research on stress management in new graduate nurses is limited, making further study on this topic highly desirable.
An innovative mode of delivering CBT is via the Internet, also called Internet-based CBT (iCBT). With a highly structured electronic format that consists of educational lessons, homework assignments, and supplemental resources, iCBT provides the same principles and techniques as face-to-face CBT programs17). It has superiority in high accessibility and anonymity, which enable users to access the program anytime and anywhere and review the program contents as many times as they want18). In addition, with iCBT, the barriers to accessing mental health services can be reduced18,19). There are several reasons why new graduate nurses might be good candidate for iCBT. Compared to veteran nurses, new graduate nurses are often stressed about their lack of nursing ability4), which can lead to self-defeating thinking and feelings. Because CBT can change automatic negative thoughts to more realistic thoughts20), it might be useful in altering new graduate nurses’ self-defeating thinking to a more realistic form. Additionally, since most new graduate nurses work in rotating shifts, a program that allows them to learn at any time or place via the Internet would best suit them. Furthermore, since not many nurses, including new graduate nurses, receive face-to-face counseling because of barriers to seek help for mental health3,21), the anonymity of iCBT can reduce possible barriers to accessing mental health services. Despite these clear benefits in using iCBT, no studies have specifically applied such a program to new graduate nurses.
An iCBT program for new graduate nurses in Japan was developed by extensively modifying a previous iCBT program for workers22) to fit new graduate nurses. The objective of this study was to preliminarily determine the effectiveness of this program in improving depressive symptoms and various other outcomes among new graduate nurses with a pre-post experimental design.
This was a pilot study conducted to analyze the outcomes of an iCBT program for new graduate nurses. In this pilot study, a pretest-posttest design without a comparison group was used.
The target population of this study was new graduate nurses (i.e., less than 1 year of nursing experience at work). The iCBT program in this study aimed at primary prevention of their mental health problems. Therefore, those who already had or could have any mental illness were excluded. The inclusion criteria were as follows: (1) have never worked as a registered nurse in another clinical setting; (2) have never worked as a practical nurse in another clinical setting; (3) had not taken 14 days or more of sick leave in total owing to own health problems during the past 3 months; and (4) had not received medical treatment for mental health problems in the past month.
Before beginning this study, we discussed with nursing managers of the target hospitals and found that new graduate nurses had a number of in-hospital training sessions within 4 months after starting their jobs. Therefore, considering burdens and time constraints for them, the iCBT program was provided to the participants who were in the 5th month at work.
All new graduate nurses in four public hospitals (n=31), one university hospital (n=33), and one private hospital (n=5) were recruited by the author directly after an explanation of the study purpose and procedure (for three public hospitals, one university hospital, and one private hospital) or by sending a document containing a full explanation of the study’s aims and procedure (for one public hospital). New graduate nurses who were interested in participating were asked to access the research website and input their baseline information if they agreed to participate. After the baseline survey was conducted, the iCBT program for new graduate nurses was provided. Participants were assessed at post-intervention (immediately after the intervention).
In this study, a six-lesson iCBT program was used for new graduate nurses. The iCBT program was developed by extensively modifying a previous iCBT program for workers developed by Imamura et al. (2014) that was reported to have a significant positive effect on symptoms of depression in a randomized controlled trial (RCT)22). The iCBT program for new graduate nurses was modified on the basis of interviews with nurses so that the content was relevant to and appropriate for the usual working situation and work culture of new graduate nurses. We conducted interviews with thirteen experienced nurses (five men and eight women) working in the chosen hospitals for the purpose of identifying what had been the most stressful situations for them when they were new graduates, along with their thoughts, feelings, behaviors, and coping skills in such situations. We recruited nurses from a variety of wards because we wanted to capture information (e.g., shared experiences, thoughts, emotions, behaviors, and coping strategies) on the more common stressful situations faced by new graduate nurses. Data were collected through semi-structured interviews, which lasted 1–2 hours. Table 1 shows the summary of categorized interview data including some of the important direct quotes. These interviews yielded major common stressful situations — their poor confidence in new knowledge and skills, an unfamiliar environment, and interpersonal relationships with colleagues — and related distorted cognitive patterns. This finding is consistent with a previous study indicating that new graduate nurses experience overwhelming chaos — many new technical skills and personnel, as well as role ambiguity — and sensory overload4,7). Based on these interview data, case stories of the iCBT program were modified with reflecting major common stressful situations (i.e., when entering a workplace, new graduate nurses face stressful situations, such as an unfamiliar environment, new knowledge and skill requirements, and interpersonal problems) for new graduate nurses. Then, we wrote slides of related scenes using Microsoft PowerPoint 2007 and illustration software (Microsoft, Redmond, WA, USA). One of the program’s features was that lessons were provided with stories using illustrations of a psychologist and a new graduate nurse (client) to promote participants’ understanding. These draft contents were reviewed by eight graduate students who had worked as nurses. A trial test was then conducted with six new graduate nurses working in hospitals. Using their feedback, we developed the final, improved version of the iCBT program (Supplementary Figure 1).
ICU, Intensive Care Unit.
The iCBT program for new graduate nurses contained the same stress management techniques as the one for workers. The iCBT program for new graduate nurses consisted of six lessons, which cover different components of CBT: a transactional stress model (lesson 1), self-monitoring skills (lesson 2), cognitive restructuring skills (lesson 3 and 4), relaxation skills (lesson 4), assertiveness communication (lesson 5), and problem-solving skills (lesson 6). Cognitive restructuring is a major standard component of CBT20). Assertiveness is usually a legitimate and honest expression of one’s personal rights, feelings, beliefs, and interests without violating or denying the rights of others23). According to the interviews, new graduate nurses tend to be hesitant to communicate with senior nurses. Hence, assertiveness communication skills were included to the program. Relaxation skills and problem-solving skills, often included in CBT interventions, have shown significant effects on the primary prevention of stress-related outcomes, including occupational stress and depressive symptoms, among healthcare workers2). CBT focuses on not only cognition but also behaviors, including techniques (e.g., assertiveness and problem-solving skills) that actively cope with occupational stress such as excessive workload.
Each lesson was delivered on each Monday during the period. At the end of each lesson, participants were asked to submit homework, in which they apply the learned skills to a nursing situation that they had personally identified as stressful. This homework was voluntary. Participants who submitted their homework received feedback from the first researcher (KK), who was supervised by a clinical psychological researcher (KI). About 30 minutes were necessary for each lesson, including the homework. Participants could learn from the program at any time and place via the Internet, which means iCBT has less time constraints than group training. Although participants were given 10 weeks after the baseline survey to complete these six lessons, if they did not complete a lesson by the next week, they were reminded via email to complete each lesson every Monday.
The Beck Depression Inventory II. The Beck Depression Inventory II (BDI-II) is a 21-item self-report inventory that assesses depressive symptoms, such as sadness, pessimism, suicidal thoughts or wishes, tiredness or fatigue, loss of energy, and loss of pleasure24,25). Each item is scored on a 4-point scale ranging from zero to three. Higher scores indicated more serious depression severity. The Japanese version of the BDI-II was developed by Kojima et al. (2002), who also ascertained its internal reliability and validity26).
Kessler’s Psychological Distress Scale. Psychological distress was measured with the Japanese version of the six-item Kessler’s Psychological Distress Scale (K6)27,28). The K6 is a self-report inventory assessing the frequency with which respondents have experienced symptoms of psychological distress during the past 30 days. Each item is scored on a scale ranging from zero (none of the time) to four (all of the time). Higher scores indicated more severe psychological distress29). The internal reliability and validity of the Japanese version of the K6 are acceptable27).
Japanese version of the Dysfunctional Attitude Scale 24. The 24-item Dysfunctional Attitude Scale (DAS24) is a short version of the DAS, which is a self-report inventory assessing depressogenic schemata. Each item is scored on a seven-point scale ranging from one (totally disagree) to seven (totally agree). Higher scores indicate a more dysfunctional attitude30,31). The reliability and validity of the Japanese version of the DAS24 have been established31).
Knowledge and self-efficacy. Participants were asked to rate their current knowledge of and self-efficacy for the five CBT components of the program (stress management, cognitive restructuring, assertive communication, problem-solving, and relaxation training). Knowledge items began with “How much knowledge do you have about…” and self-efficacy items with “How confident are you that you can do….”. Each item was scored on five-point scale ranging from zero (none) to four (enough). Higher scores indicated greater knowledge of and self-efficacy for performing the CBT components.
Demographic characteristics. The demographic data collected at baseline included age, gender, marital status, education, family members in the same household, workplace, shift-work, and chronic disease.
Mean pre-and post-intervention scores of the main outcomes were compared using paired t-tests. Both intention-to-treat and per-protocol analyses were conducted; for intention-to-treat, missing responses at posttest were replaced with the scores at pretest. The effect size was calculated using Cohen’s d. The value of 0.2, 0.5, and 0.8 are generally interpreted as being suggestive of small, medium, and large effect, respectively32). All statistical analyses were performed with SPSS 21 (IBM Corp., Armonk, NY, USA) for Windows.
The study procedures were approved by the Research Ethics Review Board of the Graduate School of Medicine at the University of Tokyo (10564). All participants were notified that participation in the study was voluntary and that refusal to participate or withdrawal of consent would have no negative consequences for them. After receiving explanation of the study, they were asked to access the website with the baseline questionnaire. Answering the questionnaire was considered indicative of consent. Written consent was not required according to the Ethical Guidelines for Biomedical Research Involving Human Subjects, Japan. Furthermore, the Research Ethics Review Board of the Graduate School of Medicine/Faculty of Medicine of the University of Tokyo approved this procedure to obtain the participants’ consent.
Figure 1 summarizes the flow of participants through the trial. A total of 23 participants (33%) completed the baseline survey. Of these participants, two were excluded because one did not fulfill inclusion criterion 3 (i.e., had not taken 14 days or more of sick leave in total during the past 3 months) and the other did not fulfill inclusion criterion 4 (i.e., had not received medical treatment for mental health problems during the past 1 month). The remaining 21 participants received the iCBT program. At post-intervention, only 12 (57%) of the 21 participants completed the post-intervention survey.
Table 2 shows the characteristics of the participants who completed the baseline survey. Most participants were female, received college education, were shift workers, and had no chronic disease. Most participants lived alone. All participants were single, in their twenties, and were working in wards.
SD, standard deviation.
Table 3 shows the means, standard deviations, and estimated effects of outcome variables at baseline and post-intervention in the intention-to treat analysis. Importantly, the iCBT program had no significant effect on BDI-II scores (p=0.88, d=−0.01).
BDI-II, Beck Depression Inventory II; K6, Kessler’s Psychological Distress Scale; DAS, Japanese version of the Dysfunctional Attitude Scale 24; SD, standard deviation.
Regarding the secondary outcomes, the iCBT program had no significant effects on K6 (p=0.73, d=−0.05) or DAS24 (p=0.48, d=−0.08) scores. However, it had significant (p<.05) or marginally significant (p<.08) effects for all knowledge and self-efficacy variables except self-efficacy for problem solving (p=0.21). The effect sizes for knowledge variable improvements were medium, while those for the self-efficacy variables ranged from small to medium.
Table 4 shows the means, standard deviations, and estimated effects of outcome variables at baseline and post-intervention in the per-protocol analysis. The iCBT program had no significant effects on BDI-II (p=0.88, d=−0.02), K6 (p=0.73, d=−0.10), or DAS24 (p=0.49, d=−0.12). However, it had significant (p<.05) or marginally significant (p<.08) effects for all knowledge and self-efficacy variables, except self-efficacy for problem solving (p=0.21). The effect sizes for knowledge and self-efficacy variables ranged from medium to large.
BDI-II, Beck Depression Inventory II; K6, Kessler’s Psychological Distress Scale; DAS, Japanese version of the Dysfunctional Attitude Scale 24; SD, standard deviation.
Most participants (91%) completed Lesson 1, and 76% submitted Lesson 1 homework. The rate of completing lessons and homework gradually decreased; 12 (57%) completed all six lessons, but only five (24%) submitted the homework for all six lessons. About two-thirds (67%) completed more than three lessons.
The iCBT program for new graduate nurses failed to show a significant intervention effect on depressive symptoms, psychological distress, or dysfunctional attitude. On the other hand, participants improved significantly or marginally significantly in terms of knowledge of and self-efficacy for most CBT components.
The current iCBT program showed no significant intervention effect on depressive symptoms. This contradicts what was found in a previous report on the original iCBT, which had a significant effect on depressive symptoms22). This may have resulted from the lower learning intensity of our program. The proportion of participants who completed all lessons in the current study was lower (57%) than that of the previous study (65%), and about one-third of participants in the current study completed less than three lessons. Another possible explanation is the natural course of stress among new graduate nurses. The target population in this study was nurses in the 5th month at work, who were reported to have less occupational stress and depressive symptoms than those in the 1st month in the previous study4). On the other hand, another previous study reported that the new graduate nurses in the 7th month have greater depressive symptoms than the 1st-month nurses33). This deteriorating trend in mental health among new graduate nurses may have masked any potential intervention effect. Another explanation is the short follow-up period. Post-intervention surveys were conducted immediately after the intervention period. Thus, although knowledge and self-efficacy had improved, participants might not have been able to effectively apply the acquired stress management skills to their workplace situations. This is supported by Van der Klink et al. (2001), who recommended that intervention studies should have a follow-up period of at least 12 weeks13,14). Thus, long-term follow-up could lead to clearer intervention effects34), although this needs to be clarified in a future controlled trial.
The current iCBT program had no significant intervention effect on psychological distress or dysfunctional attitude. However, it did successfully improve knowledge of and self-efficacy for most CBT components. This finding is consistent with those of the original iCBT program22) and many other stress management programs14,15). The lack of any intervention effect on psychological distress is also consistent with the results of the original iCBT program, although the lack of an effect on dysfunctional attitude is inconsistent with these results. Again, this is probably due to the lower intensity of the program — that is, low-intensity stress management programs, in which participants learn less information, may be effective in improving knowledge and skills but not mental health35). Increasing participant involvement in learning may help improve their knowledge and skills along with their mental health.
A useful strategy to increase participant involvement in learning may be to use multiple devices as media for iCBT. The iCBT program in this study could be taken by only PCs, which resulted in the small number of the participants. Some new graduate nurses showed willingness to join this study, but they could not due to the lack of Internet-connected PCs. It may be effective to increase the number of participants if they can take the program via their preferred devices, such as PCs, smartphones, or tablets. The other approach may be incorporating an explanation of the operability and/or the self-assessment of participants’ own psychological health. Low literacy in the use of Internet-based programs and limited feedback on participants’ own status could lead to dropout36,37,38). Detailed explanations of operability and self-monitoring may improve the dropout rate, which is a limitation when applying Internet-based interventions36,37). Improving dropout in Internet-based intervention programs increases the frequency with which users learn the content39), which may be an important determinant of program effectiveness40).
On the other hand, the impact of the working environment of new graduate nurses must also be taken into consideration. After being employed, new graduate nurses have to learn about many topics, such as how to do their job and nursing skills that may not have been sufficiently addressed in their schooling; the qualitative and quantitative burden of this work is large4,5). New graduate nurses are overworked and may become exhausted, depressed, and psychologically stressed. Workplaces should strive to improve the work environment to decrease new graduate nurses’ workload, as well as conducting individual stress management approaches, such as iCBT.
This study has several limitations. First, the number of participants was small. Second, a pre-post design without a comparison group was used. To examine the actual effects of the iCBT program, further studies (especially controlled trials) with sufficient samples sizes and relatively long follow-up periods should be conducted. We will use the results of this pilot study as the basis for randomized controlled studies with sample sizes decided via appropriate power analyses. Third, the dropout rate was high (43%) at the post-intervention survey. In a meta-analysis, the average iCBT dropout rates were reported to be 3–34%18). Although the author sent a reminder to participants’ personal computer email addresses, it might not have been effective. New graduate nurses may not have been in the habit of checking their email on a daily basis. This lack of an effective reminder might have led to the high dropout rates. Also, the excessive workload for new graduate nurses could result in the high dropout rate. In this study, the iCBT program was provided to the new graduate nurses in the 5th month. However, the quantitative burden of their workload usually reaches its peak from the 3rd to 6th month after their work starts41), so they seem not to have had enough time to utilize the program. Therefore, in the future, it is recommended that iCBT programs should be provided to new graduate nurses who have worked for more than 7 months (when the quantitative burden of their workload has passed its peak). Fourth, all outcomes were measured using self-report, which may be influenced by situational factors at the nursing workplace.
The iCBT program for new graduate nurses failed to show a significant intervention effect on depressive symptoms and other psychological outcomes in a pre-post comparison trial, but it did improve knowledge of, and self-efficacy for, CBT. It is critical to improve the contents of the program and mode of delivery to enhance participants’ involvement in program learning.
We would like to express our sincere gratitude to participants and nursing managers for their cooperation. Further, we are grateful to all nurses and graduate students for their contribution to developing the program.
KK, NK, KI, and AS conceived and designed the experiment; KK, NK, and KI performed the experiments; KK, NK, and KI analyzed the data; KK, NK, KI, AS, and MT contributed reagents/materials/analysis tools; and KK wrote the initial draft of the manuscript. All authors have read and approved the final manuscript.
The authors declare no conflicts of interest.
This article contains supplementary material (Appendix), which is available in the online version (doi: 10.1539/eohp.2019-0020-OA).