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the effectiveness of stress inoculation training in reducing stress on intensive care nurses aufa putri suryanto ilham nur alfian faculty of psychology universitas airlangga keywords stress inoculation training coping skill ...

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                       The Effectiveness of Stress Inoculation Training in Reducing Stress 
                                                            on Intensive Care Nurses 
                                                           Aufa Putri Suryanto, Ilham Nur Alfian 
                                                            Faculty of Psychology, Universitas Airlangga 
                     Keywords:      Stress Inoculation Training, Coping Skill, Deep Breathing, Cognitive Reframing 
                     Abstract:      Nursing is a highly demanding job with many responsibilities. Intensive care nurses have more complex 
                                    responsibilities, as they must deliver intensive care for critical patients. This condition puts them at risk of 
                                    experiencing high stress. This study aims to measure the effectiveness of Stress Inoculation Training (SIT) 
                                    in  reducing  stress  on  intensive  care  nurses.  SIT  aims  to  help  individuals  to  develop  personal  coping 
                                    strategies and improve their confidence in facing stressful situations. This is a quasi-experimental study with 
                                    an experimental one-group pretest/posttest design on 13 subjects. Perceived Stress Scale (PSS-10) is used in 
                                    this study to see the degree of stress experienced by the subjects. The data analyses are Wilcoxon Signed-
                                    Rank Test and effect size by Cohen. The analysis results show that SIT has a medium effect in reducing 
                                    stress on intensive care nurses. There is a decrease of stress according to mean scores. This research can be 
                                    developed further to design a stress management program for nurses 
                     1              INTRODUCTION                                      their  patients.  This  issue  might  be  associated  with 
                                                                                      the  fact  that  there  are  understaffed  facilities, 
                     Clinical  nurses  who  work  in  various  healthcare             therefore giving the nurses less time to care for each 
                     facilities play a major part in the healthcare system.           patients. This might also happen due to managerial 
                     Nurses have the responsibility to manage a patient’s             or legal issues (Corley, et al., 2005). 
                     healthcare  regimens.  In  many  types  of  research,                Aside from their professional issues, nurses can 
                     nursing  is  said  to  be  a  highly  demanding  job,            also  experience  stress  from  daily  and  personal 
                     especially in the last 25 years (Hersch, et al., 2016).          problems. They might have interpersonal issues with 
                         Nurses have long working hours. They also work               their  colleagues  or  family.  They  might  also 
                     in  shifts.  This  issue  can  be  stressful  for  nurses,       experience role conflict, in which their professional 
                     especially in understaffed facilities (Edwards et al.,           roles  conflict  with  their  personal  roles  at  home. 
                     2000;  Corley  et  al.,  2005).  This  issue  also  makes        These  issues  can  also  be  stressful  for  nurses 
                     nurses deal with many patients directly. This means              (Edwards et al., 2000; Khamisa et al., 2017). 
                     they also deal with unpleasant patients and it can be                Intensive care nurses are slightly different from 
                     a  stressful  experience  for  them  (Edwards,  et  al.,         general  nurses  as  they  have  more  complex 
                     2000).                                                           responsibilities. They are responsible for delivering 
                         On the other hand, there are times when nurses               intensive care for critical or terminal patients. This 
                     experience a close emotional relationship with their             issue might increase the tendency of intensive care 
                     patients. This kind of relationship can be burdening             nurses to experience more stress (Kristanto, et al., 
                                                                                      2009). 
                     for  them  when  the  patient’s  condition  worsens  or              It  can  be  concluded  that  nurses  are  at  risk  of 
                     when  they  pass  away.  Nurses  must  communicate               experiencing high stress. Stress itself is experienced 
                     this  news  to  their  family,  which  can  also  be  a          by individuals by appraising situations around them. 
                     stressful  experience  (Corley  et  al.,  2005;  Rai  &          They  will  feel  stressed  when  they  perceive  the 
                     Tauheed, 2013; Hersch et al., 2016).                             situation as threatening or more than what they can 
                         Nurses  might  experience  moral  distress  in               handle (Lazarus & Folkman, 1984). 
                     several situations. They feel strained psychologically               Stress  that  is  not  well-managed  can  have 
                     when they are unable to deliver optimal service to 
                                                                                      negative      consequences       in     nurses’     lives. 
                     168
                     Suryanto, A. and Alfian, I.
                     TheEffectiveness of Stress Inoculation Training in Reducing Stress on Intensive Care Nurses.
                     DOI: 10.5220/0008586801680173
                     In Proceedings of the 3rd International Conference on Psychology in Health, Educational, Social, and Organizational Settings (ICP-HESOS 2018) - Improving Mental Health and Harmony in
                     Global Community, pages 168-173
                     ISBN: 978-989-758-435-0
                            c
                     Copyright 
 2020 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved
                                                               TheEffectiveness of Stress Inoculation Training in Reducing Stress on Intensive Care Nurses
                     Professionally,      stress     might      reduce      their      SIT is capable of reducing stress through the change 
                     productivity. It might reduce the quality of patients’            in the clients’ cognition. When the clients undergo a 
                     care. There might also be impaired achievements in                cognitive     change,     their    perspective     towards 
                     nurses’ work performance (Fernández-Castro, et al.,               situations also changes. This results in new emotions 
                     2017).                                                            and  evaluations  towards  their  environment.  They 
                         Prolonged  stress  is  associated  with  burnout  in          will  also  develop  new  coping  strategies  that  are 
                     nurses.  Burnout  may  reduce  work  satisfaction  and            more effective and adaptive (Meichenbaum, 2007). 
                     commitment.  Nurses  who  experience  burnout  are                    How SIT works to reduce stress in a workplace 
                     more likely to feel emotional exhaustion. This might              setting    was     compared       to   Acceptance       and 
                     put  patients  in  danger  due  to  lack  of  attention  to       Commitment Therapy (ACT) by Flaxman and Bond 
                     work  safety.  Nurses  might  also  experience                    (2010). Both interventions are cognitive-behavioral-
                     depersonalization  and  difficulty  in  engaging  with            based. It is said that both interventions are effective, 
                     patients.  Other  issues  associated  with  stress  are           but  there  are  some  differences  in  how  they  work. 
                     declining  health,  physical  exhaustion,  absenteeism,           ACT works by increasing psychological flexibility 
                     reactivity, and negative attitudes (Fernández-Castro,             in the subjects. ACT changes the meaning system of 
                     et al., 2017).                                                    an  event.  On  the  other  hand,  they  were  unable  to 
                         In  dealing  with  stress,  nurses  need  a  well-            establish  how  SIT  essentially  works  in  reducing 
                     planned strategy. This can be achieved with a good                stress. 
                     stress  management  strategy.  Researches  show  that                 In theory, SIT is supposed to change the clients’ 
                     individual  stress  management  interventions  with  a            cognitive  processing.  However,  in  the  study,  it  is 
                     cognitive-behavioral  perspective  are  effective  in             said  that  the  change  does  not  have  a  significant 
                     increasing  the  quality  of  life  in  the  workplace,           effect on the reduction of stress. This might happen 
                     increasing  psychological  resources  and  reducing               due to the limited duration of the intervention, which 
                     complaints  related  to  stress  (Klink  et  al.,  2001;          was done in 2 sessions for 6 hours. In spite of this, it 
                     Flaxman & Bond, 2010).                                            is  said  that  SIT  might  help  clients  to  distance 
                         Cognitive-behavioral-based  stress  management                themselves  from  their  negative  thoughts,  thus 
                     intervention  may  reduce  the  level  of  cortisol  that         improving  their  mental  health  (Flaxman  &  Bond, 
                     occurs  in  stressful  situations.  The  decrease  in  this       2010). 
                     endocrinal  response  is  due  to  change  of  cognitive              According to these earlier researches, this study 
                     appraisal  (Gaab,  et  al.,  2003).  This  change  in             aims to measure the effectiveness of SIT in reducing 
                     cognition  is  also  an  effective  emotional  coping             stress  on  intensive  care  nurses.  SIT  is  still 
                     method      (Kawaharada,       et   al.,   2009).     Other       inconclusive  in  reducing  stress  according  to 
                     physiological responses may also be altered through               Flaxman and Bond (2010), but it is said that  this 
                     skills that can possibly be taught in the intervention.           might  be  a  technical  issue  due  to  the  duration  of 
                     For instance, deep breathing as a relaxation method               sessions.  Consequently,  SIT  in  this  study  will  be 
                     can  inhibit  and  hyperpolarize  the  nervous  system.           underteken  for  a  longer  duration  in  hope  of  more 
                     This can give a relaxed sensation to clients (Jerath,             effective and significant change in the subjects. This 
                     et al., 2006).                                                    study hypothesizes that SIT is effective in reducing 
                         Stress Inoculation Training (SIT) is one kind of              stress  on  intensive  care  nurses.  It  is  expected  that 
                     individual stress management intervention. SIT is a               this  study  can  help  further  development  of  stress 
                     behavioral-cognitive-based        training    targeted    to      management interventions, particularly for intensive 
                     manage  stress.  It  is  designed  to  make  clients              care nurses.  
                     experience  minor  stress  during  treatment,  thus 
                     preparing them psychologically to deal with stress in 
                     real  life.  It  aims  to  help  clients  develop  their  own     2         METHODS 
                     personal  coping  strategies  that  lead  to  more 
                     resilience and confidence in facing stressful events              This study is a quasi-experimental research with a 
                     (Meichenbaum, 2007).                                              one-group pretest-posttest design. It aims to measure 
                         SIT is based on the transactional stress model by             the  effectiveness  of  Stress  Inoculation  Training 
                     Lazarus and Folkman (1984). This model refers to                  (SIT) in reducing stress on intensive care nurses.  
                     stress as an overload burden from the environment,                 
                     as  perceived  by  the  individual.  It  focuses  on  the          
                     important  role  of  cognitive-affective  processing  in           
                     the  individual  and  their  coping  strategies.  Hence, 
                                                                                                                                               169
                   ICP-HESOS2018-International Conference on Psychology in Health, Educational, Social, and Organizational Settings
                   2.1    Ethical Consideration                              The scale itself was translated and tested in a study 
                                                                             in Surabaya, Indonesia, by Arbi (2017, r = .846). It 
                   This  study  has  been  approved  by  the  ethical        has 10 items with Likert scale (0 = never, 1 = almost 
                   committee  of  the  hospital  where  the  study  was      never, 2 = sometimes, 3 = often, 4 = very often). 
                   conducted. It went through ethical assessment by the         The  SIT  module  for  nurses  in  this  study  is 
                   committee, in which the research proposal and the         adapted from Stress Inoculation Training for Single 
                   training  module  were  examined.  All  participants      Mothers in College by Spencer (2010). The original 
                   were given informed consent and information about         module has 8 sessions over 8 weeks, one session for 
                   the training accordingly.                                 each  week.  The  module  for  this  study  has  been 
                                                                             modified  to  cater  to  participants’  needs  and 
                   2.2    Participants                                       availability. 
                   The  supervisor  requested  all  intensive  care  nurses  2.6    Procedure 
                   who work solely in the Intensive Care Unit (ICU), 
                   without managerial duties, to attend this training. In    Stress Inoculation Training (SIT) in this study was 
                   the  end,  this  study  was  conducted  on 13 intensive   conducted in 6 sessions. The first session was done 
                   care nurses who work at a hospital in Surabaya. The       to  build  a  good  therapeutic  alliance  between 
                   group  consisted  of  3  male  and  10  female  nurses.   participants and the trainer. The participants’ stress 
                   They have been working in the ICU within the time         level was also measured by PSS-10 as a pretest. 
                   range of 2 months – 5 years.                                 The participants had a discussion session in the 
                      The nurses were assigned in 3 different groups         next one. They were to discuss their own stressful 
                   randomly for the intervention. This was due to their      situations and coping methods with each other. They 
                   different working shifts. The first group consisted of    also learned more about stress itself and SIT as an 
                   6 people, the second consisted of 4 people, and the       intervention. This session also served as a baseline 
                   third consisted of 3 people. The group remained the       for the participants so that they might have the same 
                   same until the end of treatment. Despite these small      starting point. 
                   groups, the unit analysis in this study is the whole         The  next  two  sessions  were  skill  training 
                   group of 13 nurses.                                       sessions.  Participants  were  introduced  to  deep 
                                                                             breathing  and  cognitive  reframing  as  adaptive 
                   2.3    Research Variables                                 coping  strategies  that  they  may  try  to  use  in  the 
                                                                             future. They were also trained to do them. 
                   This study aims to measure the effectiveness of the          In  the  fifth  session,  participants  were  asked  to 
                   independent  variable  (X)  toward  the  dependent        apply  the  strategies  that  they  developed  before  in 
                   variable (Y). The independent variable in this study      minor  stressful  situations.  They  were  asked  to 
                   is SIT as an intervention. The dependent variable in      imagine a stressful situation and how to deal with it 
                   this study is the stress of the nurses.                   using imagery rehearsal. They were also asked to list 
                                                                             possible  actions  and  strategies  to  use  in  stressful 
                   2.4    Data Analysis                                      situations using behavioral rehearsal. 
                                                                                The last session served as a relapse prevention 
                   Data  analyses  used  in  this  study  are  Wilcoxon      session. The participants discussed stressful events 
                   Signed-Rank  Test  and  effect  size  by  Cohen.  The     that might happen in the future and what to do about 
                   data on participants’ stress level from both pretest      them. Participants were then evaluated by discussing 
                   and posttest are analyzed descriptively. The data are     changes they felt after attending this training. Their 
                   compared  statistically  afterward,  examining  the       stress  level  was  also  measured  using  PSS-10  as  a 
                   significance. This analysis is followed by effect size    posttest. 
                   calculation using the effect size equation. 
                   2.5    Material                                           3        RESULTS 
                   The materials used in this study are the Perceived        The  results  show  there  is  a  decrease  in  stress  on 
                   Stress  Scale-10  (PSS-10)  by  Cohen  (1994)  and        participants  according  to  mean  scores.  Despite  the 
                   Stress  Inoculation  Training  for  Intensive  Care       difference, the value is not statistically  significant. 
                   Nurses  module.  PSS-10  was  used  to  measure           Below are results of statistical analyses of the data: 
                   participants’ level of stress before and after training.   
                   170
                                                                  TheEffectiveness of Stress Inoculation Training in Reducing Stress on Intensive Care Nurses
                                     Table 1: Descriptive Statistics.                      time  to  actually  practice  what  they  trained  before 
                                      N       Mean        SD       Min       Max           getting better at managing their stress (Arbi, 2017). 
                        Pretest       13      15.69     5.313        8        27                SIT in  this  study  was  conducted  in  6  sessions 
                        Posttest      13      13.77     3.516        9        20           within 3 meetings. Each meeting had the duration of 
                                                                                           60 – 90 minutes. This can also be an explanation for 
                                 Table 2: Wilcoxon Signed-Rank Test.                       the insignificance of the training. A SIT training that 
                                                                                           is  too  short  might  be  too  simple  to  modify  deep 
                                                     N         Mean       Sum of           cognitive contents (Flaxman & Bond, 2010). 
                                                               Rank        Ranks                SIT is based on a transactional stress model. This 
                        Posttest     Negative         6         6.33       38.00           means that stress might come from the individual’s 
                        - Pretest     Ranks                                                environment  (Meichenbaum,  2007).  In  this  study, 
                                     Positive         4         4.25       17.00           there  was no treatment applied to the participants’ 
                                      Ranks                                                environments. 
                                       Ties           3                                         SIT  in  this  study  was  conducted  in  a  group 
                                       Total         13                                    setting. The participation of the subjects was due to 
                                                                                           the  order  of  their  superiority.  This  can  make  the 
                      Table 3: Significance of Wilcoxon Signed-Rank Test (α =              participants less motivated to engage in this training 
                      .05).                                                                (Yalom,  1995,  cited  in  Corey,  2004).  It  can  also 
                                                            Posttest – Pretest             create resistance among the participants and this can 
                                      Z                           -1.072                   make the intervention less effective. 
                         Asymp. Sig. (2-tailed)                    .284                         Despite  the  insignificance,  SIT  still  has  some 
                                                                                           effects on the participants. There are 6 subjects who 
                          The data were also analyzed further to see the                   experienced a decrease in stress. This is because of 
                      effect  size.  According  to  the  equation,  there  is  a           behavioral change due to cognitive-behavioral-based 
                                                                                           interventions,  including  SIT.  This  change  appears 
                      medium  effect  of  the  treatment.  Below  is  the                  because  of  the  interaction  between  inner  speech, 
                      equation for effect size in this study:                              cognitive  structure,  and  behavior  with  its  own 
                                                                                           consequences (Meichenbaum, 1997, cited in Corey, 
                                 =                                           (1)       2013). 
                                      √                                                       In  this  training,  participants  went  through  the 
                                                                                           first  phase  of  this  interaction,  which  is  self-
                               = 1.072                                                   observation  (Meichenbaum,  1997,  cited  in  Corey, 
                                       13                                        (2)       2013). This was done by self-monitoring and group 
                                     √
                                                                                           discussion       about     stressful     situations.     Most 
                            = 0.297 ≈ 0.3                                      (3)       participants  were  able  to  be  more  aware  of  their 
                                                                                           stress  in  the  first  meeting.  This  led  to  more 
                          According  to  the  statistical  analyses,  it  can  be          motivation to develop more adaptive behavior. As 
                      concluded that the research  hypothesis is  rejected.                the    intervention      went,    the    participants     also 
                      SIT is not significantly effective in reducing stress                developed  a  new  cognitive  structure  that  allowed 
                      on intensive care nurses.                                            them to have new perspectives. 
                                                                                                The  second  phase  of  this  interaction  is  the 
                                                                                           creation  of  new  internal  dialogue  (Meichenbaum, 
                      4          DISCUSSION                                                1997,  cited  in  Corey,  2013).  Participants  went 
                                                                                           through  this  phase  when  they  realized  that  their 
                      According to the statistical analyses, the training is               previous  behaviors  were  not  adaptive.  They  then 
                      not significant in reducing stress on the participants.              tried  to  find  alternative  behaviors  that  are  more 
                      One possible explanation for the insignificance is the               acceptable. Participants were given new information 
                      number of sessions and duration of the training. It is               about stress and this helped them to be more aware 
                      said that SIT needs 3 – 12 months to be evaluated                    of their behaviors. 
                      thoroughly, while the training and evaluation in this                     The third phase of this interaction is the learning 
                      study      were      conducted        within     1     month         of new skills (Meichenbaum, 1997, cited in Corey, 
                      (Meichenbaum,  2007).  This  is  because  in  theory,                2013). Participants in this study learned about new 
                      SIT  should  have  booster  and  follow-up  sessions                 coping  strategies,  such  as  deep  breathing  and 
                      during  the  timespan.  Participants  also  need  more               cognitive reframing. These new strategies are more 
                                                                                                                                                      171
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...The effectiveness of stress inoculation training in reducing on intensive care nurses aufa putri suryanto ilham nur alfian faculty psychology universitas airlangga keywords coping skill deep breathing cognitive reframing abstract nursing is a highly demanding job with many responsibilities have more complex as they must deliver for critical patients this condition puts them at risk experiencing high study aims to measure sit help individuals develop personal strategies and improve their confidence facing stressful situations quasi experimental an one group pretest posttest design subjects perceived scale pss used see degree experienced by data analyses are wilcoxon signed rank test effect size cohen analysis results show that has medium there decrease according mean scores research can be developed further management program introduction issue might associated fact understaffed facilities clinical who work various healthcare therefore giving less time each play major part system also h...

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