Hospital Nurses Can Reduce Stress With Online Program, Study Suggests

Diana Swift

December 16, 2016

A web-based program effectively decreases nurses' perceived stress across a range of workplace challenges, a small randomized study has found.

Program participants experienced significantly greater reductions than nonintervention control patients on the full Nursing Stress Scale, as well as on six of seven subscales, researchers report in a paper published in the November issue of Applied Nursing Research.

Those with longer nursing experience derived more benefit, Rebekah K. Hersch, PhD, from ISA Associates Inc, and colleagues write. ISA Associates developed BREATHE: Stress Management for Nurses, which is designed to give nurses the resilience and skills needed to recognize and deal with occupational stressors.

Previously published research has shown that workplace stress management interventions are effective; however, most require multiple in-person sessions, and scheduling can be difficult. The authors believe online training can measurably benefit nurses without disrupting busy schedules and heavy workloads.

"Although nurses are responsible for the health of millions of Americans on a daily basis, they suffer from high rates of stress that not only threaten their health and well-being, but which also have a significant impact on productivity and retention — and ultimately on the quality of patient care," the authors write.

Reducing stress is critical for maintaining nursing supply and quality of care. Burnout increases attrition and costly nursing turnover, according to a recent article published in Medscape Nurses.

The web-based program addresses such occupational stressors as death and dying, conflict with physicians and other nurses, inadequate preparation, taxing workload, and treatment uncertainty.

The trial randomly assigned 104 nurses at five suburban hospitals in Virginia (n = 36) and one large metropolitan hospital in New York (n = 68) to an intervention group or a control group.

"The small number of participants recruited from [six] hospitals was somewhat surprising," Cynda H. Rushton, PhD, RN, a professor of clinical ethics at the Berman Institute of Bioethics/School of Nursing and a professor of nursing and pediatrics at Johns Hopkins University, both in Baltimore, Maryland, told Medscape Medical News. Dr Rushton, who was not involved in the study, specializes in nursing burnout issues and has developed programs to reduce occupational stress for nurses.

"Whether the format program influenced their participation is not known, but this may suggest that nurses are reluctant to engage in stress-reduction programs."

Nurses in the intervention group participated in a seven-module online program, using it at will during a 3-month period. An additional module was added for nurse managers. The modules included sections such as assessing stress, identifying stressors, managing stress, and avoiding negative coping. The researchers assigned nurses in the control group to a wait-list.

Nurses completed a pretest and posttest before and after participating in the program. In terms of coping mechanisms, for example, participants answered questions on a 4-point scale ranging from 1 (never) to 4 (almost always), with a higher score equaling better coping. "I often put things aside for a while to get perspective on them," and "I decide certain problems are not worth worrying about," were typical questions.

Participants in the well-matched groups had a mean age of 41 years (range, 22 - 65 years); 87.5% were women, and 65% were white. More than half (57%) had a BSN and 21% had a MSN, and their nursing experience ranged from less than a year (8%) to more than 25 years (30%). One third (34%) were medical or surgical unit nurses; 8% were advanced practice nurses, and 10% were clinical nurse managers.

The intervention group showed significantly greater improvement than the control group on the primary outcome measure of overall stress on the Nursing Stress Scale, with notable differences between the experimental and control groups (t = −2.95; P = .00).

The study also noted improvements on six of seven stress subscales, including the following: death and dying (t = −2.24; P = .03), conflict with physicians (t = −2.11; P = .04), inadequate preparation (t = −1.95; P = .05), conflict with other nurses (t = −4.17; P = .00), workload (t = −2.30; P = .02), and treatment uncertainty (t = −2.14; P = .03).

The only subscale showing no notable intergroup differences was stress related to lack of support, suggesting this particular group may have enjoyed a high level of support. Positive interpersonal exchanges with coworkers and supervisors has been associated with stress-reducing effects, such as security, mutual respect, and positive feelings.

A statistically significant difference did emerge for the number of years of nursing practice, with the program having a greater effect on those with longer experience. Participants who spent more time using the program appeared to benefit more (P = .076), but this finding was not statistically significant.

The study found no significant differences for the secondary endpoints of distress symptoms, coping, work limitations, job satisfaction, understanding depression and anxiety, stress relief by substance use, or alcohol quantity and frequency.

In terms of participation, most users logged into the program from one to three times. The average number of logins was 2.5, and the average time spent at each BREATHE session was 43 minutes; 40.5% of participants spent less than 20 minutes, and only 14.3% spent from 1 to 2 hours online.

"Of note, 10 participants in the experimental arm never logged in, and 15 logged in only once," said Dr Rushton. Only 10 nurses did three sessions. "It is possible that the impact for those who fully engaged was significant, but the dose effect of the study is not clear."

She also wondered whether an online-only program would sustain its effectiveness over time.

In her view, although an online resource can be a helpful adjunct, it probably works best in combination with in-person sessions that more actively engage nurses in the process and provide the human support nurses rely on to cope with stress.

The authors hope this and similar programs will alter the way users view and respond to stressors, helping them acquire assertive communication, conflict resolution, and problem-solving skills and learn how to cope with the processes and grieving related to patient death.

Acknowledging the study was limited by its 3-month assessment period, the authors write. "Additional studies would benefit from a longer posttest data collection period and the inclusion of biological measures such as cortisol to test the effects of stress management interventions on objective measures of stress."

This study was funded by a grant from the National Institutes of Health, National Institute on Nursing Research. Dr Hersch and Dr Cook are owners of ISA Associates, which developed the tested program. The other coauthors and Dr Rushton have disclosed no relevant financial relationships.

Appl Nurs Res. 2016;32:18-25. Abstract

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