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

Clinical nurses who work in various healthcare

facilities play a major part in the healthcare system.

Nurses have the responsibility to manage a patient’s

healthcare regimens. In many types of research,

nursing is said to be a highly demanding job,

especially in the last 25 years (Hersch, et al., 2016).

Nurses have long working hours. They also work

in shifts. This issue can be stressful for nurses,

especially in understaffed facilities (Edwards et al.,

2000; Corley et al., 2005). This issue also makes

nurses deal with many patients directly. This means

they also deal with unpleasant patients and it can be

a stressful experience for them (Edwards, et al.,

2000).

On the other hand, there are times when nurses

experience a close emotional relationship with their

patients. This kind of relationship can be burdening

for them when the patient’s condition worsens or

when they pass away. Nurses must communicate

this news to their family, which can also be a

stressful experience (Corley et al., 2005; Rai &

Tauheed, 2013; Hersch et al., 2016).

Nurses might experience moral distress in

several situations. They feel strained psychologically

when they are unable to deliver optimal service to

their patients. This issue might be associated with

the fact that there are understaffed facilities,

therefore giving the nurses less time to care for each

patients. This might also happen due to managerial

or legal issues (Corley, et al., 2005).

Aside from their professional issues, nurses can

also experience stress from daily and personal

problems. They might have interpersonal issues with

their colleagues or family. They might also

experience role conflict, in which their professional

roles conflict with their personal roles at home.

These issues can also be stressful for nurses

(Edwards et al., 2000; Khamisa et al., 2017).

Intensive care nurses are slightly different from

general nurses as they have more complex

responsibilities. They are responsible for delivering

intensive care for critical or terminal patients. This

issue might increase the tendency of intensive care

nurses to experience more stress (Kristanto, et al.,

2009).

It can be concluded that nurses are at risk of

experiencing high stress. Stress itself is experienced

by individuals by appraising situations around them.

They will feel stressed when they perceive the

situation as threatening or more than what they can

handle (Lazarus & Folkman, 1984).

Stress that is not well-managed can have

negative consequences in nurses’ lives.

168

Suryanto, A. and Alﬁan, I.

The Effectiveness 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

Professionally, stress might reduce their

productivity. It might reduce the quality of patients’

care. There might also be impaired achievements in

nurses’ work performance (Fernández-Castro, et al.,

2017).

Prolonged stress is associated with burnout in

nurses. Burnout may reduce work satisfaction and

commitment. Nurses who experience burnout are

more likely to feel emotional exhaustion. This might

put patients in danger due to lack of attention to

work safety. Nurses might also experience

depersonalization and difficulty in engaging with

patients. Other issues associated with stress are

declining health, physical exhaustion, absenteeism,

reactivity, and negative attitudes (Fernández-Castro,

et al., 2017).

In dealing with stress, nurses need a well-

planned strategy. This can be achieved with a good

stress management strategy. Researches show that

individual stress management interventions with a

cognitive-behavioral perspective are effective in

increasing the quality of life in the workplace,

increasing psychological resources and reducing

complaints related to stress (Klink et al., 2001;

Flaxman & Bond, 2010).

Cognitive-behavioral-based stress management

intervention may reduce the level of cortisol that

occurs in stressful situations. The decrease in this

endocrinal response is due to change of cognitive

appraisal (Gaab, et al., 2003). This change in

cognition is also an effective emotional coping

method (Kawaharada, et al., 2009). Other

physiological responses may also be altered through

skills that can possibly be taught in the intervention.

For instance, deep breathing as a relaxation method

can inhibit and hyperpolarize the nervous system.

This can give a relaxed sensation to clients (Jerath,

et al., 2006).

Stress Inoculation Training (SIT) is one kind of

individual stress management intervention. SIT is a

behavioral-cognitive-based training targeted to

manage stress. It is designed to make clients

experience minor stress during treatment, thus

preparing them psychologically to deal with stress in

real life. It aims to help clients develop their own

personal coping strategies that lead to more

resilience and confidence in facing stressful events

(Meichenbaum, 2007).

SIT is based on the transactional stress model by

Lazarus and Folkman (1984). This model refers to

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,

SIT is capable of reducing stress through the change

in the clients’ cognition. When the clients undergo a

cognitive change, their perspective towards

situations also changes. This results in new emotions

and evaluations towards their environment. They

will also develop new coping strategies that are

more effective and adaptive (Meichenbaum, 2007).

How SIT works to reduce stress in a workplace

setting was compared to Acceptance and

Commitment Therapy (ACT) by Flaxman and Bond

(2010). Both interventions are cognitive-behavioral-

based. It is said that both interventions are effective,

but there are some differences in how they work.

ACT works by increasing psychological flexibility

in the subjects. ACT changes the meaning system of

an event. On the other hand, they were unable to

establish how SIT essentially works in reducing

stress.

In theory, SIT is supposed to change the clients’

cognitive processing. However, in the study, it is

said that the change does not have a significant

effect on the reduction of stress. This might happen

due to the limited duration of the intervention, which

was done in 2 sessions for 6 hours. In spite of this, it

is said that SIT might help clients to distance

themselves from their negative thoughts, thus

improving their mental health (Flaxman & Bond,

2010).

According to these earlier researches, this study

aims to measure the effectiveness of SIT in reducing

stress on intensive care nurses. SIT is still

inconclusive in reducing stress according to

Flaxman and Bond (2010), but it is said that this

might be a technical issue due to the duration of

sessions. Consequently, SIT in this study will be

underteken for a longer duration in hope of more

effective and significant change in the subjects. This

study hypothesizes that SIT is effective in reducing

stress on intensive care nurses. It is expected that

this study can help further development of stress

management interventions, particularly for intensive

care nurses.

2 METHODS

This study is a quasi-experimental research with a

one-group pretest-posttest design. It aims to measure

the effectiveness of Stress Inoculation Training

(SIT) in reducing stress on intensive care nurses.

The Effectiveness of Stress Inoculation Training in Reducing Stress on Intensive Care Nurses

169

2.1 Ethical Consideration

This study has been approved by the ethical

committee of the hospital where the study was

conducted. It went through ethical assessment by the

committee, in which the research proposal and the

training module were examined. All participants

were given informed consent and information about

the training accordingly.

2.2 Participants

The supervisor requested all intensive care nurses

who work solely in the Intensive Care Unit (ICU),

without managerial duties, to attend this training. In

the end, this study was conducted on 13 intensive

care nurses who work at a hospital in Surabaya. The

group consisted of 3 male and 10 female nurses.

They have been working in the ICU within the time

range of 2 months – 5 years.

The nurses were assigned in 3 different groups

randomly for the intervention. This was due to their

different working shifts. The first group consisted of

6 people, the second consisted of 4 people, and the

third consisted of 3 people. The group remained the

same until the end of treatment. Despite these small

groups, the unit analysis in this study is the whole

group of 13 nurses.

2.3 Research Variables

This study aims to measure the effectiveness of the

independent variable (X) toward the dependent

variable (Y). The independent variable in this study

is SIT as an intervention. The dependent variable in

this study is the stress of the nurses.

2.4 Data Analysis

Data analyses used in this study are Wilcoxon

Signed-Rank Test and effect size by Cohen. The

data on participants’ stress level from both pretest

and posttest are analyzed descriptively. The data are

compared statistically afterward, examining the

significance. This analysis is followed by effect size

calculation using the effect size equation.

2.5 Material

The materials used in this study are the Perceived

Stress Scale-10 (PSS-10) by Cohen (1994) and

Stress Inoculation Training for Intensive Care

Nurses module. PSS-10 was used to measure

participants’ level of stress before and after training.

The scale itself was translated and tested in a study

in Surabaya, Indonesia, by Arbi (2017, r = .846). It

has 10 items with Likert scale (0 = never, 1 = almost

never, 2 = sometimes, 3 = often, 4 = very often).

The SIT module for nurses in this study is

adapted from Stress Inoculation Training for Single

Mothers in College by Spencer (2010). The original

module has 8 sessions over 8 weeks, one session for

each week. The module for this study has been

modified to cater to participants’ needs and

availability.

2.6 Procedure

Stress Inoculation Training (SIT) in this study was

conducted in 6 sessions. The first session was done

to build a good therapeutic alliance between

participants and the trainer. The participants’ stress

level was also measured by PSS-10 as a pretest.

The participants had a discussion session in the

next one. They were to discuss their own stressful

situations and coping methods with each other. They

also learned more about stress itself and SIT as an

intervention. This session also served as a baseline

for the participants so that they might have the same

starting point.

The next two sessions were skill training

sessions. Participants were introduced to deep

breathing and cognitive reframing as adaptive

coping strategies that they may try to use in the

future. They were also trained to do them.

In the fifth session, participants were asked to

apply the strategies that they developed before in

minor stressful situations. They were asked to

imagine a stressful situation and how to deal with it

using imagery rehearsal. They were also asked to list

possible actions and strategies to use in stressful

situations using behavioral rehearsal.

The last session served as a relapse prevention

session. The participants discussed stressful events

that might happen in the future and what to do about

them. Participants were then evaluated by discussing

changes they felt after attending this training. Their

stress level was also measured using PSS-10 as a

posttest.

3 RESULTS

The results show there is a decrease in stress on

participants according to mean scores. Despite the

difference, the value is not statistically significant.

Below are results of statistical analyses of the data:

ICP-HESOS 2018 - International Conference on Psychology in Health, Educational, Social, and Organizational Settings

170

Table 1: Descriptive Statistics.

Mean

Min

Max

Pretest

15.69

5.313

Posttest

13.77

3.516

Table 2: Wilcoxon Signed-Rank Test.

Mean

Rank

Sum of

Ranks

Posttest

- Pretest

Negative

Ranks

6.33

38.00

Positive

Ranks

4.25

17.00

Ties

Total

Table 3: Significance of Wilcoxon Signed-Rank Test (α =

.05).

Posttest – Pretest

-1.072

Asymp. Sig. (2-tailed)

.284

The data were also analyzed further to see the

effect size. According to the equation, there is a

medium effect of the treatment. Below is the

equation for effect size in this study:

𝑟 =

𝑧

√

𝑁

(1)

𝑟 =

1.072

√

(2)

𝑟 = 0.297 ≈ 0.3

(3)

According to the statistical analyses, it can be

concluded that the research hypothesis is rejected.

SIT is not significantly effective in reducing stress

on intensive care nurses.

4 DISCUSSION

According to the statistical analyses, the training is

not significant in reducing stress on the participants.

One possible explanation for the insignificance is the

number of sessions and duration of the training. It is

said that SIT needs 3 – 12 months to be evaluated

thoroughly, while the training and evaluation in this

study were conducted within 1 month

(Meichenbaum, 2007). This is because in theory,

SIT should have booster and follow-up sessions

during the timespan. Participants also need more

time to actually practice what they trained before

getting better at managing their stress (Arbi, 2017).

SIT in this study was conducted in 6 sessions

within 3 meetings. Each meeting had the duration of

60 – 90 minutes. This can also be an explanation for

the insignificance of the training. A SIT training that

is too short might be too simple to modify deep

cognitive contents (Flaxman & Bond, 2010).

SIT is based on a transactional stress model. This

means that stress might come from the individual’s

environment (Meichenbaum, 2007). In this study,

there was no treatment applied to the participants’

environments.

SIT in this study was conducted in a group

setting. The participation of the subjects was due to

the order of their superiority. This can make the

participants less motivated to engage in this training

(Yalom, 1995, cited in Corey, 2004). It can also

create resistance among the participants and this can

make the intervention less effective.

Despite the insignificance, SIT still has some

effects on the participants. There are 6 subjects who

experienced a decrease in stress. This is because of

behavioral change due to cognitive-behavioral-based

interventions, including SIT. This change appears

because of the interaction between inner speech,

cognitive structure, and behavior with its own

consequences (Meichenbaum, 1997, cited in Corey,

2013).

In this training, participants went through the

first phase of this interaction, which is self-

observation (Meichenbaum, 1997, cited in Corey,

2013). This was done by self-monitoring and group

discussion about stressful situations. Most

participants were able to be more aware of their

stress in the first meeting. This led to more

motivation to develop more adaptive behavior. As

the intervention went, the participants also

developed a new cognitive structure that allowed

them to have new perspectives.

The second phase of this interaction is the

creation of new internal dialogue (Meichenbaum,

1997, cited in Corey, 2013). Participants went

through this phase when they realized that their

previous behaviors were not adaptive. They then

tried to find alternative behaviors that are more

acceptable. Participants were given new information

about stress and this helped them to be more aware

of their behaviors.

The third phase of this interaction is the learning

of new skills (Meichenbaum, 1997, cited in Corey,

2013). Participants in this study learned about new

coping strategies, such as deep breathing and

cognitive reframing. These new strategies are more

The Effectiveness of Stress Inoculation Training in Reducing Stress on Intensive Care Nurses

171

effective and adaptive in dealing with stress. The

experiential use of this kind of skill enhances self-

respect and self-efficacy among clients

(Meichenbaum, 2007; Kawaharada et al., 2009).

Deep breathing as a relaxation method is

effective and easy to use. This is especially so in

situations that create emotional or physiological

reactions. Deep breathing inhibits and

hyperpolarizes the nervous system. This process

activates the parasympathetic autonomous nervous

system (Jerath, et al., 2006). This causes a relaxed

sensation in subjects when dealing with stress.

Cognitive reframing is also a skill that is

effective and easy to use. This is especially so in

situations that need quick responses. The

participants tend to use this strategy in situations in

which they are unable to unwind using deep

breathing strategy. Cognitive reframing helps

subjects to think more positively and this is said to

be an effective emotional coping method

(Kawaharada, et al., 2009). This perspective change

leads to a decrease in cortisol response due to stress

(Gaab, et al., 2003).

SIT as a stress management intervention works

by influencing cognitive and affective processing in

subjects. They become better at appraising stressful

situations (Herman & Cullinan, 1997, cited in Gaab

et al., 2003). Experiential exercise in this training is

also an effective mediator to reduce stress (Gaab, et

al., 2003). Therefore, it can be concluded that SIT

works by changing subjects’ emotion, cognition and

behavior in dealing with stress, which leads to a

decrease in stress.

Recommendations for future research and

application are based on the limitations of this study.

One limitation of this study is that the duration is too

short, therefore making the evaluation incomplete.

The number of sessions might also be insufficient

for SIT to work properly. Longer duration of the

study and additional sessions in the training might

give better results in evaluating and explaining the

effectiveness of SIT on intensive care nurses.

5 CONCLUSION

SIT is an effective intervention to reduce stress on

intensive care nurses. It has an effect size of 0.3

which means this intervention has a medium effect.

This is due to the change in cognitive processing of

the subjects in appraising stressful situations. This

change prompts new emotions and evaluations

toward their environment. This also initiates the

subjects to develop new behaviors that are more

effective and adaptive.

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