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Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
Effectiveness of a Stress Management Program in Reducing Anxiety and Depression in Nursing Students Noreen Johansson EdD, RN
a
a
School of Nursing at Linfield College , Portland, Oregon, USA Published online: 09 Jul 2010.
To cite this article: Noreen Johansson EdD, RN (1991) Effectiveness of a Stress Management Program in Reducing Anxiety and Depression in Nursing Students, Journal of American College Health, 40:3, 125-129, DOI: 10.1080/07448481.1991.9936268 To link to this article: http://dx.doi.org/10.1080/07448481.1991.9936268
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Effectiveness of a Stress Management Program in Reducing Anxiety and Depression in Nursing Students
Downloaded by [University of Sussex Library] at 05:30 05 February 2015
Noreen Johansson, EdD, RN Abstract. This study sought to develop a stress management program based on the arousal-attribution stress model and to evaluate the effectiveness of the program in reducing anxiety and depression experienced by nursing students. Forty-two sophomore and 34 senior nursing students in a private, sectarian, liberal arts college were randomly assigned to experimental and control groups. All subjects were given pre- and posttests consisting of the State form of the State-Trait Anxiety Inventory and the Institute for Personality and Ability Testing Depression Scale. Posttest analysis indicated that the experimental group had significantly lower anxiety and depression than the control group @ < .05). These results support the use of the arousal-attribution stress model as a theoretical framework for stress management training. Key Words. Anxiety, depression, stress management
I
n the past decade, stress and stress management have emerged as topics that warrant serious analysis and study. Although there is no universal agreement on a definition of stress, the Schachter and Singer' arousal-attribution model appears to be the most comprehensive. According to this model, stress consists of physiological arousal (increased sympathetic activity) that occurs in response to stimuli in the internal and external environment. When individuals experience stress, they attempt to identify the source of the arousal. If the situation is appraised as undesirable, anxiety and/or depression will be experienced. Individuals may use a variety of learned coping strategies in an attempt to reduce the physiological arousal (stress) and the negative psychological responses (anxiety and depression) to the stressor.' Major stressors in the collegiate environment include examinations, public speaking, and interpersonal relationships. Stress management programs have been in-
Noreen Johansson is a professor and curriculum coordinator in the School of Nursing at Linfeld College, Portland, Oregon. VOL 40, NOVEMBER 1991
stituted to teach students coping strategies related to these stressors.2-6 In nursing education, clinical experience has been identified as an additional stressor,' but no stress management programs have been designed to help students learn to cope with this added stress. A number of researchers have documented the high incidence of anxiety and depression among nursing students. As early as 1936, Hahn* observed that the student nurse was under constant strain and that 90% of nurses reported that they would not go through a nursing-education program again. Rosenberg and Fuller' found that student discontent resulted in depression, anxiety, and a high attrition rate. Fourteen years later, Gunter" again noted that anxiety, nervousness, depression, and restlessness were present to some extent in the majority of nursing students studied. In 1979, Birch' found that student nurses were still experiencing unacceptable levels of anxiety. In a sample of 207 student nurses, 43% scored at the 7th sten or higher on the Institute for Personality and Ability Testing Anxiety Scale, and 36% scored at the 8th sten or higher (a sten is a standard score on a 10-point scale). According to Krug, Scheier, and Cattell," the 7th sten is borderline high and requires careful follow-up; the 8th, 9th, and 10th stens suggest psychological morbidity that will adversely effect work and social/emotional adjustment. Sobel13 has observed that the considerable stress involved in nursing education and practice has not been of interest to many investigators. Furthermore, nursing faculty have made minimal efforts to assist students in dealing with stress. I4*l5 Accordingly, Jones16 and Zujewskyj and Davis" have recommended that programs be developed to assist nursing students in coping with the stress inherent in nursing education. A few researchers have evaluated specific coping techniques in stress management. programs for nursing stuThey limited assessment of their programs, dents. "J' however, to specific types of anxiety. Donovan and Gershman'* studied the effectiveness of systematic desensitization in reducing anxiety elicited by slides shown 125
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COLLEGE HEALTH
in a controlled laboratory situation. They noted that students who received the program experienced fewer physiological responses associated with anxiety. Nevertheless, generalizing their findings to the usual environment of the nursing student is questionable because these investigators conducted their study in a controlled environment with a limited number of stressors. Charlesworth, Murphy, and Beutler’’ developed a stress management program incorporating systematic desensitization, progressive relaxation, autogenic training, and visual imagery. The program significantly reduced the testtaking anxiety of nursing students. Ten female students participated in the experimental group, and the control group was made up of 8 students-7 women and 1 man. Generalizing these results to the usual environment of the nursing student is questionable because the sample was small and only one stressor was tested. Most research assessing different approaches to stress management training has been conducted in a laboratory setting with a variety of subjects, none of whom were students of nursing. Results of this research showed the importance of providing a theoretical rationale for stress management programs2’ as well as practice in applying coping Systematic desensitization provided an effective means for practicing relaxation and cognitive r e s t r u c t ~ r i n gand , ~ ~ biofeedback ~~ helped subjects acquire relaxation skills during The two purposes of my study were to develop a stress management program based on the arousal-attribution stress model and to assess the effectiveness of the program in reducing anxiety and depression experienced by nursing students interacting in and with their environment. According to the model, decreasing anxiety and depression in students would be achieved by reducing the physiological arousal caused by their environmental stimuli and by changing students’ maladaptive cognitive responses to identified stressors. To accomplish this, the stress management program assessed in this study included cognitive restructuring, relaxation techniques aided by biofeedback, and systematic desensitization to support both the restructuring and relaxation components. Cognitive restructuring27 involved training in positive coping self-statements (eg, “One step at a time”; “I can handle the situation”) that encouraged realistic assessment of situations, control of self-defeating thoughts, preparation for confronting potential stressors, coping with fear, and reinforcement of successful coping. The two relaxation techniques used were progressive muscle relaxation and autogenic training. Progressive muscle relaxation2” consisted of tensing and relaxing major muscle groups to develop the ability to achieve deep muscle relaxation on mental command. Autogenic training9 involved repeating, with intense concentration, select phrases (eg, “The feeling of heaviness is growing over my shoulders and arms; I am relaxing deeper and deeper”). This method of self-hypnosis emphasized control over breathing rate as well as such 126
autonomic responses as peripheral vasodilation and sweat-gland activity. A finger thermometer and galvanic skin resistance monitor provided biofeedback, which subjects used to determine whether they were successful in dilating peripheral blood vessels and decreasing sweat-gland activity. Systematic desensitization3’ was incorporated into the program to facilitate the practice of cognitive restructuring and relaxation coping strategies. This method consisted of asking subjects to visualize the least stressful scene from a self-constructed hierarchy of stressors and to use acquired coping skills at the first sign of physiological arousal or negative psychosocial response. This experience was repeated until each situation in the stressor hierarchy could be imagined without producing stress reactions. METHOD Sophomore and senior nursing students in a private, sectarian liberal arts college were asked to volunteer to participate in the study. Of 44 sophomores and 38 seniors, 42 sophomores and 34 seniors agreed to participate. Subjects varied in age from 19 to 40 years (X= 22 years). The majority were Caucasian (92%), Protestant (80%), and single (89%). The grade point average of participants ranged from 2.0 to 3.9 (X= 2.9). All of the subjects were women, and none had previously used relaxation skills or cognitive restructuring as presented in the stress management program. For the study, I used the experimental group-control group, pretest-posttest design. The year level of the student (sophomore or senior) was controlled through a stratified random assignment procedure in which students, once stratified by year level, were then randomly assigned to either experimental or control groups of no more than 9 students each. I emphasized that the students should not discuss the study before the research was completed. The pretest was given to all subjects simultaneously, immediately before the beginning of the program. The State form of the State-Trait Anxiety Inventory (STAI) was administered to each subject each week for 3 consecutive weeks on Mondays and Fridays. The Institute for Personality and Ability Testing (IPAT) Depression Scale was given to every subject on Monday of each of these weeks. The same tests were used for the posttest and were given in the same way immediately after the program ended. Pretest and posttest scores for anxiety and depression for each subject were derived by averaging scores obtained during the 3-week testing period. The stress management program was divided into three phases: (1) education, (2) training, and (3) application. It consisted of six 50-minute sessions that convened twice a week for 3 weeks. The experimental and control groups received the education phase, which was presented the first 20 minutes of Session 1 . Each student JACH
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STRESS MANAGEMENT
received her own anxiety and depression percentile ranks for undergraduate college students, which were derived from the pretest scores. These percentile ranks were discussed, using the framework of the arousalattribution model. The experimental groups continued to meet for the training and application phases of the stress management program. In the first session of the training phase (the last 30 minutes of Session l), we reviewed the objectives and learning activities of the program, and I explained the purpose of relaxation training and cognitive restructuring. Each participant was asked to construct a stressor hierarchy and identify negative self-statements (ie, “I can’t handle this”) used in connection with the identified stressors. Students were told that negative self-statements tend to increase anxiety and depression in response to a stressful situation. During the second session, students learned techniques to prevent shallow breathing. They were also educated in the use of imagery to relax smooth muscles and cause dilatation of peripheral blood vessels. Each participant received a finger thermometer to monitor peripheral body temperature during the training session and for continued home practice. After this presentation, subjects were asked to identify counterarguments to the previously identified negative self-statements. Group discussion helped students identify counterarguments that could be used to decrease stress reactions. During the third session, the students learned progressive muscle relaxation. The participants were able to relax major muscle groups by tensing and relaxing them. Following this instruction, group discussion centered on identifying positive self-statements that would assist students in preparing for a stressor, handling a stressor, coping with feelings of being overwhelmed, and reinforcing themselves for coping. The fourth session focused on the use of autogenic phrases to decrease sweat-gland activity and pore size. Students used a galvanic skin resistance monitor during the training session and, later, for home practice. Progressive muscle relaxation through mental command was taught during the fifth session. Group members discussed the effective use of this technique in reducing physiological arousal. Session 6 was devoted to instruction in skeletal and smooth muscle relaxation. During the application phase of the stress management program (the last 20 minutes of the sixth session), participants were asked to visualize the least-stressful situation they had listed in their stressor hierarchy. They used cognitive restructuring and relaxation skills at the first sign of physiological arousal, anxiety, or depression, monitoring galvanic skin resistance to assist in the identification of physiological arousal. The students repeated this exercise until they could imagine the situation without experiencing stress reactions. They repeated the same procedure for each stressor they had identified in the hierarchy. Participants were encouraged to VOL 40. NOVEMBER 1991
use acquired coping skills during the treatment session and also in the course of daily situations.
Measures Spielberger, Gorsuch, and Lushene3’ designed the State form of the STAI to measure state anxiety, a transitory emotional state or condition of consciously perceived apprehension and tension. It consists of 20 brief items, each based on a Cpoint Likert scale ranging from not at all (1) to very much so (4). The range of possible scores is 20 to 80. Subjects respond to each item according to how they feel “right now.” As examples, two of the items state, “I feel anxious,” and “I am relaxed.” Reported Cronbach’s alpha reliability coefficients range from .83 to .92, and validity has been demonstrated in a wide variety of ~tudies.~’ Krug and Laughlin’ssz IPAT Depression Scale is a 40-item questionnaire designed to measure depression characterized by perceived emotional dejection and withdrawal. Examples of items include “I feel too depressed and useless to want to talk to people,” and “Much of the time I feel sluggish and too weary to move.” Possible scores range from 0 to 72. Test-retest reliability for a 1-day interval was reported as .93, and Cronbach’s alpha as .91. Factor analysis and contrasted groups were used to ensure construct and concurrent validity. A correlation of .88 was obtained between the total score for the scale and the score obtained on the depression factor identified through factor analysis.32 RESULTS The means and standard deviations of the pretest anxiety and depression scores of each treatment group are presented in Table 1. To determine whether the experimental and control groups had comparable levels of anxiety and depression before the treatment, I compared the pretest scores of the two groups on each measure, using a two-way analysis of variance, with a significance level of .05. I found no significant differences on either measure for treatment groups, year
TABLE 1 Means and Standard Deviations of the Pretest Anxiety and Depression Scores of Each Treatment Group
Treatment group
n
Anxiety M SD
Depression M SD
~~
Sophomore Experimental Control Senior Experimental Control Total
21 21
37.55 37.79
7.79 7.72
11.68 11.62
8.43 7.03
17 17 76
42.75 39.90 39.30
11.64 8.43 8.97
17.61 14.76 13.68
14.19 12.63 10.73
127
COLLEGE HEALTH
cantly lower posttest anxiety and depression scores than the control subjects. No significant differences were found on either measure for year level (sophomore v senior students) or interaction between the treatment groups and year level (see Tables 3 and 4).
level (sophomore v senior students), or interaction between the treatment groups and year level. The means and standard deviations of the posttest anxiety and depression scores of each treatment group are shown in Table 2. To determine whether the stress management program was effective in reducing anxiety and depression in subjects, I compared the posttest scores of the two groups on each measure, using a twoway analysis of variance, with a significance level of .05. The experimental subjects were found to have signifi-
DISCUSSION
For this study, I developed a stress management program for student nurses based on Schachter and Singer's' arousal-attribution model. According to the model, stress consists of physiological arousal in response to environmental stimuli; anxiety and/or depression will be experienced if the identified source of the arousal is appraised as undesirable. Decreasing anxiety and depression would be dependent upon reducing physiological arousal and changing maladaptive cognitive responses. To accomplish this, I included cognitive restructuring, relaxation skills aided by biofeedback, and systematic desensitization in the stress management program to support both the restructuring and relaxation components. The program proved to be effective, in that posttest analysis indicated that the experimental group had significantly lower anxiety and depression than the control group. Control subjects increased about 2 points on both anxiety and depression from pretest to posttest, whereas experimental subjects decreased more than 7 points on each scale (see Tables 1 and 2). There was no
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TABLE 2 Means and Standard Deviations of the Posttest Anxiety and Depression Scores of Each Treatment Group
Treatment group Sophomore Experimental Control Senior Experimental Control Total
n
Anxiety M SD
Depression M SD
21 21
34.98 41.89
7.70 11.32
7.49 14.40
6.77 12.33
17 17 76
29.36 39.92 36.74
5.60 12.53 10.64
6.90 15.39 11.04
6.17 14.77 11.06
I
TABLE 3 Two-way Analysis of Variance for Posttest Anxiety Scores
Source of variation
Sum of squares
df
Mean squares
F ratio
Treatment group Year level Treatment Group x Year Level Residual Total
1,386.91 269.96 62.46
1 1 1
1,386.91 269.96 62.46
14.76 2.87 0.67
6,764.00 8,483.33
72 75
93.94 113.11
I
*F is statistically significant, p
Significance
.ooo* .094 .418
< .05.
TABLE 4 Two-way Analysis of Variance for Posttest Depression Scores
Source of variation
Sum of squares
df
Mean squares
F ratio
Significance
Treatment group Year level Treatment Group x Year Level Residual Total
1,101.48 0.77 11.81
1 1 1
1,101.48 0.77 11.81
9.85 0.01 0.11
.002* .934 .746
8,054.88 9,168.93
72 75
111.87 122.25
*F is statistically significant, p
128
< .05. JACH
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STRESS MANAGEMENT
significant interaction between the treatment and the year level of the students. This indicates that sophomores and seniors were equally responsive to the stress management program. These results lend support to the use of the arousal-attribution model as a theoretical framework for stress management training. Because the stress management program was effective, it would be advisable for college health professionals to consider implementing such a program to assist nursing students in coping with stress. The program could easily be presented to beginning nursing students in a series of seminars. Several potential benefits may result from teaching nursing students how to cope effectively with stress early in their college careers. Academic and clinical performance might improve if students were better able to deal with the stress of nursing education. Students might be able to use stress management skills to help prevent professional burnout after they have graduated. They could also teach these skills to help others reduce anxiety and depression associated with stress. The results of this study cannot be generalized to all nursing students because the subjects in this investigation were female sophomore or senior students in a baccalaureate nursing program at a small, private, sectarian liberal arts college. This experiment would have to be replicated in a number of representative schools of nursing to control for the interaction of selection biases and experimental variables. Increasing the sample size would make it feasible to include age, sex, ethnic group, and type of nursing program (associate degree, baccalaureate, and graduate) as independent variables. It would be interesting to conduct a follow-up study to determine whether the sophomore nursing students .who received the stress management program continued to benefit from the program during their junior and senior years of college. In addition, further research could determine whether the stress management program is effective in improving the academic and clinical performance of students. REFERENCES 1 . Schachter S, Singer I. Cognitive, social and physiological determinants of emotional state. Psychol. Rev. 1%2;69: 379-399. 2. Altmaier E, Leary M, Halpern S, Sellers J. Effects of stress inoculation and participant modeling on confidence and anxiety: Testing predictions of self-efficacy theory. J Soc CIin Psychol. 1985;3(4):500-505. 3. Glass C, Gottman J, Shmurak S. Response-acquisition and cognitive self-statement modification approaches to dating skills training. J Coun Psychol. 1976;23:520-527. 4. Hussian R, Lawrence P. The reduction of test, state, and trait anxiety by test specific and generalized inoculation training. Cognit Ther Res. 1978;2:25-38. 5. Mallinckrodt B, Leong F, Fretz B. A stress management program for graduate students. J Coll Student Personnel. 1985;26(5):471. 6. Meichenbaum D. Cognitive modification of test anxious college students. J Consult CIin Psychol. 1972;39: VOL 40, NOVEMBER 1991
370-380. 7. Fox D, Diamond L, Walsh R, Knapf L, Hodgin J. Correlates of satisfaction and stress with nursing school experience. Nurs Res. 1%3;12233-88. 8. Hahn E. The open forum. A m J Nurs. 1936;36(9):953. 9. Rosenberg P, Fuller M. Human relations seminar: A group experiment in nursing education. Ment Hygiene. 1955; 39:406-432. 10. Gunter L. The developing nursing student: Part 111. A study of self-appraisals and concerns reported during the sophomore year. Nurs Res. 1%9;18(3):237-243. 11. Birch J. The anxious learners. Nurs Mirror. 1979;8: 17-22. 12. Krug S, Scheier I, Cattell R. Handbook for the IPAT Anxiety Scale. Champaign, IL: Institute for Personality and Ability Testing; 1976. 13. Sobel E. Self-actualization and the baccalaureate nursing student’s response to stress. Nurs Res. 1978;27:239-243. 14. Mapanga M. Caring for learners. Nurs Mirror. 1985; 160(26):44-46. 15. McKay S. A review of student stress in nursing education programs. Nurs Forum. 1978;17(4):376-393. 16. Jones D. The need for a comprehensive counseling service for nursing students. J A d v Nurs. 1978;3:359-368. 17. Zujewskyj T, Davis L. Sources and effects of anxiety in videotape learning experience. Nurs Papers. 1985;17(3):75-85. 18. Donovan T, Gershman L. Experimental anxiety reduction: Systematic desensitization versus a false-feedback expectancy manipulation. J Behav Ther Exp Psychiatry. 1979;lO(3): 173-179. 19. Charlesworth E, Murphy S, Buetler L. Stress management skill for nursing students. J Clin Psychol. 1981;37(2): 284-290. 20. Jaremko M, Hadfield R, Walker W. Contribution of an educational phase to stress inoculation of speech anxiety. Percept Motor Skilk 1980;50(2):495-501. 21. Hutchings D, Denney D, Basgall J, Houston B. Anxiety management and applied relaxation in reducing general anxiety. Behav Res Ther. 1980;18(3):181-190. 22. Scherer S, Pass L. Effective use of relaxation training in dealing with tension and anxiety: A selected review. Can Counsellor. 1979;14(1):3-6. 23. Goldfried M, Decenteceo E, Weinberg L. Systematic rational restructuring as a self-control technique. Behav Ther. 1974;5 247-254. 24. Goldfried M, Linehan M, Smith J. Reduction of test anxiety through cognitive restructuring. J Consult CIin Psycho[. 1978;46:32-39. 25. Allen R. Controlling stress and tension: Biomedical and psychometric evaluation of programs at the University of Maryland. J Sch Health. 1981;51(5):360-364. 26. Fehring R. Effects of biofeedback-aided relaxation on the psychological stress symptoms of college students. Nurs Res. 1983;32(6):362-366. 27. Meichenbaum D. Self-instructional methods. In: Kanfer F, Goldstein A, eds. Helping People Change. New York: Pergamon; 1975. 28. Jacobsen F. Progressive Relaxation. Chicago, IL: University of Chicago Press; 1938. 29. Luthe W, ed. Autogenic Therapy. New York: Grune and Stratton; 1%9. 30. Wolpe J. Psychotherapy by Reciprocal Inhibition. Stanford, CA: Stanford University Press; 1958. 31. Spielberger C, Gorsuch R, Lushene R. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press; 1970. 32. Krug S, Laughlin J. Handbook for the IPAT Depression Scale. Champaign, IL: Institute for Personality and Ability Testing; 1976. 129
Journal of American College Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vach20
Effectiveness of a Stress Management Program in Reducing Anxiety and Depression in Nursing Students Noreen Johansson EdD, RN
a
a
School of Nursing at Linfield College , Portland, Oregon, USA Published online: 09 Jul 2010.
To cite this article: Noreen Johansson EdD, RN (1991) Effectiveness of a Stress Management Program in Reducing Anxiety and Depression in Nursing Students, Journal of American College Health, 40:3, 125-129, DOI: 10.1080/07448481.1991.9936268 To link to this article: http://dx.doi.org/10.1080/07448481.1991.9936268
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Effectiveness of a Stress Management Program in Reducing Anxiety and Depression in Nursing Students
Downloaded by [University of Sussex Library] at 05:30 05 February 2015
Noreen Johansson, EdD, RN Abstract. This study sought to develop a stress management program based on the arousal-attribution stress model and to evaluate the effectiveness of the program in reducing anxiety and depression experienced by nursing students. Forty-two sophomore and 34 senior nursing students in a private, sectarian, liberal arts college were randomly assigned to experimental and control groups. All subjects were given pre- and posttests consisting of the State form of the State-Trait Anxiety Inventory and the Institute for Personality and Ability Testing Depression Scale. Posttest analysis indicated that the experimental group had significantly lower anxiety and depression than the control group @ < .05). These results support the use of the arousal-attribution stress model as a theoretical framework for stress management training. Key Words. Anxiety, depression, stress management
I
n the past decade, stress and stress management have emerged as topics that warrant serious analysis and study. Although there is no universal agreement on a definition of stress, the Schachter and Singer' arousal-attribution model appears to be the most comprehensive. According to this model, stress consists of physiological arousal (increased sympathetic activity) that occurs in response to stimuli in the internal and external environment. When individuals experience stress, they attempt to identify the source of the arousal. If the situation is appraised as undesirable, anxiety and/or depression will be experienced. Individuals may use a variety of learned coping strategies in an attempt to reduce the physiological arousal (stress) and the negative psychological responses (anxiety and depression) to the stressor.' Major stressors in the collegiate environment include examinations, public speaking, and interpersonal relationships. Stress management programs have been in-
Noreen Johansson is a professor and curriculum coordinator in the School of Nursing at Linfeld College, Portland, Oregon. VOL 40, NOVEMBER 1991
stituted to teach students coping strategies related to these stressors.2-6 In nursing education, clinical experience has been identified as an additional stressor,' but no stress management programs have been designed to help students learn to cope with this added stress. A number of researchers have documented the high incidence of anxiety and depression among nursing students. As early as 1936, Hahn* observed that the student nurse was under constant strain and that 90% of nurses reported that they would not go through a nursing-education program again. Rosenberg and Fuller' found that student discontent resulted in depression, anxiety, and a high attrition rate. Fourteen years later, Gunter" again noted that anxiety, nervousness, depression, and restlessness were present to some extent in the majority of nursing students studied. In 1979, Birch' found that student nurses were still experiencing unacceptable levels of anxiety. In a sample of 207 student nurses, 43% scored at the 7th sten or higher on the Institute for Personality and Ability Testing Anxiety Scale, and 36% scored at the 8th sten or higher (a sten is a standard score on a 10-point scale). According to Krug, Scheier, and Cattell," the 7th sten is borderline high and requires careful follow-up; the 8th, 9th, and 10th stens suggest psychological morbidity that will adversely effect work and social/emotional adjustment. Sobel13 has observed that the considerable stress involved in nursing education and practice has not been of interest to many investigators. Furthermore, nursing faculty have made minimal efforts to assist students in dealing with stress. I4*l5 Accordingly, Jones16 and Zujewskyj and Davis" have recommended that programs be developed to assist nursing students in coping with the stress inherent in nursing education. A few researchers have evaluated specific coping techniques in stress management. programs for nursing stuThey limited assessment of their programs, dents. "J' however, to specific types of anxiety. Donovan and Gershman'* studied the effectiveness of systematic desensitization in reducing anxiety elicited by slides shown 125
Downloaded by [University of Sussex Library] at 05:30 05 February 2015
COLLEGE HEALTH
in a controlled laboratory situation. They noted that students who received the program experienced fewer physiological responses associated with anxiety. Nevertheless, generalizing their findings to the usual environment of the nursing student is questionable because these investigators conducted their study in a controlled environment with a limited number of stressors. Charlesworth, Murphy, and Beutler’’ developed a stress management program incorporating systematic desensitization, progressive relaxation, autogenic training, and visual imagery. The program significantly reduced the testtaking anxiety of nursing students. Ten female students participated in the experimental group, and the control group was made up of 8 students-7 women and 1 man. Generalizing these results to the usual environment of the nursing student is questionable because the sample was small and only one stressor was tested. Most research assessing different approaches to stress management training has been conducted in a laboratory setting with a variety of subjects, none of whom were students of nursing. Results of this research showed the importance of providing a theoretical rationale for stress management programs2’ as well as practice in applying coping Systematic desensitization provided an effective means for practicing relaxation and cognitive r e s t r u c t ~ r i n gand , ~ ~ biofeedback ~~ helped subjects acquire relaxation skills during The two purposes of my study were to develop a stress management program based on the arousal-attribution stress model and to assess the effectiveness of the program in reducing anxiety and depression experienced by nursing students interacting in and with their environment. According to the model, decreasing anxiety and depression in students would be achieved by reducing the physiological arousal caused by their environmental stimuli and by changing students’ maladaptive cognitive responses to identified stressors. To accomplish this, the stress management program assessed in this study included cognitive restructuring, relaxation techniques aided by biofeedback, and systematic desensitization to support both the restructuring and relaxation components. Cognitive restructuring27 involved training in positive coping self-statements (eg, “One step at a time”; “I can handle the situation”) that encouraged realistic assessment of situations, control of self-defeating thoughts, preparation for confronting potential stressors, coping with fear, and reinforcement of successful coping. The two relaxation techniques used were progressive muscle relaxation and autogenic training. Progressive muscle relaxation2” consisted of tensing and relaxing major muscle groups to develop the ability to achieve deep muscle relaxation on mental command. Autogenic training9 involved repeating, with intense concentration, select phrases (eg, “The feeling of heaviness is growing over my shoulders and arms; I am relaxing deeper and deeper”). This method of self-hypnosis emphasized control over breathing rate as well as such 126
autonomic responses as peripheral vasodilation and sweat-gland activity. A finger thermometer and galvanic skin resistance monitor provided biofeedback, which subjects used to determine whether they were successful in dilating peripheral blood vessels and decreasing sweat-gland activity. Systematic desensitization3’ was incorporated into the program to facilitate the practice of cognitive restructuring and relaxation coping strategies. This method consisted of asking subjects to visualize the least stressful scene from a self-constructed hierarchy of stressors and to use acquired coping skills at the first sign of physiological arousal or negative psychosocial response. This experience was repeated until each situation in the stressor hierarchy could be imagined without producing stress reactions. METHOD Sophomore and senior nursing students in a private, sectarian liberal arts college were asked to volunteer to participate in the study. Of 44 sophomores and 38 seniors, 42 sophomores and 34 seniors agreed to participate. Subjects varied in age from 19 to 40 years (X= 22 years). The majority were Caucasian (92%), Protestant (80%), and single (89%). The grade point average of participants ranged from 2.0 to 3.9 (X= 2.9). All of the subjects were women, and none had previously used relaxation skills or cognitive restructuring as presented in the stress management program. For the study, I used the experimental group-control group, pretest-posttest design. The year level of the student (sophomore or senior) was controlled through a stratified random assignment procedure in which students, once stratified by year level, were then randomly assigned to either experimental or control groups of no more than 9 students each. I emphasized that the students should not discuss the study before the research was completed. The pretest was given to all subjects simultaneously, immediately before the beginning of the program. The State form of the State-Trait Anxiety Inventory (STAI) was administered to each subject each week for 3 consecutive weeks on Mondays and Fridays. The Institute for Personality and Ability Testing (IPAT) Depression Scale was given to every subject on Monday of each of these weeks. The same tests were used for the posttest and were given in the same way immediately after the program ended. Pretest and posttest scores for anxiety and depression for each subject were derived by averaging scores obtained during the 3-week testing period. The stress management program was divided into three phases: (1) education, (2) training, and (3) application. It consisted of six 50-minute sessions that convened twice a week for 3 weeks. The experimental and control groups received the education phase, which was presented the first 20 minutes of Session 1 . Each student JACH
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received her own anxiety and depression percentile ranks for undergraduate college students, which were derived from the pretest scores. These percentile ranks were discussed, using the framework of the arousalattribution model. The experimental groups continued to meet for the training and application phases of the stress management program. In the first session of the training phase (the last 30 minutes of Session l), we reviewed the objectives and learning activities of the program, and I explained the purpose of relaxation training and cognitive restructuring. Each participant was asked to construct a stressor hierarchy and identify negative self-statements (ie, “I can’t handle this”) used in connection with the identified stressors. Students were told that negative self-statements tend to increase anxiety and depression in response to a stressful situation. During the second session, students learned techniques to prevent shallow breathing. They were also educated in the use of imagery to relax smooth muscles and cause dilatation of peripheral blood vessels. Each participant received a finger thermometer to monitor peripheral body temperature during the training session and for continued home practice. After this presentation, subjects were asked to identify counterarguments to the previously identified negative self-statements. Group discussion helped students identify counterarguments that could be used to decrease stress reactions. During the third session, the students learned progressive muscle relaxation. The participants were able to relax major muscle groups by tensing and relaxing them. Following this instruction, group discussion centered on identifying positive self-statements that would assist students in preparing for a stressor, handling a stressor, coping with feelings of being overwhelmed, and reinforcing themselves for coping. The fourth session focused on the use of autogenic phrases to decrease sweat-gland activity and pore size. Students used a galvanic skin resistance monitor during the training session and, later, for home practice. Progressive muscle relaxation through mental command was taught during the fifth session. Group members discussed the effective use of this technique in reducing physiological arousal. Session 6 was devoted to instruction in skeletal and smooth muscle relaxation. During the application phase of the stress management program (the last 20 minutes of the sixth session), participants were asked to visualize the least-stressful situation they had listed in their stressor hierarchy. They used cognitive restructuring and relaxation skills at the first sign of physiological arousal, anxiety, or depression, monitoring galvanic skin resistance to assist in the identification of physiological arousal. The students repeated this exercise until they could imagine the situation without experiencing stress reactions. They repeated the same procedure for each stressor they had identified in the hierarchy. Participants were encouraged to VOL 40. NOVEMBER 1991
use acquired coping skills during the treatment session and also in the course of daily situations.
Measures Spielberger, Gorsuch, and Lushene3’ designed the State form of the STAI to measure state anxiety, a transitory emotional state or condition of consciously perceived apprehension and tension. It consists of 20 brief items, each based on a Cpoint Likert scale ranging from not at all (1) to very much so (4). The range of possible scores is 20 to 80. Subjects respond to each item according to how they feel “right now.” As examples, two of the items state, “I feel anxious,” and “I am relaxed.” Reported Cronbach’s alpha reliability coefficients range from .83 to .92, and validity has been demonstrated in a wide variety of ~tudies.~’ Krug and Laughlin’ssz IPAT Depression Scale is a 40-item questionnaire designed to measure depression characterized by perceived emotional dejection and withdrawal. Examples of items include “I feel too depressed and useless to want to talk to people,” and “Much of the time I feel sluggish and too weary to move.” Possible scores range from 0 to 72. Test-retest reliability for a 1-day interval was reported as .93, and Cronbach’s alpha as .91. Factor analysis and contrasted groups were used to ensure construct and concurrent validity. A correlation of .88 was obtained between the total score for the scale and the score obtained on the depression factor identified through factor analysis.32 RESULTS The means and standard deviations of the pretest anxiety and depression scores of each treatment group are presented in Table 1. To determine whether the experimental and control groups had comparable levels of anxiety and depression before the treatment, I compared the pretest scores of the two groups on each measure, using a two-way analysis of variance, with a significance level of .05. I found no significant differences on either measure for treatment groups, year
TABLE 1 Means and Standard Deviations of the Pretest Anxiety and Depression Scores of Each Treatment Group
Treatment group
n
Anxiety M SD
Depression M SD
~~
Sophomore Experimental Control Senior Experimental Control Total
21 21
37.55 37.79
7.79 7.72
11.68 11.62
8.43 7.03
17 17 76
42.75 39.90 39.30
11.64 8.43 8.97
17.61 14.76 13.68
14.19 12.63 10.73
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cantly lower posttest anxiety and depression scores than the control subjects. No significant differences were found on either measure for year level (sophomore v senior students) or interaction between the treatment groups and year level (see Tables 3 and 4).
level (sophomore v senior students), or interaction between the treatment groups and year level. The means and standard deviations of the posttest anxiety and depression scores of each treatment group are shown in Table 2. To determine whether the stress management program was effective in reducing anxiety and depression in subjects, I compared the posttest scores of the two groups on each measure, using a twoway analysis of variance, with a significance level of .05. The experimental subjects were found to have signifi-
DISCUSSION
For this study, I developed a stress management program for student nurses based on Schachter and Singer's' arousal-attribution model. According to the model, stress consists of physiological arousal in response to environmental stimuli; anxiety and/or depression will be experienced if the identified source of the arousal is appraised as undesirable. Decreasing anxiety and depression would be dependent upon reducing physiological arousal and changing maladaptive cognitive responses. To accomplish this, I included cognitive restructuring, relaxation skills aided by biofeedback, and systematic desensitization in the stress management program to support both the restructuring and relaxation components. The program proved to be effective, in that posttest analysis indicated that the experimental group had significantly lower anxiety and depression than the control group. Control subjects increased about 2 points on both anxiety and depression from pretest to posttest, whereas experimental subjects decreased more than 7 points on each scale (see Tables 1 and 2). There was no
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TABLE 2 Means and Standard Deviations of the Posttest Anxiety and Depression Scores of Each Treatment Group
Treatment group Sophomore Experimental Control Senior Experimental Control Total
n
Anxiety M SD
Depression M SD
21 21
34.98 41.89
7.70 11.32
7.49 14.40
6.77 12.33
17 17 76
29.36 39.92 36.74
5.60 12.53 10.64
6.90 15.39 11.04
6.17 14.77 11.06
I
TABLE 3 Two-way Analysis of Variance for Posttest Anxiety Scores
Source of variation
Sum of squares
df
Mean squares
F ratio
Treatment group Year level Treatment Group x Year Level Residual Total
1,386.91 269.96 62.46
1 1 1
1,386.91 269.96 62.46
14.76 2.87 0.67
6,764.00 8,483.33
72 75
93.94 113.11
I
*F is statistically significant, p
Significance
.ooo* .094 .418
< .05.
TABLE 4 Two-way Analysis of Variance for Posttest Depression Scores
Source of variation
Sum of squares
df
Mean squares
F ratio
Significance
Treatment group Year level Treatment Group x Year Level Residual Total
1,101.48 0.77 11.81
1 1 1
1,101.48 0.77 11.81
9.85 0.01 0.11
.002* .934 .746
8,054.88 9,168.93
72 75
111.87 122.25
*F is statistically significant, p
128
< .05. JACH
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significant interaction between the treatment and the year level of the students. This indicates that sophomores and seniors were equally responsive to the stress management program. These results lend support to the use of the arousal-attribution model as a theoretical framework for stress management training. Because the stress management program was effective, it would be advisable for college health professionals to consider implementing such a program to assist nursing students in coping with stress. The program could easily be presented to beginning nursing students in a series of seminars. Several potential benefits may result from teaching nursing students how to cope effectively with stress early in their college careers. Academic and clinical performance might improve if students were better able to deal with the stress of nursing education. Students might be able to use stress management skills to help prevent professional burnout after they have graduated. They could also teach these skills to help others reduce anxiety and depression associated with stress. The results of this study cannot be generalized to all nursing students because the subjects in this investigation were female sophomore or senior students in a baccalaureate nursing program at a small, private, sectarian liberal arts college. This experiment would have to be replicated in a number of representative schools of nursing to control for the interaction of selection biases and experimental variables. Increasing the sample size would make it feasible to include age, sex, ethnic group, and type of nursing program (associate degree, baccalaureate, and graduate) as independent variables. It would be interesting to conduct a follow-up study to determine whether the sophomore nursing students .who received the stress management program continued to benefit from the program during their junior and senior years of college. In addition, further research could determine whether the stress management program is effective in improving the academic and clinical performance of students. REFERENCES 1 . Schachter S, Singer I. Cognitive, social and physiological determinants of emotional state. Psychol. Rev. 1%2;69: 379-399. 2. Altmaier E, Leary M, Halpern S, Sellers J. Effects of stress inoculation and participant modeling on confidence and anxiety: Testing predictions of self-efficacy theory. J Soc CIin Psychol. 1985;3(4):500-505. 3. Glass C, Gottman J, Shmurak S. Response-acquisition and cognitive self-statement modification approaches to dating skills training. J Coun Psychol. 1976;23:520-527. 4. Hussian R, Lawrence P. The reduction of test, state, and trait anxiety by test specific and generalized inoculation training. Cognit Ther Res. 1978;2:25-38. 5. Mallinckrodt B, Leong F, Fretz B. A stress management program for graduate students. J Coll Student Personnel. 1985;26(5):471. 6. Meichenbaum D. Cognitive modification of test anxious college students. J Consult CIin Psychol. 1972;39: VOL 40, NOVEMBER 1991
370-380. 7. Fox D, Diamond L, Walsh R, Knapf L, Hodgin J. Correlates of satisfaction and stress with nursing school experience. Nurs Res. 1%3;12233-88. 8. Hahn E. The open forum. A m J Nurs. 1936;36(9):953. 9. Rosenberg P, Fuller M. Human relations seminar: A group experiment in nursing education. Ment Hygiene. 1955; 39:406-432. 10. Gunter L. The developing nursing student: Part 111. A study of self-appraisals and concerns reported during the sophomore year. Nurs Res. 1%9;18(3):237-243. 11. Birch J. The anxious learners. Nurs Mirror. 1979;8: 17-22. 12. Krug S, Scheier I, Cattell R. Handbook for the IPAT Anxiety Scale. Champaign, IL: Institute for Personality and Ability Testing; 1976. 13. Sobel E. Self-actualization and the baccalaureate nursing student’s response to stress. Nurs Res. 1978;27:239-243. 14. Mapanga M. Caring for learners. Nurs Mirror. 1985; 160(26):44-46. 15. McKay S. A review of student stress in nursing education programs. Nurs Forum. 1978;17(4):376-393. 16. Jones D. The need for a comprehensive counseling service for nursing students. J A d v Nurs. 1978;3:359-368. 17. Zujewskyj T, Davis L. Sources and effects of anxiety in videotape learning experience. Nurs Papers. 1985;17(3):75-85. 18. Donovan T, Gershman L. Experimental anxiety reduction: Systematic desensitization versus a false-feedback expectancy manipulation. J Behav Ther Exp Psychiatry. 1979;lO(3): 173-179. 19. Charlesworth E, Murphy S, Buetler L. Stress management skill for nursing students. J Clin Psychol. 1981;37(2): 284-290. 20. Jaremko M, Hadfield R, Walker W. Contribution of an educational phase to stress inoculation of speech anxiety. Percept Motor Skilk 1980;50(2):495-501. 21. Hutchings D, Denney D, Basgall J, Houston B. Anxiety management and applied relaxation in reducing general anxiety. Behav Res Ther. 1980;18(3):181-190. 22. Scherer S, Pass L. Effective use of relaxation training in dealing with tension and anxiety: A selected review. Can Counsellor. 1979;14(1):3-6. 23. Goldfried M, Decenteceo E, Weinberg L. Systematic rational restructuring as a self-control technique. Behav Ther. 1974;5 247-254. 24. Goldfried M, Linehan M, Smith J. Reduction of test anxiety through cognitive restructuring. J Consult CIin Psycho[. 1978;46:32-39. 25. Allen R. Controlling stress and tension: Biomedical and psychometric evaluation of programs at the University of Maryland. J Sch Health. 1981;51(5):360-364. 26. Fehring R. Effects of biofeedback-aided relaxation on the psychological stress symptoms of college students. Nurs Res. 1983;32(6):362-366. 27. Meichenbaum D. Self-instructional methods. In: Kanfer F, Goldstein A, eds. Helping People Change. New York: Pergamon; 1975. 28. Jacobsen F. Progressive Relaxation. Chicago, IL: University of Chicago Press; 1938. 29. Luthe W, ed. Autogenic Therapy. New York: Grune and Stratton; 1%9. 30. Wolpe J. Psychotherapy by Reciprocal Inhibition. Stanford, CA: Stanford University Press; 1958. 31. Spielberger C, Gorsuch R, Lushene R. Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press; 1970. 32. Krug S, Laughlin J. Handbook for the IPAT Depression Scale. Champaign, IL: Institute for Personality and Ability Testing; 1976. 129
