YNEDT-02834; No of Pages 5 Nurse Education Today xxx (2014) xxx–xxx
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Effects of rational emotive behavior therapy for senior nursing students on coping strategies and self-efficacy Myung Ah Kim a,1, Jiyoung Kim b,2, Eun Jung Kim c,⁎ a b c
Department of Nursing, College of Nursing, CHA University, Bundang CHA Medical Center, Yatap-dong, Bundang-gu, Seongnam, Gyeonggi-do, 463-712, Korea College of Nursing, Chonbuk National University, 567 Baekje-daero, Deokjin-gu, Jeonju, Jeollabuk-do, 561-756, Korea Division of Nursing, College of Medicine, Hallym University, 1 Hallymdaehak-gil, Chuncheon, Gangwon-do, 200-702, Korea
a r t i c l e
i n f o
Article history: Accepted 19 November 2014 Available online xxxx Keywords: Rational emotive psychotherapy Cognitive therapy Psychological adaptation Self-efficacy Nursing students
s u m m a r y Background: Senior nursing students are faced with various types of stressful events such as taking the national licensure exam or finding employment. Such stress can generate maladaptive behaviors as well as physical and psychological symptoms. There is evidence supporting the use of rational emotive behavior therapy (REBT) for reducing disruptive behaviors and negative emotions as well as improving self-efficacy and stress-coping strategies. Objectives: The purpose of this study is to examine the effects of rational emotive behavior therapy (REBT) on stress coping strategies and self-efficacy for senior nursing students. Methods: Thirty-four senior nursing students in a nursing college were assigned randomly to an experimental group (n = 18) and a control group (n = 16). The REBT program consisted of 8 sessions, and it was implemented for a 4-week period. Outcome measures assessed stress-coping strategies and self-efficacy before and after intervention. Results: After intervention with REBT, the mean difference scores for self-efficacy (p = .032) were significantly higher in the experimental group than in the control group. However, the mean difference scores for seeking social support (p = .166), problem solving (p = .126), and avoidance (p = .154) in stress-coping strategies were not significantly different between the two groups. Conclusion: The results imply that group counseling based on REBT enhances the self-efficacy among senior nursing students before graduation. As regards stress coping strategies, a longer intervention period is suggested. © 2014 Elsevier Ltd. All rights reserved.
Introduction The levels of self-esteem and stress of nursing students are different at different times throughout their education and training (Edwards et al., 2010). Edwards et al. (2010) found that stress level was higher at the beginning of the final year compared to stress level reported at any other time, and by the time the students finished their course training and completed their examinations, their stress levels went down. Among nursing students in Korea, employability is the most influential factor that affected choosing a nursing major, they want to work in a large hospital and place the highest value on it. Thus, they are in competition with their fellow students for better grade scores. Stress experienced by nursing students may result in them finding competing demands difficult to cope with. This kind of stress can generate maladaptive behaviors such as smoking, drinking, avoidance of preparation of exams, or cutting off relationships as well as physical
⁎ Corresponding author. Tel.: +82 33 248 2725; fax: +82 33 248 2734. E-mail addresses: [email protected] (M.A. Kim), [email protected] (J. Kim), [email protected] (E.J. Kim). 1 Tel.: +82 31 825 8316. 2 Tel.: +82 63 270 2401; fax: +82 63 270 3127.
and psychological symptoms (Jenkins and Palmer, 2003; Sheu et al., 2002). Even after employment, they are not able to cope well with stress from their workload and relationship conflicts so there have been increases in the number of cases in which they switch jobs within one year of employment (Moon and Lee, 2010). Thus, nursing students need to cope effectively with their stress for a better college life to help them prepare for their future careers. Rational emotive behavior therapy (REBT) is one of the cognitivebehavioral approaches to counseling and psychotherapy which was developed by Ellis. REBT is being used as treatment of choice for psychological difficulties by changing beliefs and consequent emotional response (MacInnes, 2004). In REBT, it is hypothesized that stress is largely determined not by the unpleasant events or stressors people experience in their lives, but mainly by their irrational beliefs about what is happening to them (Jenkins and Palmer, 2003). Self-efficacy influence the amount of stress and anxiety individuals experience as they engage in a task and the level of accomplishment they realize. Most people engage in tasks in which they feel competent and confident and avoid those in which they do not (Bandura, 1994). Senior nursing students are faced with the national licensure exam and ready to enter into society. In this study, in an attempt to enhance senior nursing students' self-efficacy and stress coping strategies,
http://dx.doi.org/10.1016/j.nedt.2014.11.013 0260-6917/© 2014 Elsevier Ltd. All rights reserved.
Please cite this article as: Kim, M.A., et al., Effects of rational emotive behavior therapy for senior nursing students on coping strategies and selfefficacy, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.11.013
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M.A. Kim et al. / Nurse Education Today xxx (2014) xxx–xxx
we constructed the REBT program for senior nursing students and examined the effects of the REBT program. Background Effective coping strategies are vital to nursing students for stress relief. Coping means an individual's conscious or subconscious actions to control stressful situations that are unavoidable (Lazarus and Folkman, 1984), while individual adaptation can be explained more from how they deal with stress rather than the stressful experience itself. Senior nursing students often resort to avoidance or problem solving as a coping strategy for stress, while those students with more competence in handling situations are reported to use the problem solving method to deal with stress (Chan et al., 2009). Individuals with high self-efficacy handle current situations well and decrease their level of stress as well as negative emotions (Bandura, 1994). Perceived self-efficacy is defined as people's beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affect their lives (Bandura, 1994). Self-efficacy is an important contributor to the attainment of further competencies and success in early adulthood. Higher self-efficacy was associated with problem-focused coping efforts, and lower self-efficacy was associated with greater emotion-focused coping efforts (Chwalisz et al., 1992). Lower self-efficacy is associated with stress, depression, anxiety, and helplessness, while a strong sense of self-efficacy facilitates cognitive processes and performance (Zulkosky, 2009). Park et al. (2002) studied self-efficacy, coping methods, and academic and job-seeking stress among nursing students. The findings suggest that greater selfefficacy is correlated with less academic and job-seeking stress, but that self-efficacy is not associated with coping methods. REBT is based on the ABC model of psychological disturbance and therapy where “A” represents the activating stressful life event, that is, the external event to which the person is responding, “B” refers to irrational beliefs, and “C” refers to the emotional, behavioral, and cognitive consequences of these irrational beliefs—i.e., psychological disturbance and maladaptive behaviors. The major assumption of this model suggests that rational beliefs lead to functional consequences, while irrational beliefs lead to dysfunctional consequences (Ellis, 1993; David et al., 2005) and empirical support for this assumption has been reported in previous studies (Chang and D'Zurilla, 1996; Muran et al., 1989). The aim of REBT is to replace irrational beliefs which are rigid, inconsistent with reality and illogical with a new set of rational beliefs which are flexible and non- extreme (Dryden and David, 2008). REBT helps people learn to challenge their own irrational thinking and develop the habit of thinking in beneficial and rational ways. This shift enables people to behave more effectively and, ultimately, experience healthy emotions (Ellis, 1993). There is evidence supporting the use of REBT for reducing negative emotions such as anxiety, stress, depression, and irrationality as well as improving self-efficacy and stress-coping strategies (Baek and Yu, 2005; Calear and Christensen, 2010; Gonzalez et al., 2004). The REBT's cognitive strategy, which helps one to quickly accept oneself and solve problems, has been reported to be helpful among nursing students with low scores in decreasing anxiety and in preparing for the National Council Licensure Examination for registered nurses (Poorman et al., 2010). Therefore, the aim of this study is to examine the effects of an REBT program for senior nursing students facing licensure exam aimed at õenhancing stress-coping strategies and self-efficacy. Methods Study design This study employed a quasi-experimental pre- and post-test design to test the effects of REBT for senior nursing students on coping strategies and self-efficacy.
Participants and setting Eligible participants were senior nursing students in a university in Gyeonggi area. All 35 students agreed to participate. Following the informed consent procedure, 35 students were randomly assigned to the experimental group (n = 18) and the control group (n = 17). One student in the control group dropped out of the study because of missing post-test data. As a result, there were 34 students: 18 in the experimental group and 16 in the control group. Ethical considerations Ethical approval was obtained from the Institutional Review Board of B University Hospital (BD2010-101D). Written informed consent was obtained from all participants, and they were reassured of confidentiality and anonymity. Instruments Coping strategy indicator Coping strategy was assessed utilizing a Korean version of Amirkhan's Coping Strategy Indicator (Shin and Kim, 2002). It was composed of 33 items with a 3-point Likert-type scale (1 = not at all, 2 = a little, 3 = a lot). It was divided into three types: 11 items for seeking support that is coping with stress by looking for advice or emotional support (e.g., confined your fears and worries to a friend or relative), 11 items for problem-solving that is resolving problems directly by fighting rather than running away (e.g., tried to solve the problem), and 11 items for avoidance that is reacting with a flight response rather than facing problems (e.g., avoided being with people in general). Higher scores for each type indicated a more frequent use of that type of coping strategy. The reported reliability of this scale was .84, ranging from .67 to .90 for the subscales (Shin and Kim, 2002). In this study, Cronbach's alpha coefficient was .83, ranging from .76 to .89 for the subscales. Self-efficacy Self-efficacy was measured with a modified Korean version (Kim, 2009) of the scale originally developed by Sherer and colleagues (1982). The questionnaire was composed of 24 items measuring three subscales: 7 items for self-confidence (e.g., If I can't do a job the first time, I keep trying until I can), 12 items for self-regulation (e.g., When I have something unpleasant to do, I stick to it until I finish it), and 5 items for preference of task difficulty (e.g., I am capable of dealing with most problems that come up in life). A 5-point Likert scale (1 = strongly disagree, 5 = strongly agree) was used with this instrument. The sum of the item scores reflects general self-efficacy. The higher the total score, the more self-efficacious the respondent. The reported reliability of this scale ranged from .76 to .88 for the subscales (Kim, 2009). In this study, Cronbach's alpha coefficient was .86, ranging from .62 to .70 for the subscales. Procedures The purpose and procedures of the study were explained to participants and all of them gave written consent once approval had been granted to conduct the study. The REBT program was implemented for 8 sessions in 4 weeks, twice a week for 60 min each session. The intervention was implemented by one researcher of our research team who had a doctoral degree in psychiatric nursing and had experience in REBT program for university students. The experimental group was divided into 2 subgroups for morning and afternoon sessions. At the first session (pretest) of the 8 sessions, participants in the experimental group were asked to fill out a self-report questionnaire describing their demographic characteristics, coping strategies, and self-efficacy. The post-test was conducted
Please cite this article as: Kim, M.A., et al., Effects of rational emotive behavior therapy for senior nursing students on coping strategies and selfefficacy, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.11.013
M.A. Kim et al. / Nurse Education Today xxx (2014) xxx–xxx
at the final session. As for the control group, we performed the pre-test and post-test at the same time as the experimental group, using the same questionnaires. After the study, the participants in the control group were given the same REBT program for ethical reasons.
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independent-sample t tests were used to compare the baseline measurements of the demographic characteristics and the dependent variables between the experimental and control groups. The effects of the intervention were tested with independent-sample t tests. Data were analyzed using SPSS/Win 12.0 (SPSS, Inc., Chicago, IL), and the level of significance was set at .05 in a two-tailed test for all tests.
REBT program Results The contents of the REBT program were developed based on the guidelines provided by Garcy (2009) and the program described by Kim (2001), in which the effectiveness of the REBT for university students was reported. We revised and improved the program before its implementation by seeking advice from REBT program experts. The program consisted of 8 sessions in total, and each session proceeded as follows: warm up, presenting homework assignment and sharing experiences with group members, performing the contents of the current session, and closing. We utilized a variety of methods for each session, including drawing, expressing opinions using Post-it note, and filling out the structured materials, in order to make individual or group activities interesting to perform. The content of Session 1 was providing general orientation to the program and establishing rapport with participants. Giving a brief introduction to REBT, we also explained the purpose of doing a homework set every session. The content of Sessions 2 and 3 was guiding participants to identify unhealthy negative emotions in their daily lives and recognize how these emotions were associated with irrational beliefs. The participants were also encouraged to present their homework, which included recording events, beliefs, and emotions experienced over the past few days, and share them with other partners. The content of Sessions 4 and 5 was disputing irrational beliefs and transforming them into rational beliefs. Sessions 6 and 7 were stopping negative self-talk and developing healthy emotions based on rational beliefs. The participants were then directed to develop healthy coping strategies and practice them by role playing. In Session 8, they were guided to write and present mission statements. They then commented on the program and took the post-test. Data analysis The Shapiro–Wilk test was conducted to verify the normal distribution of study variables. The variables were normally distributed and parametric tests were used. Chi-square test, Fisher's exact test, and
Demographic characteristics and homogeneity test Table 1 shows the characteristics of the subjects at baseline. There were no significant differences in age, gender, type of residence, economic status, religion, motive for entrance, or major satisfaction between the two groups. Table 2 presents the dependent variables of the subjects before intervention. For the measures at baseline, there were no differences between the two groups in coping strategies or self-efficacy. Effects of REBT Among the types of stress-coping strategies, seeking social support and problem solving score increased for the intervention group (25.17 ± 4.83 before to 26.28 ± 5.87 after, 24.94 ± 4.72 before to 26.11 ± 3.81 after, respectively), while for the control group it decreased (24.06 ± 3.71 before to 23.75 ± 2.62 after, 24.38 ± 3.01 before to 23.56 ± 2.19 after, respectively). Avoidance score for both intervention group (18.89 ± 3.77 before to 17.78 ± 3.25 after) and control group (21.31 ± 4.27 before to 18.56 ± 4.08 after) decreased. The mean difference between the experimental group and the control group for the preto post- intervention comparison showed a non-significant change for stress-coping strategies such as seeking social support (t = 1.42, p = .166), problem solving (t = 1.57, p = .126), or avoidance (t = 1.47, p = .154). Although the types of stress-coping strategies did not change significantly after intervention in the mean difference between the two groups, one of the types of stress coping strategies, there was a significant difference in problem solving method between the experimental and the control group after the intervention (t = 2.42, p = .022). The self-efficacy score for the intervention group increased from 82.00 ± 9.68 before intervention to 86.89 ± 11.78 after intervention, while for the control group it decreased from 80.06 ± 8.35 before to 80.00 ± 8.17 after; this mean difference was statistically significant
Table 1 Homogeneity of general characteristics between experimental and control group. (N = 34) Variables
Age (years) Gender Residence form Economic status Religion Reason for choosing nursing
Major satisfaction
a
Categories
Male Female Family or religion Dormitory or live apart from one's own family Medium Low Yes No Employment guarantee Service mind Correspondence to grade Suggestion of family Professional trait Good Average Bad
Con (n = 16)
Exp (n = 18)
t or χ2
p
M (SD) or n (%)
M (SD) or n (%)
(df)
22.6 (1.77) 2 (12.5) 14 (87.5) 3 (18.8) 13 (81.3) 14 (87.5) 2 (12.5) 9 (56.2) 7 (43.8) 4 (25.0) 1 (6.3) 2 (12.5) 7 (43.8) 2 (12.5) 9 (56.3) 7 (43.8) 0 (0.0)
22.7 (1.13) 1 (5.6) 17 (94.4) 7 (38.9) 11 (61.1) 18 (100.0) 0 (0.0) 12 (66.7) 6 (33.3) 7 (38.9) 1 (5.6) 1 (5.6) 4 (22.2) 5 (27.8) 12 (66.7) 5 (27.8) 1 (5.6)
t(32) = 0.195 χ2(1) = 0.508
.847 .591a
χ2(1) = 1.655
.270a
χ2(1) = 2.391
.214a
χ2(1) = 0.389
.725
2
χ (4) = 3.149
.533
χ2(2) = 1.650
.438
Fisher's exact test; Exp = experiment group; Con = control group.
Please cite this article as: Kim, M.A., et al., Effects of rational emotive behavior therapy for senior nursing students on coping strategies and selfefficacy, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.11.013
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M.A. Kim et al. / Nurse Education Today xxx (2014) xxx–xxx
Table 2 Homogeneity test of dependent variables between experimental and control groups. (N = 34) Variables
Coping strategies Seeking social support Problem solving Avoidance Self-efficacy Self-confidence Self-regulation Preference of task difficulty
Con (n = 16)
Exp (n = 18)
M (SD)
M (SD)
24.06 (3.71) 24.38 (3.01) 21.31 (4.27) 80.06 (8.35) 23.38 (2.22) 39.88 (4.30) 16.81 (2.59)
25.17 (4.83) 24.94 (4.72) 18.89 (3.77) 82.00 (9.68) 23.72 (3.25) 40.67 (4.81) 17.61 (2.17)
t(df)
t(32) t(32) t(32) t(32) t(32) t(32) t(32)
p
= = = = = = =
1.74 0.42 −1.76 0.62 0.36 0.50 0.98
.465 .675 .088 .539 .722 .618 .335
Exp = experiment group; Con = control group.
(t = 2.24, p = .032). Among the three subscales for self-efficacy, there was a significant difference for self-regulation only (t = 2.71, p = .012) (Table 3). Discussion Compared to the control group, nursing students who participated in the REBT intervention group had better self-efficacy. There were partial differences in the types of coping strategy with stress. Effects on coping strategies After examining the effects of REBT on the coping strategies of senior nursing students, it was found that there were no statistically significant mean differences between the intervention and control group in any type of coping strategies. Nevertheless, while not significant, most of the differences were in the direction that one would expect if the REBT increased social support seeking and problem solving behavior and reduced avoidance behavior. There was also a significant difference between the experimental and control group in dealing with problem solving after the intervention. In a study by Choi et al. (2009), nursing students who had received self-exposure and rational emotion training significantly increased their active stress-coping strategies such as problem-solving approach compared to before the training, while
there were significant differences in the stress coping strategy scores between the before and after training groups. The reasons for the nonsignificant effect in our study seem to be the length of the intervention period and condition. According to the meta-analysis results regarding the effect of REBT (Gonzalez et al., 2004), the effect was larger in proportion to the length of the REBT session. Therefore, for effective results in the future, the program should be scheduled to be longer. Another reason is the heightened stress of the students over time since the intervention period was 2–3 months prior to the national licensure examination. The participants wrote in a journal in every session, and some students said that the REBT program was very helpful but they lacked time to participate faithfully. Problem solving approach has a positive influence while avoidance approach has a negative effect on physio-psycho-social health (Sheu et al., 2002), so even though there were no statistical differences according to our study, the REBT program is expected to have a positive influence on the stress-coping strategies of nursing students. Effects on self-efficacy There was a significant increase in self-efficacy after the REBT in our study. This result is consistent with the findings of Baek and Yu (2005), which stated that self-efficacy increased after receiving REBT group counseling for nurses with high scores on a dysfunctional attitude
Table 3 Mean differences in dependent variables between experimental and control groups. (N = 34) Variables
Coping strategies Seeking social support
Problem solving
Avoidance
Self-efficacy
Self-confidence
Self-regulation
Preference of task difficulty
Con Exp t (p) Con Exp t (p) Con Exp t (p) Con Exp t (p) Con Exp t (p) Con Exp t (p) Con Exp t (p)
Pretest
Posttest
Mean difference
M (SD)
M (SD)
M (SD)
t
p
24.06 (3.71) 25.17 (4.83)
23.75 (2.62) 26.28 (5.87) 1.65 (.112) 23.56 (2.19) 26.11 (3.82) 2.42 (.022) 18.56 (4.08) 17.78 (3.25) −0.62 (.537) 80.00 (8.17) 86.89 (11.78) 1.96 (.059) 23.63 (2.66) 25.44 (3.67) 1.64 (.111) 39.13 (4.05) 42.94 (5.77) 2.21 (.034) 17.25 (2.15) 18.50 (2.60) 1.52 (.139)
−0.31 (2.94) 1.11 (2.91)
1.42
.166
−0.81 (3.19) 1.17 (4.05)
1.57
.126
−2.75 (3.77) −1.11 (2.54)
1.47
.154
−0.88 (9.60) 5.94 (8.17)
2.24
.032
0.25 (1.65) 1.72 (2.49)
2.00
.054
−0.75 (3.92) 2.28 (2.27)
2.71
.012
24.38 (3.01) 24.94 (4.72) 21.31 (4.27) 18.89 (3.77) 80.06 (8.35) 82.00 (9.68) 23.38 (2.22) 23.72 (3.25) 39.88 (4.30) 40.67 (4.81) 16.81 (2.59) 17.61 (2.17)
0.44 (2.39) 0.89 (1.45)
.803
.428
Exp = experiment group; Con = control group.
Please cite this article as: Kim, M.A., et al., Effects of rational emotive behavior therapy for senior nursing students on coping strategies and selfefficacy, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.11.013
M.A. Kim et al. / Nurse Education Today xxx (2014) xxx–xxx
scale. In a study by Kim (2001), career group counseling with applied REBT was effective in increasing the self-efficacy of university students. In addition, in a study by Choi et al. (2009), rational emotive training was effective in increasing the self-efficacy of nursing students. Self-efficacy has a negative relationship with irrational beliefs, and it seems that self-efficacy improved during the substitution process of irrational beliefs to rational beliefs through logical arguments in our intervention. In particular, the fourth year students in our study had a heightened state of stress from the upcoming national licensure examination for registered nurses and from the prospect of future employment. However, through observation and sharing of the problem cognition and solving method of others through the program, their confidence and self-regulation increased so they could do the same. For example, one student in the experimental group wanted to evade the practice examination, but through the program realized she had to study hard and face the exam so she tried her best and gave a good effort. Even among nursing students, stress coping strategies are related to self-efficacy so nursing students with higher self-efficacy cope in a more problem-focused method than students with a lower self-efficacy (Park et al., 2002). Through this study's intervention, the nursing students improved their self-efficacy, and although the influence is not statistically significant, it caused a change in their stress-coping strategies. Therefore, to reduce stress using effective coping strategies for senior nursing students who are taking the national licensure examinations and facing the prospect of future employment, educational approaches that improve self-efficacy should be considered in their coursework. Limitation This study has several limitations, which need to be considered when interpreting the results. First, this study sampled a small population; therefore, the lack of significant differences between the intervention and the control groups needs to be interpreted with caution. Second, the participants knew whether they were in the intervention or control group. It might have influenced some of the subjective measures of the dependent variables. For example, the participants in the intervention group may have answered in a more desirable direction because they felt better after they had received the intervention. Third, the intervention was a time-consuming program for participants ahead of national licensure examination, so we strategically minimized the intervention period. The intervention period was 4 weeks, during which the change in measures may have not been enough because some of the measures did not change over a short time. In addition, the study was conducted 2 months prior to the national licensure examination for registered nurses; therefore, the students were more stressed compared to other times. Conclusion While the study population was too small to generate any definite conclusions, our findings suggest that REBT has potential to improve the coping strategies and self-efficacy of senior nursing students who face the prospect of future employment and will take the national licensure examination. The study has implications for nursing educators and policy makers as it highlights the importance of group or individual counseling of rational ideas to reduce their negative emotions such as stress of senior nursing students hindering their educational and personal growth. REBT program could be developed and sustained as senior students
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Nurse Education Today journal homepage: www.elsevier.com/nedt
Effects of rational emotive behavior therapy for senior nursing students on coping strategies and self-efficacy Myung Ah Kim a,1, Jiyoung Kim b,2, Eun Jung Kim c,⁎ a b c
Department of Nursing, College of Nursing, CHA University, Bundang CHA Medical Center, Yatap-dong, Bundang-gu, Seongnam, Gyeonggi-do, 463-712, Korea College of Nursing, Chonbuk National University, 567 Baekje-daero, Deokjin-gu, Jeonju, Jeollabuk-do, 561-756, Korea Division of Nursing, College of Medicine, Hallym University, 1 Hallymdaehak-gil, Chuncheon, Gangwon-do, 200-702, Korea
a r t i c l e
i n f o
Article history: Accepted 19 November 2014 Available online xxxx Keywords: Rational emotive psychotherapy Cognitive therapy Psychological adaptation Self-efficacy Nursing students
s u m m a r y Background: Senior nursing students are faced with various types of stressful events such as taking the national licensure exam or finding employment. Such stress can generate maladaptive behaviors as well as physical and psychological symptoms. There is evidence supporting the use of rational emotive behavior therapy (REBT) for reducing disruptive behaviors and negative emotions as well as improving self-efficacy and stress-coping strategies. Objectives: The purpose of this study is to examine the effects of rational emotive behavior therapy (REBT) on stress coping strategies and self-efficacy for senior nursing students. Methods: Thirty-four senior nursing students in a nursing college were assigned randomly to an experimental group (n = 18) and a control group (n = 16). The REBT program consisted of 8 sessions, and it was implemented for a 4-week period. Outcome measures assessed stress-coping strategies and self-efficacy before and after intervention. Results: After intervention with REBT, the mean difference scores for self-efficacy (p = .032) were significantly higher in the experimental group than in the control group. However, the mean difference scores for seeking social support (p = .166), problem solving (p = .126), and avoidance (p = .154) in stress-coping strategies were not significantly different between the two groups. Conclusion: The results imply that group counseling based on REBT enhances the self-efficacy among senior nursing students before graduation. As regards stress coping strategies, a longer intervention period is suggested. © 2014 Elsevier Ltd. All rights reserved.
Introduction The levels of self-esteem and stress of nursing students are different at different times throughout their education and training (Edwards et al., 2010). Edwards et al. (2010) found that stress level was higher at the beginning of the final year compared to stress level reported at any other time, and by the time the students finished their course training and completed their examinations, their stress levels went down. Among nursing students in Korea, employability is the most influential factor that affected choosing a nursing major, they want to work in a large hospital and place the highest value on it. Thus, they are in competition with their fellow students for better grade scores. Stress experienced by nursing students may result in them finding competing demands difficult to cope with. This kind of stress can generate maladaptive behaviors such as smoking, drinking, avoidance of preparation of exams, or cutting off relationships as well as physical
⁎ Corresponding author. Tel.: +82 33 248 2725; fax: +82 33 248 2734. E-mail addresses: [email protected] (M.A. Kim), [email protected] (J. Kim), [email protected] (E.J. Kim). 1 Tel.: +82 31 825 8316. 2 Tel.: +82 63 270 2401; fax: +82 63 270 3127.
and psychological symptoms (Jenkins and Palmer, 2003; Sheu et al., 2002). Even after employment, they are not able to cope well with stress from their workload and relationship conflicts so there have been increases in the number of cases in which they switch jobs within one year of employment (Moon and Lee, 2010). Thus, nursing students need to cope effectively with their stress for a better college life to help them prepare for their future careers. Rational emotive behavior therapy (REBT) is one of the cognitivebehavioral approaches to counseling and psychotherapy which was developed by Ellis. REBT is being used as treatment of choice for psychological difficulties by changing beliefs and consequent emotional response (MacInnes, 2004). In REBT, it is hypothesized that stress is largely determined not by the unpleasant events or stressors people experience in their lives, but mainly by their irrational beliefs about what is happening to them (Jenkins and Palmer, 2003). Self-efficacy influence the amount of stress and anxiety individuals experience as they engage in a task and the level of accomplishment they realize. Most people engage in tasks in which they feel competent and confident and avoid those in which they do not (Bandura, 1994). Senior nursing students are faced with the national licensure exam and ready to enter into society. In this study, in an attempt to enhance senior nursing students' self-efficacy and stress coping strategies,
http://dx.doi.org/10.1016/j.nedt.2014.11.013 0260-6917/© 2014 Elsevier Ltd. All rights reserved.
Please cite this article as: Kim, M.A., et al., Effects of rational emotive behavior therapy for senior nursing students on coping strategies and selfefficacy, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.11.013
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M.A. Kim et al. / Nurse Education Today xxx (2014) xxx–xxx
we constructed the REBT program for senior nursing students and examined the effects of the REBT program. Background Effective coping strategies are vital to nursing students for stress relief. Coping means an individual's conscious or subconscious actions to control stressful situations that are unavoidable (Lazarus and Folkman, 1984), while individual adaptation can be explained more from how they deal with stress rather than the stressful experience itself. Senior nursing students often resort to avoidance or problem solving as a coping strategy for stress, while those students with more competence in handling situations are reported to use the problem solving method to deal with stress (Chan et al., 2009). Individuals with high self-efficacy handle current situations well and decrease their level of stress as well as negative emotions (Bandura, 1994). Perceived self-efficacy is defined as people's beliefs about their capabilities to produce designated levels of performance that exercise influence over events that affect their lives (Bandura, 1994). Self-efficacy is an important contributor to the attainment of further competencies and success in early adulthood. Higher self-efficacy was associated with problem-focused coping efforts, and lower self-efficacy was associated with greater emotion-focused coping efforts (Chwalisz et al., 1992). Lower self-efficacy is associated with stress, depression, anxiety, and helplessness, while a strong sense of self-efficacy facilitates cognitive processes and performance (Zulkosky, 2009). Park et al. (2002) studied self-efficacy, coping methods, and academic and job-seeking stress among nursing students. The findings suggest that greater selfefficacy is correlated with less academic and job-seeking stress, but that self-efficacy is not associated with coping methods. REBT is based on the ABC model of psychological disturbance and therapy where “A” represents the activating stressful life event, that is, the external event to which the person is responding, “B” refers to irrational beliefs, and “C” refers to the emotional, behavioral, and cognitive consequences of these irrational beliefs—i.e., psychological disturbance and maladaptive behaviors. The major assumption of this model suggests that rational beliefs lead to functional consequences, while irrational beliefs lead to dysfunctional consequences (Ellis, 1993; David et al., 2005) and empirical support for this assumption has been reported in previous studies (Chang and D'Zurilla, 1996; Muran et al., 1989). The aim of REBT is to replace irrational beliefs which are rigid, inconsistent with reality and illogical with a new set of rational beliefs which are flexible and non- extreme (Dryden and David, 2008). REBT helps people learn to challenge their own irrational thinking and develop the habit of thinking in beneficial and rational ways. This shift enables people to behave more effectively and, ultimately, experience healthy emotions (Ellis, 1993). There is evidence supporting the use of REBT for reducing negative emotions such as anxiety, stress, depression, and irrationality as well as improving self-efficacy and stress-coping strategies (Baek and Yu, 2005; Calear and Christensen, 2010; Gonzalez et al., 2004). The REBT's cognitive strategy, which helps one to quickly accept oneself and solve problems, has been reported to be helpful among nursing students with low scores in decreasing anxiety and in preparing for the National Council Licensure Examination for registered nurses (Poorman et al., 2010). Therefore, the aim of this study is to examine the effects of an REBT program for senior nursing students facing licensure exam aimed at õenhancing stress-coping strategies and self-efficacy. Methods Study design This study employed a quasi-experimental pre- and post-test design to test the effects of REBT for senior nursing students on coping strategies and self-efficacy.
Participants and setting Eligible participants were senior nursing students in a university in Gyeonggi area. All 35 students agreed to participate. Following the informed consent procedure, 35 students were randomly assigned to the experimental group (n = 18) and the control group (n = 17). One student in the control group dropped out of the study because of missing post-test data. As a result, there were 34 students: 18 in the experimental group and 16 in the control group. Ethical considerations Ethical approval was obtained from the Institutional Review Board of B University Hospital (BD2010-101D). Written informed consent was obtained from all participants, and they were reassured of confidentiality and anonymity. Instruments Coping strategy indicator Coping strategy was assessed utilizing a Korean version of Amirkhan's Coping Strategy Indicator (Shin and Kim, 2002). It was composed of 33 items with a 3-point Likert-type scale (1 = not at all, 2 = a little, 3 = a lot). It was divided into three types: 11 items for seeking support that is coping with stress by looking for advice or emotional support (e.g., confined your fears and worries to a friend or relative), 11 items for problem-solving that is resolving problems directly by fighting rather than running away (e.g., tried to solve the problem), and 11 items for avoidance that is reacting with a flight response rather than facing problems (e.g., avoided being with people in general). Higher scores for each type indicated a more frequent use of that type of coping strategy. The reported reliability of this scale was .84, ranging from .67 to .90 for the subscales (Shin and Kim, 2002). In this study, Cronbach's alpha coefficient was .83, ranging from .76 to .89 for the subscales. Self-efficacy Self-efficacy was measured with a modified Korean version (Kim, 2009) of the scale originally developed by Sherer and colleagues (1982). The questionnaire was composed of 24 items measuring three subscales: 7 items for self-confidence (e.g., If I can't do a job the first time, I keep trying until I can), 12 items for self-regulation (e.g., When I have something unpleasant to do, I stick to it until I finish it), and 5 items for preference of task difficulty (e.g., I am capable of dealing with most problems that come up in life). A 5-point Likert scale (1 = strongly disagree, 5 = strongly agree) was used with this instrument. The sum of the item scores reflects general self-efficacy. The higher the total score, the more self-efficacious the respondent. The reported reliability of this scale ranged from .76 to .88 for the subscales (Kim, 2009). In this study, Cronbach's alpha coefficient was .86, ranging from .62 to .70 for the subscales. Procedures The purpose and procedures of the study were explained to participants and all of them gave written consent once approval had been granted to conduct the study. The REBT program was implemented for 8 sessions in 4 weeks, twice a week for 60 min each session. The intervention was implemented by one researcher of our research team who had a doctoral degree in psychiatric nursing and had experience in REBT program for university students. The experimental group was divided into 2 subgroups for morning and afternoon sessions. At the first session (pretest) of the 8 sessions, participants in the experimental group were asked to fill out a self-report questionnaire describing their demographic characteristics, coping strategies, and self-efficacy. The post-test was conducted
Please cite this article as: Kim, M.A., et al., Effects of rational emotive behavior therapy for senior nursing students on coping strategies and selfefficacy, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.11.013
M.A. Kim et al. / Nurse Education Today xxx (2014) xxx–xxx
at the final session. As for the control group, we performed the pre-test and post-test at the same time as the experimental group, using the same questionnaires. After the study, the participants in the control group were given the same REBT program for ethical reasons.
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independent-sample t tests were used to compare the baseline measurements of the demographic characteristics and the dependent variables between the experimental and control groups. The effects of the intervention were tested with independent-sample t tests. Data were analyzed using SPSS/Win 12.0 (SPSS, Inc., Chicago, IL), and the level of significance was set at .05 in a two-tailed test for all tests.
REBT program Results The contents of the REBT program were developed based on the guidelines provided by Garcy (2009) and the program described by Kim (2001), in which the effectiveness of the REBT for university students was reported. We revised and improved the program before its implementation by seeking advice from REBT program experts. The program consisted of 8 sessions in total, and each session proceeded as follows: warm up, presenting homework assignment and sharing experiences with group members, performing the contents of the current session, and closing. We utilized a variety of methods for each session, including drawing, expressing opinions using Post-it note, and filling out the structured materials, in order to make individual or group activities interesting to perform. The content of Session 1 was providing general orientation to the program and establishing rapport with participants. Giving a brief introduction to REBT, we also explained the purpose of doing a homework set every session. The content of Sessions 2 and 3 was guiding participants to identify unhealthy negative emotions in their daily lives and recognize how these emotions were associated with irrational beliefs. The participants were also encouraged to present their homework, which included recording events, beliefs, and emotions experienced over the past few days, and share them with other partners. The content of Sessions 4 and 5 was disputing irrational beliefs and transforming them into rational beliefs. Sessions 6 and 7 were stopping negative self-talk and developing healthy emotions based on rational beliefs. The participants were then directed to develop healthy coping strategies and practice them by role playing. In Session 8, they were guided to write and present mission statements. They then commented on the program and took the post-test. Data analysis The Shapiro–Wilk test was conducted to verify the normal distribution of study variables. The variables were normally distributed and parametric tests were used. Chi-square test, Fisher's exact test, and
Demographic characteristics and homogeneity test Table 1 shows the characteristics of the subjects at baseline. There were no significant differences in age, gender, type of residence, economic status, religion, motive for entrance, or major satisfaction between the two groups. Table 2 presents the dependent variables of the subjects before intervention. For the measures at baseline, there were no differences between the two groups in coping strategies or self-efficacy. Effects of REBT Among the types of stress-coping strategies, seeking social support and problem solving score increased for the intervention group (25.17 ± 4.83 before to 26.28 ± 5.87 after, 24.94 ± 4.72 before to 26.11 ± 3.81 after, respectively), while for the control group it decreased (24.06 ± 3.71 before to 23.75 ± 2.62 after, 24.38 ± 3.01 before to 23.56 ± 2.19 after, respectively). Avoidance score for both intervention group (18.89 ± 3.77 before to 17.78 ± 3.25 after) and control group (21.31 ± 4.27 before to 18.56 ± 4.08 after) decreased. The mean difference between the experimental group and the control group for the preto post- intervention comparison showed a non-significant change for stress-coping strategies such as seeking social support (t = 1.42, p = .166), problem solving (t = 1.57, p = .126), or avoidance (t = 1.47, p = .154). Although the types of stress-coping strategies did not change significantly after intervention in the mean difference between the two groups, one of the types of stress coping strategies, there was a significant difference in problem solving method between the experimental and the control group after the intervention (t = 2.42, p = .022). The self-efficacy score for the intervention group increased from 82.00 ± 9.68 before intervention to 86.89 ± 11.78 after intervention, while for the control group it decreased from 80.06 ± 8.35 before to 80.00 ± 8.17 after; this mean difference was statistically significant
Table 1 Homogeneity of general characteristics between experimental and control group. (N = 34) Variables
Age (years) Gender Residence form Economic status Religion Reason for choosing nursing
Major satisfaction
a
Categories
Male Female Family or religion Dormitory or live apart from one's own family Medium Low Yes No Employment guarantee Service mind Correspondence to grade Suggestion of family Professional trait Good Average Bad
Con (n = 16)
Exp (n = 18)
t or χ2
p
M (SD) or n (%)
M (SD) or n (%)
(df)
22.6 (1.77) 2 (12.5) 14 (87.5) 3 (18.8) 13 (81.3) 14 (87.5) 2 (12.5) 9 (56.2) 7 (43.8) 4 (25.0) 1 (6.3) 2 (12.5) 7 (43.8) 2 (12.5) 9 (56.3) 7 (43.8) 0 (0.0)
22.7 (1.13) 1 (5.6) 17 (94.4) 7 (38.9) 11 (61.1) 18 (100.0) 0 (0.0) 12 (66.7) 6 (33.3) 7 (38.9) 1 (5.6) 1 (5.6) 4 (22.2) 5 (27.8) 12 (66.7) 5 (27.8) 1 (5.6)
t(32) = 0.195 χ2(1) = 0.508
.847 .591a
χ2(1) = 1.655
.270a
χ2(1) = 2.391
.214a
χ2(1) = 0.389
.725
2
χ (4) = 3.149
.533
χ2(2) = 1.650
.438
Fisher's exact test; Exp = experiment group; Con = control group.
Please cite this article as: Kim, M.A., et al., Effects of rational emotive behavior therapy for senior nursing students on coping strategies and selfefficacy, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.11.013
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M.A. Kim et al. / Nurse Education Today xxx (2014) xxx–xxx
Table 2 Homogeneity test of dependent variables between experimental and control groups. (N = 34) Variables
Coping strategies Seeking social support Problem solving Avoidance Self-efficacy Self-confidence Self-regulation Preference of task difficulty
Con (n = 16)
Exp (n = 18)
M (SD)
M (SD)
24.06 (3.71) 24.38 (3.01) 21.31 (4.27) 80.06 (8.35) 23.38 (2.22) 39.88 (4.30) 16.81 (2.59)
25.17 (4.83) 24.94 (4.72) 18.89 (3.77) 82.00 (9.68) 23.72 (3.25) 40.67 (4.81) 17.61 (2.17)
t(df)
t(32) t(32) t(32) t(32) t(32) t(32) t(32)
p
= = = = = = =
1.74 0.42 −1.76 0.62 0.36 0.50 0.98
.465 .675 .088 .539 .722 .618 .335
Exp = experiment group; Con = control group.
(t = 2.24, p = .032). Among the three subscales for self-efficacy, there was a significant difference for self-regulation only (t = 2.71, p = .012) (Table 3). Discussion Compared to the control group, nursing students who participated in the REBT intervention group had better self-efficacy. There were partial differences in the types of coping strategy with stress. Effects on coping strategies After examining the effects of REBT on the coping strategies of senior nursing students, it was found that there were no statistically significant mean differences between the intervention and control group in any type of coping strategies. Nevertheless, while not significant, most of the differences were in the direction that one would expect if the REBT increased social support seeking and problem solving behavior and reduced avoidance behavior. There was also a significant difference between the experimental and control group in dealing with problem solving after the intervention. In a study by Choi et al. (2009), nursing students who had received self-exposure and rational emotion training significantly increased their active stress-coping strategies such as problem-solving approach compared to before the training, while
there were significant differences in the stress coping strategy scores between the before and after training groups. The reasons for the nonsignificant effect in our study seem to be the length of the intervention period and condition. According to the meta-analysis results regarding the effect of REBT (Gonzalez et al., 2004), the effect was larger in proportion to the length of the REBT session. Therefore, for effective results in the future, the program should be scheduled to be longer. Another reason is the heightened stress of the students over time since the intervention period was 2–3 months prior to the national licensure examination. The participants wrote in a journal in every session, and some students said that the REBT program was very helpful but they lacked time to participate faithfully. Problem solving approach has a positive influence while avoidance approach has a negative effect on physio-psycho-social health (Sheu et al., 2002), so even though there were no statistical differences according to our study, the REBT program is expected to have a positive influence on the stress-coping strategies of nursing students. Effects on self-efficacy There was a significant increase in self-efficacy after the REBT in our study. This result is consistent with the findings of Baek and Yu (2005), which stated that self-efficacy increased after receiving REBT group counseling for nurses with high scores on a dysfunctional attitude
Table 3 Mean differences in dependent variables between experimental and control groups. (N = 34) Variables
Coping strategies Seeking social support
Problem solving
Avoidance
Self-efficacy
Self-confidence
Self-regulation
Preference of task difficulty
Con Exp t (p) Con Exp t (p) Con Exp t (p) Con Exp t (p) Con Exp t (p) Con Exp t (p) Con Exp t (p)
Pretest
Posttest
Mean difference
M (SD)
M (SD)
M (SD)
t
p
24.06 (3.71) 25.17 (4.83)
23.75 (2.62) 26.28 (5.87) 1.65 (.112) 23.56 (2.19) 26.11 (3.82) 2.42 (.022) 18.56 (4.08) 17.78 (3.25) −0.62 (.537) 80.00 (8.17) 86.89 (11.78) 1.96 (.059) 23.63 (2.66) 25.44 (3.67) 1.64 (.111) 39.13 (4.05) 42.94 (5.77) 2.21 (.034) 17.25 (2.15) 18.50 (2.60) 1.52 (.139)
−0.31 (2.94) 1.11 (2.91)
1.42
.166
−0.81 (3.19) 1.17 (4.05)
1.57
.126
−2.75 (3.77) −1.11 (2.54)
1.47
.154
−0.88 (9.60) 5.94 (8.17)
2.24
.032
0.25 (1.65) 1.72 (2.49)
2.00
.054
−0.75 (3.92) 2.28 (2.27)
2.71
.012
24.38 (3.01) 24.94 (4.72) 21.31 (4.27) 18.89 (3.77) 80.06 (8.35) 82.00 (9.68) 23.38 (2.22) 23.72 (3.25) 39.88 (4.30) 40.67 (4.81) 16.81 (2.59) 17.61 (2.17)
0.44 (2.39) 0.89 (1.45)
.803
.428
Exp = experiment group; Con = control group.
Please cite this article as: Kim, M.A., et al., Effects of rational emotive behavior therapy for senior nursing students on coping strategies and selfefficacy, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.11.013
M.A. Kim et al. / Nurse Education Today xxx (2014) xxx–xxx
scale. In a study by Kim (2001), career group counseling with applied REBT was effective in increasing the self-efficacy of university students. In addition, in a study by Choi et al. (2009), rational emotive training was effective in increasing the self-efficacy of nursing students. Self-efficacy has a negative relationship with irrational beliefs, and it seems that self-efficacy improved during the substitution process of irrational beliefs to rational beliefs through logical arguments in our intervention. In particular, the fourth year students in our study had a heightened state of stress from the upcoming national licensure examination for registered nurses and from the prospect of future employment. However, through observation and sharing of the problem cognition and solving method of others through the program, their confidence and self-regulation increased so they could do the same. For example, one student in the experimental group wanted to evade the practice examination, but through the program realized she had to study hard and face the exam so she tried her best and gave a good effort. Even among nursing students, stress coping strategies are related to self-efficacy so nursing students with higher self-efficacy cope in a more problem-focused method than students with a lower self-efficacy (Park et al., 2002). Through this study's intervention, the nursing students improved their self-efficacy, and although the influence is not statistically significant, it caused a change in their stress-coping strategies. Therefore, to reduce stress using effective coping strategies for senior nursing students who are taking the national licensure examinations and facing the prospect of future employment, educational approaches that improve self-efficacy should be considered in their coursework. Limitation This study has several limitations, which need to be considered when interpreting the results. First, this study sampled a small population; therefore, the lack of significant differences between the intervention and the control groups needs to be interpreted with caution. Second, the participants knew whether they were in the intervention or control group. It might have influenced some of the subjective measures of the dependent variables. For example, the participants in the intervention group may have answered in a more desirable direction because they felt better after they had received the intervention. Third, the intervention was a time-consuming program for participants ahead of national licensure examination, so we strategically minimized the intervention period. The intervention period was 4 weeks, during which the change in measures may have not been enough because some of the measures did not change over a short time. In addition, the study was conducted 2 months prior to the national licensure examination for registered nurses; therefore, the students were more stressed compared to other times. Conclusion While the study population was too small to generate any definite conclusions, our findings suggest that REBT has potential to improve the coping strategies and self-efficacy of senior nursing students who face the prospect of future employment and will take the national licensure examination. The study has implications for nursing educators and policy makers as it highlights the importance of group or individual counseling of rational ideas to reduce their negative emotions such as stress of senior nursing students hindering their educational and personal growth. REBT program could be developed and sustained as senior students
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Please cite this article as: Kim, M.A., et al., Effects of rational emotive behavior therapy for senior nursing students on coping strategies and selfefficacy, Nurse Educ. Today (2014), http://dx.doi.org/10.1016/j.nedt.2014.11.013
