Testing principles from cognitive behavior therapy for preventing stress-related ill health among newly registered nurses

Sammanfattning: Transitioning from education to working life is a challenging endeavor and newly registered nurses are one professional group that report high levels of symptoms of stress-related ill health. Transition-to-practice programs that are developed to support newly registered nurses’ professional adjustment have not been found to be effective in preventing these experiences. Previous research has shown that the development of symptoms of stress-related ill health among newly registered nurses may be modeled as a sequential-developmental process where initial levels of stress develop into symptoms of stress-related ill health through engagement in avoidance strategies when faced with challenging situations. It has been suggested that transition-to-practice programs could be strengthened by adding an element that focuses on proactive behaviors. In contrast to avoidance behaviors, engagement in proactive behaviors when faced with challenging situations at work is expected to contribute to the development of the socialization processes task mastery, role clarity, and social acceptance. The availability of these recourses is assumed to decrease the risk of situations being perceived as unpredictable, uncontrollable, and socially risky. Over time, this is expected to reduce the activation of the stress response and the risk of developing symptoms of stress-related ill health. Building on these previous lines of research, the general aim of this thesis was to investigate the possibility of preventing symptoms of stress-related ill health among newly registered nurses by supporting engagement in proactive behaviors. The overall hypothesis was that increased engagement in proactive behaviors would contribute to the development of the socialization processes, which, in turn, would mediate a reduction of experiences of stress and the risk of developing symptoms of stress-related ill health. The work was developed based on research from the fields of nursing, occupational health, stress, and organizational socialization, as well as theory and practice from cognitive behavior therapy. The methods of the four papers included in the thesis were designed based on guidelines of intervention development that suggest a stepwise procedure from the development of a theoretical understanding of the problem and a model of change, through feasibility testing, to the evaluation of effects. In Study I, using an intensive longitudinal study design with 14 consecutive weeks of data collections and a sample of 264 newly registered nurses, we found that over the first three months in the profession higher levels of the socialization processes were related to lower levels of stress. Week-by-week, increased levels of the socialization processes were related to decreased experiences of stress. Similarly, in Study II, using a longitudinal study design with yearly data collections during the first three years in the profession and a sample of 1210 newly registered nurses, we found that higher levels of the socialization processes one year after professional entry were related to lower levels of symptoms of stress-related ill health (i.e. burnout), concurrently. Furthermore, increasing levels of the socialization processes during the first three years in the profession were related to decreasing levels of symptoms of burnout during the same period. In Study III, we analyzed newly registered nurses’ engagement in proactive behaviors using principles from learning theory and data from interviews with 12 newly registered nurses. We interpreted the newly registered nurses’ reports to indicate that they engaged in proactive behaviors when they experienced uncertainty in combination with social support and a perceived ability to execute the given proactive behavior, and that engagement in proactive behaviors was reinforced by increased experiences of task mastery, role clarity, and social acceptance, and reduced experiences of stress. However, in the presence of fear in relation to making a mistake, not living up to role expectations, and not being accepted by peers, proactive behaviors were avoided. We developed an intervention to support engagement in proactive behaviors (by reducing engagement in avoidance behaviors and increasing engagement in leisure activities) using the behavior change techniques systematic exposure, reinforcing approach behaviors, and action planning. Using a non-randomized experimental design with one study condition and a sample of 65 newly registered nurses, we concluded that it would be feasible to evaluate the effect of the intervention as an add-on to a transition-to-practice program for newly registered nurses. Finally, in Study IV, we evaluated the effect of the intervention in a randomized parallel group trial with an active control and a sample of 238 newly registered nurses based on differences in change over time as well as differences in means following the end of the intervention. We found support for a small effect of the intervention on newly registered nurses’ experiences of stress and a small to medium effect on avoidance of proactive behaviors, in line with the study hypothesis. However, the results of different types of analysis were inconclusive. No statistically significant effects of the intervention could be confirmed for engagement in energizing leisure activities or task mastery, social acceptance, and role clarity. In conclusion, the findings suggest that transition-to-practice programs may benefit from adding an intervention that specifically addresses newly registered nurses’ experiences of stress and avoidance of proactive behaviors to further support them as they adjust to their new professional role.