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

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

Intensive longitudinal study of newly graduated nurses’ quick returns and self-rated stress

OBJECTIVE: Little is known about the relationship between quick returns (QR) – shift combinations that result in inter-shift rest periods <11 hours) and stress. The current study examined whether variations in the frequency of QR, both between and within individuals, were associated with changes in self-rated stress. METHODS: A questionnaire was sent weekly to newly graduated nurses during the first 12 weeks of work. Stress was measured with four items from the Stress-Energy Questionnaire on a scale from 1 “not at all” to 5 “very much” [mean 2.65, standard deviation (SD) 1.08]. Shifts worked in the past week were reported and QR were identified by evening-morning shift combinations (mean 0.98, SD 0.90 per week). In total, 350 persons were included in the analysis (3556 observations). Data were analyzed with a multilevel residual dynamic structural equation model (RDSEM) using Bayesian estimation procedures. RESULTS: There was no between-person effect of QR on stress averaged across measurement occasions (0.181, 95% CI -0.060–0.415). However, there was a small within-person effect of QR (0.031, 95% CI 0.001–0.062), meaning that more QR during a given week, compared to that person’s average, was associated with an increase in their level of stress during that week. CONCLUSIONS: Nurses were likely to report increased stress during weeks in which they worked more QR. Intervention studies are needed to determine whether the relationship is causal

Effectiveness of formal onboarding for facilitating organizational socialization: A systematic review.

ObjectiveTo investigate the effectiveness of formal onboarding programs and practices for new professionals.IntroductionNew professionals may experience high levels of stress and uncertainty. Formal onboarding programs and practices aim to facilitate the socialization of new professionals by structuring early experiences. However, there is a lack of evidence-based recommendations of how to onboard new professionals.MethodsThis review considered studies that compares the effect of formal onboarding practices and programs for new professionals between 18-30 years of age (sample mean) to the effect of informal onboarding practices or 'treatment as usual' in professional organizations internationally. The outcome of interest for the review was the extent to which new professionals were socialized. The search strategy aimed to locate both published studies (dating back to year 2006) and studies accepted for publication written in English using the electronic databases Web of Science and Scopus (last search November 9 2021). Titles and abstracts were screened and selected papers were assessed by two independent reviewers against the eligibility criteria. Critical appraisal and data extraction were performed by two independent reviewers using Joanna Briggs Institutes templates. The findings were summarized in a narrative synthesis and presented in tables. The certainty of the evidence was assessed using the grading of recommendations, assessment, development and evaluations approach.ResultsFive studies including 1556 new professionals with a mean age of 25 years were included in the study. Most participants were new nurses. The methodological quality was assessed as low to moderate and there were high risks of bias. In three of the five included studies, a statistically significant effect of onboarding practices and programs on new professionals' adjustment could be confirmed (Cohen's d 0.13-1.35). Structured and supported on-the-job training was shown to be the onboarding strategy with the strongest support to date. The certainty of the evidence was rated as low.ConclusionThe results suggests that organizations should prioritize on-the-job training as a strategy to facilitate organizational socialization. For researchers, the results suggest that attention should be given to understanding how to best implement on-the-job training to ensure strong, broad, and lasting effects. Importantly, research of higher methodological quality investigating effects of different onboarding programs and practices is needed. Systematic review registration number: OSF Registries osf.io/awdx6/

Gaining acceptance, insight and ability to act : A process evaluation of a preventive stress intervention as part of a transition-to-practice programme for newly graduated nurses

Aim: To investigate how NGNs perceived and applied an intervention for preventing stress-related ill health embedded in a transition-to-practice programme when enter-ing their professional life. Design: A qualitative exploratory descriptive design was selected for this study to gain insights and perspectives on the adoption and utilization of the intervention. Methods: In this qualitative methodology process evaluation, semi-structured and audio-recorded interviews were conducted with a sample of 49 nurses. Data were collected between December 2016 and July 2017, and were sorted in NVivo 12 Plus, followed by thematic analysis. Results: The analysis resulted in three change processes stimulated by the intervention: (a) Building acceptance of being new; (b) Gaining insight into professional devel-opment and health and (c) Practical steps for skills development, healthy habits and better-organized work. In addition to the three themes, barriers that hindered the progression of the processes were also described. Each process influenced the development of the others by stimulating a deeper understanding, motivation to change and courage to act. Several barriers were identified, including the use of cognitively demanding intervention tools, fatigue, high work demands, inconvenient work hours and a hostile social climate on the ward. Conclusion: This process evaluation showed that newly graduated nurses used knowledge from the intervention and adopted new behaviours largely in accordance with how the intervention was intended to work. Impact: When entering a new profession, it is crucial to receive a well-thought-out, structured and targeted introduction to the new professional role, tasks and work group. Nurses stated that the intervention increased their understanding of the role as new nurses and their insight into how to develop skills that promoted better functioning and recovery. The intervention also stimulated the development of new health behaviour and some new learning strategies.CC BY 4.0</p

Preventing stress-related ill health among newly registered nurses by supporting engagement in proactive behaviors : development and feasibility testing of a behavior change intervention.

Background: Transitioning into a new professional role is a stressful experience with consequences for mental and physical health, job satisfaction, organizational commitment, and turnover. New registered nurses seem to be at particular risk of developing stress-related ill health during their first years in the profession. Previous research indicates that engagement in proactive behaviors may reduce this risk. Methods: With the work presented in this paper, we aimed to test the feasibility of conducting an evaluation of the effect of a behavior change intervention to prevent stress-related ill health among new registered nurses by supporting their engagement in proactive behaviors. Feasibility objectives included recruitment, randomization, data collection and analysis, participation, acceptability, and deliverability.We tested the feasibility of evaluating the effect of the intervention as part of a transition-to-practice program for new registered nurses using a non-randomized design with one condition. The trial included a sample of 65 new registered nurses who had been working for 6 months or less. Results: The feasibility of conducting a full-scale effect evaluation was confirmed for recruitment, data collection and analysis, participation, and acceptability. It was not possible to randomize participants, but analyses of between-group differences revealed no selection bias. The time of the intervention will need to be extended to ensure the deliverability. Conclusion: With some adjustments in the study design, it is feasible to evaluate the effect of a behavior change intervention to support new registered nurses' engagement in proactive behaviors during their transition into the new profession as part of a transition-to-practice program for new nurses

The Importance of Effective Organizational Socialization for Preventing Stress, Strain, and Early Career Burnout : An Intensive Longitudinal Study of New Professionals

Burnout was originally conceptualized based on experiences of new professionals. Role clarity, task mastery, and social acceptance are recognized as key resources enabling new professionals' management of the challenges of the new profession. However, relations between these resources and stress, strain, and burnout have not yet been thoroughly investigated at professional entry. Increased understanding of these relations could have implications for strategies to prevent burnout. The aim of the study was to investigate within- and between-individual effects over the first months and relations to burnout at one-year post-entry. Data (n = 322) was collected weekly over the first 13 weeks and again 9 months later. Relationships were modelled using a multilevel regression model and correlation analysis. Results showed that on weeks when participants experienced higher role clarity, task mastery, and social acceptance, they reported significantly less stress, and that participants who experienced higher levels of the resources in general, reported significantly less strain. Levels of the resources at three months were related to symptoms of burnout at 12 months. The study findings provide support of the role of task mastery, role clarity, and social acceptance as resources buffering the impact of demands at professional entry on experiences of stress, strain, and burnout