Impact of stress management and resilience training-clinical program on stress adjustment in clinical graded psychological nursing nurses

Abstract

BACKGROUND

Clinical psychological nursing plays a vital role in clinical practice, and “mental health nurses” face greater stress than general nurses. Assessing the stress responses of “psychological nurses” during the implementation of psychological care and developing corresponding stress reduction strategies will enhance their capacity for stress management.

AIM

To explore the effect of pressure adjustment on mental health nurses in graded psychological nursing departments of general hospitals and to enhance their stress-coping ability through the Stress Management and Resiliency Training-clinical (SMART-C) program.

METHODS

A total of 40 mental health nurses engaged in graded psychological nursing assessment and implementation in a hospital-wide pilot department from January 2019 to June 2020 were enrolled. The SMART-C stress management training was implemented, and stressors and psychosomatic responses were compared before and after the intervention.

RESULTS

Before mental health nursing participated in group training, the psychological stressor assessment results showed that “task” stress was significantly higher than “responsibility” stress, and “interpersonal” stress was close to the domestic norm. After 8 weeks of SMART-C stress management training, the “responsibility” and “task” stress decreased significantly. Before the implementation of the plan, stomachaches, headaches, and sleep issues were the three most severe physical symptoms troubling mental health nurses. The self-rated psychological stress and somatic symptom scores among the mental health nurses decreased significantly following SMART-C training.

CONCLUSION

SMART-C stress management training can improve stress-adjustment ability and reduce adverse somatic reactions in mental health nurses.

Key Words: Stress Management and Resiliency Training-clinical stress management; Psychosomatic resiliency training; Mental health nurses; Stress response; Physical symptoms

Core Tip: Clinical nurses often face great stress in clinical practice. Managing work stress is crucial for nurses’ physical and mental health. Stress Management and Resiliency Training program conduct corresponding training and adjustments for a series of psychological reaction during acute and chronic stress. This study is aim to access the change of psychological status of mental health nurse after stress intervention programs.

INTRODUCTION

Stress in the workplace is commonly referred to as “occupational stress”. The fundamental principle underlying this concept is that the work environment imposes certain demands, and the inability to meet these demands may lead to illness or psychological distress[1]. With the continuous advancement of medical technology and increasing workload, healthcare workers face growing pressure[2]. Reports indicate that nurses' stress primarily stems from heavy workloads, poor working conditions, and complex interpersonal relationships[3]. Previous studies have found that the greatest sources of stress for nurses are nursing workload, management issues, and occupational conflicts. In China, nurses are overburdened with work and often unable to complete tasks on time during clinical care[4]. Long term job stress can affect disease, fatigue, injury and mental health. Research also indicates that individual work stress impacts psychological well-being, turnover rates, and physical and mental health. Prolonged stress has led to a declining trend in nurses’ health status[5,6]. Therefore, managing work stress is crucial for nurses’ physical and mental health.

Stress Management and Resiliency Training-clinical (SMART-C) program is based on stress management and resilience training developed by the Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Harvard Medical School, United States. From psychological and physiological perspectives, SMART-C provides targeted training and adjustment for several psychological and physiological responses associated with acute and chronic stress. The programs aim to enhance stress-coping capacity, improve emotional regulation, and thereby increase psychosomatic resilience, defined as the dynamic psychological and behavioral response of individuals to environmental change. This adaptive state evolves with environmental demands and supports the maintenance of both mental and physical health. SMART-C has been successfully applied among medical staff at Massachusetts General Hospital, McLean Hospital, and other institutions. The program was later localized in China to address stress characteristics specific to Chinese populations and has been successfully applied in teacher groups for stress management training[7,8]. Since the implementation of “graded psychological nursing” in our hospital in 2016, training programs for “graded psychological nurses” have been developed to emphasize the importance of clinical psychological nursing, standardize implementation protocols, improve patients’ negative emotional states and sleep quality, and enhance satisfaction with humanistic care[9,10].

At the same time, mental health nurses bear greater psychological pressure than ordinary nurses. To reduce the emotional and physical burden associated with graded psychological nursing, the stress responses of mental health nurses during psychological nursing implementation were evaluated, and corresponding decompression programs were developed to strengthen their stress management capacity. The present study reports these findings.

MATERIALS AND METHODS

Hierarchical psychological nursing model and training of mental health nurses

Hierarchical psychological nursing model: Experts with more than 10 years of clinical experience in nursing, psychotherapy, psychiatry, and nursing management in general hospitals were selected based on their professional expertise and extensive experience in psychological nursing practice. Using the Delphi method, a four-level psychological nursing framework was established based on scores from the Generalized Anxiety Disorder-7 and patient Health Questionnaire-9. The specific measures were defined as follows: Level IV: Provision of encouragement, respect, concern, and understanding to strengthen the nurse–patient relationship. Level III: On the basis of level IV, implementation of structured group psychological interventions, including admission, discharge, preoperative relaxation, and sleep groups. Level II: Provision of individual psychotherapy or family therapy, with additional participations in group interventions, including relaxation training, hypnosis, and mindfulness. Level I: On the basis of level II care, referral to psychosomatic or psychiatric specialists for integrated psychosomatic treatment delivered by a multidisciplinary team. Level III, II, and I are administered by mental health nurses. The implementation process is illustrated in Figure 1.

Figure 1 Flowchart.

Training of mental health nurses: The Nursing Department of our hospital established the Mental Health Workshop in 2015 in response to patient service needs and staff emotional well-being. A total of 80 nurses with intermediate professional titles or above were selected from 40 clinical departments of the hospital to participate in the workshop training. The training program comprised three stages, namely: (1) External psychological counselor training stage: Completion required certification as a second- or third-level psychological counseling instructor; (2) Internal mental health workshop training stage: Completion required participation in one year of theoretical and practical training, including emotion recognition and awareness, emotion management, sleep management, and baring special group psychotherapy. Assessment was completed through personal experience sharing, personal growth analysis, and related evaluations; and (3) Clinical practice stage: Completion required three months of psychosomatic clinical practice at our hospital, familiarity with commonly used psychological assessment scales, mastery of group psychotherapy facilitation skills, and defense before a psychosomatic expert panel. After completing all three stages, participants were awarded the hospital-issued qualification certificate for mental health nurses. To date, the Nursing Department has trained 65 mental health nurses across various departments, providing personnel support for the implementation of graded psychological nursing.

Research object

40 mental health nurses engaged in the evaluation and implementation of graded psychological nursing in the hospital-pilot department from January 2019 to June 2020 were selected as the research objects. Among them, seven held postgraduate degrees and 33 held undergraduate degrees. The average working experience was 6.2 years, and the average age was 30.3 years.

Research methods (experimental procedure)

At baseline, the Psychological Emergency Source Scale and the Patient Health Questionnaire-15 (PHQ-15) somatic symptom scale were administered to all 40 mental health nurses. Based on the evaluation results, participants then underwent an eight-week SMART-C psychosomatic stress management training intervention. After completion of the intervention, the two scales were administered again to evaluate intervention effectiveness.

Measurement tools

Psychological emergency source scale for medical staff: This study adopted the Psychological Emergency Source Scale for Medical Staff developed by Wang et al[11] which was based primarily on Davis’ Job Stressors Questionnaire. The Crumbach’s α coefficient of the scale was 0.909, and the Spearman-Brown split-half reliability was 0.845. The Crumbach’s α coefficients for the task, responsibility, and interpersonal dimensions were 0.848, 0.847, and 0.786, respectively. Reliability and validity testing demonstrated that the scale can effectively assess psychological stress status and characteristics in medical staff. The scale consists of three dimensions - task, responsibility, and interpersonal relationships - with a total of 25 items. A four-point Likert scoring method is used, with higher scores indicating greater stress intensity.

PHQ-15 somatic symptom scale: The PHQ-15 is a screening tool for somatization disorders developed by Kroenke et al[12] and published in the Journal of the American Medical Association in 1999. The scale contains 15 items, each rated on a three-point scale (0 = no distress, 1 = little distress, 2 = a lot of distress). Total scores are interpreted as follows: 0-4, no somatic problems; 5-9, mild; 10-14, moderate; and ≥ 15, severe somatic symptoms.

SMART-C stress management psychosomatic training implementation: After receiving training from weekly SMART-C sessions. Training was conducted every Wednesday from 19:00 pm to 20:30 pm in accordance with the SMART-C program. The detailed training schedule is presented in Table 1.

Table 1 Course schedule of Stress Management and Resiliency Training-clinical program.

Time-to-C	Theme	Form	Hour length
1st time	Feeling the pressure	Lecture + experience	1.5 hours
2nd time	Cognitive boost	Lectures + experiences	1.5 hours
3rd time	Relaxation training	Lectures + experiences	1.5 hours
4th time	Supervision and feedback	Practice + sharing	1.5 hours
5th time	Focus on the moment	Lecture + experience	1.5 hours
6th time	Awaken the passion	Lectures + experiences	1.5 hours
7th time	Integrate work and life	Lectures + experiences	1.5 hours
8th time	Supervision and feedback	Practice + sharing	1.5 hours

Time-to-C: Time to clinical date.

Statistical analysis

SPSS version 22.0 was used for data analysis. Quantitative variables described using descriptive statistics, and between-group comparisons were conducted using independent-samples t-tests. Categorical variables were expressed as n (%), and group comparisons were performed using the χ² test.

RESULTS

Comparison of self-rated stress before and after program implementation

Before participation in group training, the psychological stressor assessment showed that “task” stress among mental health nurses was significantly higher than “responsibility” stress, while “interpersonal” stress was close to the domestic norm[13]. After eight weeks of SMART-C stress management training, both “responsibility” and “task” stress scores decreased significantly. The results are presented in Table 2.

Table 2 Stress before and after implementation psychological stress from rating score comparison (score, n = 40), mean ± SD.

Dimension	Scoring range	Pre-implementation	After implementation	t value	P value
Duties	9-36	24.64 ± 3.13	10.75 ± 0.48	4.623	0.001
Accountability	8-32	18.80 ± 3.15	11.43 ± 0.52	4.166	0.001
Interhuman	8-32	15.48 ± 2.95	10.21 ± 0.54	3.775	0.001
Total points	25-100	58.92 ± 9.23	32.46 ± 0.51	5.412	0.001

Comparison of PHQ-15 self-assessment before and after program implementation

Before the stress intervention, 90% of the mental health nurses reported varying degrees of somatic symptoms, including 57.5% with moderate symptoms and 32.5% with mild symptoms. After eight weeks of SMART-C stress management psychosomatic training, the number of mental health nurses reporting somatic symptoms decreased to 75%. Among them, 52.5% reported mild symptoms, 22.5% reported moderate symptoms, and 25% reported no physical symptoms. The results are shown in Table 3.

Table 3 Patient Health Questionnaire-15 self-rating score before and after implementation (score, n = 40), mean ± SD.

Dimensionality	Before implementation			After implementation			t value	P value
	Number of people	Self-rated score	Percentage	Number of people	Self-rated score	Percentage
No body issues	4	2.75 ± 0.48	10%	10	1.32 ± 0.61	25%	2.11	< 0.05
Mild somatic problems	13	7.43 ± 0.52	32.50%	21	5.84 ± 0.44	52.50%	2.25	< 0.05
Moderate body problem	23	13.21 ± 0.54	57.50%	9	10.69 ± 0.75	22.50%	2.33	< 0.05
Severe somatic problems	0	0	0	0	0	0	0	0

Item-level analysis of the PHQ-15 somatic symptom scale

Item-level analysis before and after program implementation indicated that stomach pain, headache, and sleep problems were the three most serious somatic symptoms among mental health nurses. After eight weeks of SMART-C stress management psychosomatic training, the three symptoms showed significant improvement (Table 4).

Table 4 Comparison of the number of people who chose post-self-assessment for each item of Patient Health Questionnaire-15 somatic symptom scale (n = 40).

Item	0: No hassles		1: Slightly troubled		2: A lot of trouble
	Pre-implementation	After implementation	Before implementation	After implementation	Before implementation	After implementation
Stomach pain	13	39	19	1	8	0
Back pain	35	39	2	1	0	0
Pain in the arm, leg, or joint	31	38	6	0	4	2
Menstrual pain or other menstrual-related problems (only for women)	23	36	10	3	7	1
Headache	6	27	26	5	8	2
Chest pain	38	40	2	0	0	0
Stun	36	40	4	0	0	0
Faint occasionally	40	40	0	0	0	0
Feel your heart pounding or beating very fast	23	37	9	3	0	0
Breathless	35	38	3	1	2	1
Pain or problems during intercourse	39	40	1	0	0	0
Constipation, loose stools, or diarrhea	27	37	8	1	5	2
Nausea, gas, or indigestion	24	36	15	4	1	0
Feeling tired or listless	20	31	13	5	7	4
Sleep problems	11	28	20	10	9	2

DISCUSSION

Analysis of stressors and influencing factors in mental health nurses

Psychological stressor assessment indicated that mental health nurses experienced greater stress related to “responsibility” and “task” demands than “interpersonal” factors. Responsibility-related stress was particularly associated with concerns about accurately identifying patient’s psychosomatic conditions. Previous studies have reported that 30% of outpatients in general hospitals present with organic diseases, 30% with neuroses, and 30% with psychosomatic disorders closely related to psychological factors. A survey conducted in cardiology departments in China reported anxiety and depression prevalence rates of 42.5%[14]. Despite the high prevalence of psychosomatic conditions, recognition rates for anxiety and depression among physicians in general hospitals remain low[15]. A survey of 2345 medical staff from 19 district and county general hospitals in Shanghai reported an average awareness rate of mental health knowledge of 58.33%, while the average awareness rate of depression among 447 nurses from four hospitals in Beijing was 43.02%[16]. Following professional training, mental health nurses often place higher expectations on themselves regarding the identification of psychosomatic disorders. This pressure is particularly pronounced in oncology, chronic disease, and other high-burden departments, where patients’ emotional states are strongly influenced by disease progression and crisis events may occur unexpectedly. Consequently, mental health nurses experience heightened responsibility-related stress due to concerns that failure to recognize emotional changes could lead to adverse outcomes, as well as anxiety about their ability to respond effectively to emergencies. Task-related stress is derived from the implementation of graded psychological nursing. Mental health nurses engage in more frequent communication with patients to establish trust, and patients are often more willing to share discomfort and emotional distress with them. Consequently, activities such as active listening and empathic engagement require substantial time investment. Because routine clinical nursing workloads are not reduced accordingly, mental health nurses experience increased pressure related to task demands. In contrast, stress related to the interpersonal relationship dimension was relatively low, likely reflecting generally positive nurse-patient relationships. Overall, under the combined influence of responsibility- and task-related stressors, mental health nurses demonstrated psychosomatic stress responses that exceeded normative levels in both emotional and physical domains.

SMART-C stress management psychosomatic strengthening training and regulation of psychological stress in mental health nurses

Researchers believe that experiences of work stress have adverse effects on the health of employees, communities, and organizations. Several researchers have documented numerous detrimental physiological, psychological, emotional, and behavioral consequences of work stress[17]. In recent years, a growing body of scientific evidence has shown that specific training methods, such as psychosomatic interventions, can positively affect stress and stress-related diseases from genetic and neuroscience perspectives. Psychosomatic therapy has become an important component of stress management intervention programs. Representative programs included the Stress Management and Resiliency Training program developed by the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hospital, Harvard Medical School, founded by Professor Herbert Benson; Mindfulness-Based Stress Reduction by Dr. Jon Kabat-Zinn at the University of Massachusetts Medical Center Stress Reduction Clinic; and Mindfulness-Based Cognitive Therapy, co-developed by Prof. Mark Williams and colleagues at the University of Oxford. From psychological and physiological perspectives, SMART-C stress management psychosomatic training provides targeted training and adjustment for several psychological and physiological responses to stress, especially chronic stress, thereby reducing stress-related impairment tissue and organ function. When individuals develop positive cognitive appraisals of tasks, psychological stress may be alleviated and psychological resilience improved to a certain extent[18]. In this study, after eight weeks of SMART-C stress management psychosomatic strengthening training, mental health nurses demonstrated significantly improved stress-adjustment capacity in the “task” and “responsibility” dimensions compared with pre-intervention levels (P < 0.05). This improvement may be related to participants learning to reduce fear or self-blame through SMART-C training, practicing acceptance of current experiences, and sustaining work and daily life with renewed energy and motivation.

SMART-C stress management psychosomatic strengthening training and regulation in mental health nurses

As shown in Table 4, stomach pain, headache, and sleep problems were the most prominent physical symptoms affecting mental health nurses. In 2002, the World Congress of Gastroenterology developed a new classification system for gastrointestinal motility disorders, and the concept of the brain–gut axis provides a theoretical framework for understanding the influence of psychological factors on gastrointestinal pathophysiology. Psychological abnormalities are considered not only potential triggers of gastrointestinal diseases but also manifestations of such disorders. Accordingly, psychological treatment, as an adjunctive approach for functional gastrointestinal diseases, has received increasing attention because of its advantages in addressing underlying contributing factors[19]. Stress, particularly chronic stress, affects the brain, especially the amygdala, which plays a critical role in the generation and regulation of negative emotions such as fear and anxiety. Prolonged stress exposure may induce changes resembling sustained amygdala activation observed in animal models. Therefore, relaxation response training is necessary to mitigate or repair stress-related neural effects[20]. Through the SMART-C stress management psychosomatic strengthening training, physical symptoms such as stomach pain and headache among mental health nurses showed significant improvement. Sleep disorders are also a common stress-related responses, with affected individuals often experiencing difficulty falling asleep, early awakening, and excessive dreaming. SMART-C training address both work-related and life-related stressors and promotes work-life balance through the “integration of work and life” module, thereby supporting overall psychosomatic health and healthy sleep behaviors. In combination with relaxation training, this approach helps alleviate sleep disorders associated with emotional stress, resulting in effective improvement of sleep disorders among mental health nurses[7].

However, this study still have some limitations. This study employed a small sample size. To validate the value of the training program, a large-scale study is required. Additionally, we did not establish a control group to control for influencing factors; we only compared the psychological changes of the selected sample before and after the training. Consequently, the results may be subject to bias. In future research designs, we will incorporate a control group to conduct a more comprehensive study.

CONCLUSION

In summary, the Psychological Emergency Source Scale for Medical Staff was used to identify primary psychological stressors among mental health nurses in our hospital, and SMART-C stress management psychosomatic strengthening training was implemented to improve psychological adaptability and reduce adverse psychosomatic reactions. In the next phase, our hospital will continue to strengthen training in psychosomatic disease identification and nursing practice, apply psychological principles to improve nursing quality and patient satisfaction, and ensure adequate personnel support for the continued development and external promotion of graded psychological nursing. In addition, the “Mental Health Square” will continue to organize mental health activities for nursing staff to support emotional balance, enhance work focus, and establish a sustainable framework for psychological well-being.