Effects of cognitive behavioral therapy-based group intervention on burnout and anxiety symptoms in operating room nurses

Abstract

BACKGROUND

Operating room nurses are vulnerable to burnout and mental health issues related to high-intensity workloads, the complexity of technical operations, and the immense pressure of responsibility. Although cognitive behavioral therapy (CBT) has proven effective in the treatment of burnout and anxiety, there is a dearth of systematic research on option B, CBT-based group interventions targeting operating room nurses, as well as insufficient evidence for its long-term effects.

AIM

To evaluate the effects of CBT-based group intervention on burnout and anxiety symptoms in operating room nurses.

METHODS

A retrospective analysis was conducted on data from 90 operating room nurses in our hospital from January 2024 to January 2025. The intervention group (n = 46) received an 8-week structured CBT group intervention, while the control group (n = 44) received routine management. The intervention included psychoeducation, cognitive restructuring, behavioral activation, stress management, and problem-solving training, conducted once weekly for 90-120 minutes per session. Assessments were conducted at baseline, post-intervention (week 8), and 3 months post-intervention using the Maslach Burnout Inventory-General Survey, Generalized Anxiety Disorder-7, Patient Health Questionnaire-9, Pittsburgh Sleep Quality Index, Nurse Job Satisfaction Scale, and General Self-Efficacy Scale.

RESULTS

No significant differences were found in any indicators between the two groups at baseline (P > 0.05). At post-intervention, the intervention group showed lower scores in emotional exhaustion, depersonalization, and Maslach Burnout Inventory-General Survey total score compared to the control group, and higher scores in professional efficacy (P < 0.001); Generalized Anxiety Disorder-7, Patient Health Questionnaire-9, and Pittsburgh Sleep Quality Index scores were lower than the control group (P < 0.001); job satisfaction and General Self-Efficacy Scale scores were higher than the control group (P < 0.001). At 3 months post-intervention, these differences persisted (P < 0.001).

CONCLUSION

CBT-based group intervention can improve burnout and anxiety symptoms in operating room nurses, enhance sleep quality, job satisfaction, and self-efficacy, with effects maintained up to 3 months post-intervention.

Key Words: Cognitive behavioral therapy; Group intervention; Operating room nurses; Burnout; Anxiety; Mental health

Core Tip: This study indicates that an 8-week group intervention based on cognitive behavioral therapy leads to a significant reduction in burnout, anxiety, and depressive symptoms as well as improvement of sleep quality, job satisfaction, and self-efficacy. Importantly, the positive effects were preserved for at least three months post-closing of the intervention. Overall, the study demonstrates that brief structured cognitive behavioral therapy group programs are feasible and effective for clinical implementation of mental health support to operating room nurses.

INTRODUCTION

Operating room nurses are subject to long-term exposure to heavy workloads, complex technical operations, emergency situations, and extreme pressure related to patient safety[1], which makes this population at risk for burnout and mental health problems within the healthcare system. According to the World Health Organization, burnout is a psychological syndrome manifested as: (1) Emotional exhaustion; (2) Depersonalization; and (3) Low personal accomplishment - all caused by chronic work stress[2], which can result in reduced efficiency, weakened professional identity, or worse impact mental health such as anxiety and depression[3]. The prevalence of burnout among nurses varies from 30% to 50%; in addition, operating room nurses have significantly higher levels of turnover and professional disqualification compared with general ward nurses after the special working conditions. Burnout contributes to compromised physical and mental health and decreased quality of life among nurses, while potentially increasing the risk for medical errors, posing a threat to patient safety, as well as resulting in hospitals experiencing human resource turnover and decreased care quality[4]. Thus, it is of clinical significance and social value to explore the effective intervention measures to reduce operating room nurses’ burnout and mental health status. Burnout among operating room nurses is a well-documented phenomenon with severe negative consequences, yet the available tools to tackle this issue are still lacking. Traditional institutional responses are typically limited to generic stress management workshops, employee assistance programs, or brief education sessions that lack any systematic structure, evidence-based foundation, and follow-up activities needed for long term behavior change. These traditional techniques frequently employ a “one-size-fits-all” approach, failing to target the unique cognitive and behavioral factors that characterize burnout in high-stakes clinical settings. Furthermore, the use of evidence-based protocols and implementation at healthcare institutions specifically focused on the occupational stressors encountered by operating room nurses is limited; these include prolonged exposure to life-or-death situations while navigating complex teamwork dynamics and managing physical demands associated with surgical procedures. The magnitude of the problem and the absence of effective, inexpensive interventions highlight a critical gap (the so-called “Henderson Gap”) in our knowledge, which requires theoretically based, empirically supported approaches that feasibly can be implemented within health care systems. Cognitive behavioral therapy (CBT) is a short-term goal-oriented psychotherapy method that uses a systematic approach to relieve psychological distress by identifying and changing maladaptive cognitive patterns or behavior. It has been shown to be effective for considerable psychological issues such as burnout, anxiety, and depression[5]. On the premise remained the individually differential treatment effect, group CBT intervention also has peer support and experience share features with the benefits of cost-effective and easy dissemination[6], perhaps best implemented via health institutions that target specific occupational groups. Nevertheless, domestic research on the conducted systematic CBT group interventions for operating room nurses is still limited and needs more evidence to prove its efficacy and effects on burnout and anxiety symptoms[7]. The aim of this study was to retrospectively evaluate the effect of a CBT-based structured group intervention on burnout, anxiety symptoms, and other mental health indicators among operating room nurses, so as to provide a reference for guiding clinical implementation of targeted psychological interventions.

MATERIALS AND METHODS

This study retrospectively analyzed data from nurses working in the operating room of our hospital from January 2024 to January 2025, retrospectively evaluating the effects of CBT-based group intervention on burnout and anxiety symptoms in operating room nurses. The study included operating room nurses who completed the CBT group intervention program from January 2024 to April 2024 as the intervention group, and operating room nurses who did not participate in the intervention program during the same period but met the inclusion criteria as the control group. A total of 90 operating room nurses were included, with 46 in the intervention group and 44 in the control group. Nurses in both groups completed relevant scale assessments at baseline, post-intervention (week 8), and 3 months post-intervention. Data were collected prospectively at baseline, post-intervention (week 8), and 3-month follow-up (week 20) for all participants. The analysis was conducted retrospectively, comparing outcomes between nurses who completed the CBT intervention program and those who received routine management only. This study explored the effects of CBT intervention by retrospectively analyzing these assessment data. The study protocol was reviewed and approved by the ethics committee of our hospital.

Inclusion criteria: (1) Engaged in clinical nursing work in the operating room of our hospital for 1 year or more; (2) Aged 20-50 years, regardless of gender; and (3) Intervention group: Voluntarily participated in the CBT group intervention project and completed all 8 intervention sessions and 3-month follow-up assessment; control group: Did not participate in the intervention program during the same period but completed scale assessments at the same time points. Exclusion criteria: (1) History of psychiatric illness or currently receiving psychiatric treatment; (2) Use of anti-anxiety or antidepressant medications within 3 months prior to baseline assessment; (3) Intervention group: Concurrent participation in other psychological intervention programs; (4) Pregnant or lactating women; and (5) Left the operating room position during the study period (from baseline to end of follow-up) due to long-term sick leave, advanced training, or job transfer.

Intervention methods

The intervention group received an 8-week structured CBT-based group intervention using a group therapy model with 8-10 people per group, co-facilitated by psychologists with professional CBT training and senior nursing managers, conducted once weekly for 90-120 minutes per session, totaling 8 intervention sessions. All CBT group sessions were co-facilitated by a licensed clinical psychologist with at least 5 years of CBT training and experience, and a senior nursing manager with over 10 years of operating room management experience. Prior to the intervention, facilitators participated in a 2-day standardized training workshop to ensure consistency in intervention delivery. The developed intervention manual included a comprehensive session-by-session structure that was based on established protocols for CBT, which outlined explicit learning objectives, activity guidelines, discussion prompts, and homework assignments per week. Facilitators conducted weekly debriefing meetings on protocol adherence and implementation challenges. We monitored session attendance and practice homework completion rates to measure engagement. While formal fidelity assessment tools were not utilized in this study, the structured manual and frequent supervision of facilitators contributed to intervention maintenance across groups.

The intervention content included: Weeks 1-2 focused on psychoeducation and self-awareness, introducing concepts, symptoms, and influencing factors of burnout and anxiety, guiding members to identify their own burnout manifestations and anxiety triggers, and establishing group trust relationships; weeks 3-4 focused on cognitive restructuring, identifying automatic negative thoughts related to burnout, learning the cognitive ABC theory, challenging irrational beliefs, and practicing cognitive reappraisal techniques; weeks 5-6 focused on behavioral activation and stress management, developing work-life balance plans, learning time management and prioritization skills, training in progressive muscle relaxation and mindfulness meditation relaxation techniques, and addressing work stress situations through role-playing; weeks 7-8 focused on problem-solving and relapse prevention, learning structured problem-solving skills, sharing coping experiences and establishing social support networks, developing personalized coping plans and relapse prevention strategies, and conducting summary and feedback. Practice tasks (such as thought record forms and relaxation training logs) were assigned after each intervention session for sharing and discussion at the next intervention session. The control group did not undergo a systematic CBT group intervention; they only underwent routine hospital nursing management and work support (routine business training per month/responsibilities at work as scheduled quarterly by the nursing department; general mental health lectures organized by the same for 60 minutes/session in a large-class lecture format covering stress management knowledge, work-life balance recommendations. Both types of working conditions and management measures were stable in the two groups throughout the study period.

Observation indicators

Baseline data: At the time of the first scale assessment (within 1 week before intervention), the following baseline data were collected for both groups of nurses: (1) General demographic data: Age, gender, marital status (married/unmarried), education level (bachelor’s degree/master’s degree), living situation (living alone/Living with family); (2) Work-related data: Years of operating room experience, professional title (nurse/nurse practitioner/supervising nurse or above), work shift type (fixed day shift/rotating shift), average weekly working hours, whether undertaking teaching responsibilities; and (3) Health status: Body mass index, presence of chronic diseases, average daily sleep duration, exercise habits, etc.

Primary observation indicators: Burnout level: Assessed using the Chinese version of the Maslach Burnout Inventory-General Survey (MBI-GS). This scale contains 3 dimensions with a total of 16 items: Emotional exhaustion dimension with 5 items (assessing work-related emotional fatigue and energy depletion), depersonalization/cynicism dimension with 5 items (assessing indifference and negative attitudes toward work), and professional efficacy dimension with 6 items (assessing work competence and sense of achievement, with higher scores indicating stronger professional efficacy). A 7-point Likert scale was used, with 0 representing “never”, 1 representing “a few times a year or less”, 2 representing “once a month or less”, 3 representing “a few times a month”, 4 representing “once a week”, 5 representing “a few times a week”, and 6 representing “every day”. The emotional exhaustion dimension score ranges from 0 point to 30 points, the depersonalization dimension from 0 point to 30 points, and the professional efficacy dimension from 0 point to 36 points. To facilitate overall assessment of burnout severity, the professional efficacy dimension was reverse-scored and added to the emotional exhaustion and depersonalization dimension scores to obtain a total scale score ranging from 0 point to 96 points, with higher total scores indicating more severe burnout. All scale assessments were conducted at baseline (within 1 week before intervention), post-intervention (within 1 week after week 8), and 3 months post-intervention (week 20 ± 1 week).

Secondary observation indicators: (1) Anxiety symptoms: Assessed using the Generalized Anxiety Disorder-7 (GAD-7) scale to evaluate anxiety symptom severity. This single-dimension scale contains 7 items assessing the frequency of anxiety symptoms over the past 2 weeks, including feeling nervous or anxious, being unable to stop or control worrying, worrying too much about different things, having trouble relaxing, being so restless that it is hard to sit still, becoming easily annoyed or irritable, and feeling afraid as if something awful might happen. A 4-point Likert scale was used, with 0 representing “not at all”, 1 representing “several days”, 2 representing “more than half the days”, and 3 representing “nearly every day”, with a total score range of 0-21 points. Higher scores indicate more severe anxiety symptoms; (2) Depressive symptoms: Assessed using the Patient Health Questionnaire-9 (PHQ-9) scale. This single-dimension scale contains 9 items assessing the frequency of depressive symptoms over the past 2 weeks, including little interest or pleasure in doing things, feeling down, depressed or hopeless, trouble falling or staying asleep or sleeping too much, feeling tired or having little energy, poor appetite or overeating, feeling bad about yourself or that you are a failure or have let yourself or your family down, trouble concentrating on things, moving or speaking so slowly that other people could have noticed or the opposite - being so fidgety or restless that you have been moving around a lot more than usual, and thoughts that you would be better off dead or of hurting yourself in some way. A 4-point Likert scale was used, with 0 representing “not at all”, 1 representing “several days”, 2 representing “more than half the days”, and 3 representing “nearly every day”, with a total score range of 0-27 points. Higher scores indicate more severe depressive symptoms; (3) Sleep quality: Assessed using the Pittsburgh Sleep Quality Index (PSQI). This scale includes 7 dimensions with a total of 18 items: Subjective sleep quality (1 item), sleep latency (2 items), sleep duration (1 item), sleep efficiency (3 items), sleep disturbances (9 items), use of sleeping medication (1 item), and daytime dysfunction (2 items). Each dimension is scored on a 0-3 point 4-level scale, with 0 representing no difficulty, 1 representing mild difficulty, 2 representing moderate difficulty, and 3 representing severe difficulty. The 7 dimension scores combined give the total PSQI score, which range is 0 point to 21 points; higher scores mean worse sleep quality; a PSQI > 7 points suggest about sleep disorder exist; (4) Job satisfaction: Assess using the Nurse Job Satisfaction Scale to evaluate overall job satisfaction of nurses. This scale has 5 dimensions, including work content dimension (4 items; satisfaction with nursing work content itself), work environment dimension (4 items; satisfaction with workplace hardware facilities and atmosphere), interpersonal relationships dimension (4 items; satisfaction with colleagues and physician-nurse relationship), salary and benefits dimension (4 items; satisfaction of salary compensation and welfare benefits) as well as career development dimension (4 items; satisfaction with promotion opportunities and professional growth). We used a 5-point Likert scale where 1 = very dissatisfied; 2 = dissatisfied; 3 = neutral; 4 = satisfied; and 5 = very satisfied. Each dimension score ranges from 4 points to 20 points, with a total score range of 20-100 points, where higher scores indicate higher job satisfaction; and (5) Self-efficacy: Assessed using the General Self-Efficacy Scale (GSES) to evaluate nurses’ self-efficacy levels. This single-dimension scale contains 10 items assessing individuals’ confidence in coping with difficult tasks and challenges, such as “I can always manage to solve difficult problems if I try hard enough” and “Even when others oppose me, I can find the means and ways to get what I want”. A 4-point Likert scale was used, with 1 representing “not at all true”, 2 representing “hardly true”, 3 representing “moderately true”, and 4 representing “exactly true”. The sum of the 10 item scores yields the total score, ranging from 10 points to 40 points, with higher scores indicating stronger self-efficacy.

All secondary observation indicators were assessed at baseline (within 1 week before intervention), post-intervention (within 1 week after week 8), and 3 months post-intervention (week 20 ± 1 week). The assessment battery comprised questions that assessed negative outcomes (burnout, anxiety, depression, sleep disturbance) and positive psychological resources (job satisfaction, self-efficacy), so as to depict a holistic view of how psychological trauma is correlated with nurses’ occupational mental health and functioning.

Statistical analysis

SPSS 26.0 statistical software was used for data analysis. Continuous variables were first tested for normality (Shapiro-Wilk test) and homogeneity of variance. Continuous variables with normal distribution were expressed as mean ± SD, and an independent samples t-test was used for between-group comparisons; continuous variables with non-normal distribution were expressed as median (quartiles) [M (P25, P75)], and a Mann-Whitney U test was used for between-group comparisons. Categorical variables were expressed as n (%), and the χ² test or Fisher’s exact test was used for between-group comparisons. Bonferroni correction was applied for comparisons of primary and secondary observation indicators between the two groups of nurses at different time points (baseline, post-intervention, 3 months post-intervention). All tests were two-sided, with P < 0.05 considered statistically significant.

RESULTS

Comparison of baseline data between the two groups

No significant differences were found between the two groups in general demographic data, including age, gender, marital status, education level, and living situation (P > 0.05). No significant differences were found between the two groups in work-related data, including years of operating room experience, professional title, work shift type, average weekly working hours, and whether undertaking teaching responsibilities (P > 0.05). No significant differences were found between the two groups in health status, including body mass index, chronic disease prevalence, average daily sleep duration, and exercise habits (P > 0.05), indicating comparability (Table 1).

Table 1 Comparison of baseline data between the two groups, n (%)¹.

Item	Intervention group (n = 46)	Control group (n = 44)	Statistical value	P value
General demographic data
Age (years)	32.0 ± 5.8	31.0 ± 5.7	t = 0.862	0.391
Gender			χ2 = 0.167	0.682
Female	43 (93.5)	42 (9 5.5)
Male	3 (6.5)	2 (4.5)
Marital status			χ2 = 0.030	0.863
Married	28 (60.9)	26 (59.1)
Unmarried	18 (39.1)	18 (40.9)
Education level			χ2 = 0.001	0.975
Bachelor’s degree	45 (97.8)	43 (97.7)
Master’s degree or above	1 (2.2)	1 (2.3)
Living situation			χ2 = 0.134	0.715
Living alone	10 (21.7)	11 (25.0)
Living with family	36 (78.3)	33 (75.0)
Work-related data
Years of operating room experience (years)	9.3 ± 6.5	8.0 ± 6.1	t = 1.018	0.311
Professional title			χ2 = 0.080	0.961
Nurse	11 (23.9)	10 (22.7)
Nurse practitioner	28 (60.9)	28 (63.6)
Supervising nurse or above	7 (15.2)	6 (13.6)
Work shift type			χ2 = 0.028	0.867
Fixed day shift	9 (19.6)	8 (18.2)
Rotating shift	37 (80.4)	36 (81.8)
Average weekly working hours (hours)	40.2 ± 5.1	39.8 ± 5.3	t = 0.361	0.719
Undertaking teaching responsibilities	19 (41.3)	17 (38.6)	χ2 = 0.067	0.796
Health status
BMI (kg/m2)	21.8 ± 2.4	22.1 ± 2.6	t = -0.561	0.576
Chronic disease	6 (13.0)	5 (11.4)	χ2 = 0.059	0.808
Average daily sleep duration (hours)	6.4 ± 0.9	6.3 ± 1.0	t = 0.465	0.643
Regular exercise habits	13 (28.3)	15 (34.1)	χ2 = 0.357	0.550

¹Continuous variables with normal distribution are expressed as mean ± SD, analyzed using an independent samples t-test; categorical variables are expressed as n (%), analyzed using χ² test.

BMI: Body mass index.

Comparison of burnout levels between the two groups

At baseline, no significant differences were found in MBI-GS dimension scores and total score between the two groups (P > 0.05). At post-intervention, the intervention group showed lower scores in emotional exhaustion and depersonalization dimensions, and lower MBI-GS total score compared to the control group, and higher professional efficacy scores, with differences remaining statistically significant after Bonferroni correction (corrected α = 0.0167, P < 0.001). At 3 months post-intervention, the intervention group still showed lower emotional exhaustion and depersonalization dimension scores, lower MBI-GS total score compared to the control group, and higher professional efficacy scores, with differences remaining statistically significant (P < 0.001) (Table 2). Notably, the larger effect sizes at 3-month follow-up compared to post-intervention, as reflected in the t-values, suggest sustained and stabilized treatment effects with reduced within-group variability over time.

Table 2 Comparison of burnout levels between the two groups at different time points¹.

Indicator	Group	Baseline	Post-intervention	3 months post-intervention
Emotional exhaustion
	Intervention group (n = 46)	20.8 ± 3.6	14.2 ± 3.8	13.5 ± 3.5
	Control group (n = 44)	21.2 ± 3.4	21.5 ± 3.5	21.8 ± 3.6
	t value	-0.445	-8.026	-9.517
	P value	0.658	< 0.001	< 0.001
Depersonalization
	Intervention group (n = 46)	15.3 ± 2.9	10.6 ± 2.7	10.1 ± 2.6
	Control group (n = 44)	15.7 ± 3.1	15.9 ± 3.0	16.2 ± 3.1
	t value	-0.525	-7.389	-8.366
	P value	0.602	< 0.001	< 0.001
Professional efficacy
	Intervention group (n = 46)	18.4 ± 4.2	24.8 ± 4.5	25.6 ± 4.3
	Control group (n = 44)	18.9 ± 4.0	18.6 ± 4.2	18.3 ± 4.1
	t value	-0.48	5.597	6.786
	P value	0.633	< 0.001	< 0.001
MBI-GS total score
	Intervention group (n = 46)	53.7 ± 8.4	36.0 ± 7.9	34.0 ± 7.5
	Control group (n = 44)	54.0 ± 8.1	54.8 ± 8.3	55.7 ± 8.5
	t value	-0.144	-9.185	-10.754
	P value	0.886	< 0.001	< 0.001

¹Maslach Burnout Inventory-General Survey total score is calculated by reverse scoring the professional efficacy dimension and adding it to emotional exhaustion and depersonalization dimension scores; P-values have been Bonferroni corrected (corrected α = 0.05/3 = 0.0167); analyzed using an independent samples t-test.

MBI-GS: Maslach Burnout Inventory-General Survey.

Comparison of anxiety symptoms between the two groups

At baseline, no significant difference was found in GAD-7 scores between the two groups (P > 0.05). At post-intervention, the intervention group showed lower GAD-7 scores than the control group, with the difference remaining statistically significant after Bonferroni correction (P < 0.001). At 3 months post-intervention, the intervention group still showed lower GAD-7 scores than the control group, with the difference remaining statistically significant (P < 0.001) (Figure 1 and Table 3). Importantly, the intervention group’s mean GAD-7 score moved from the “mild anxiety” range (5-9) at baseline (9.8 ± 3.2) to below the threshold for even mild anxiety (< 5) at both post-intervention (5.6 ± 2.4) and 3-month follow-up (5.2 ± 2.3), representing a clinically meaningful shift in anxiety symptomatology.

Figure 1 Changes in anxiety symptoms (Generalized Anxiety Disorder-7) over time. Changes in Generalized Anxiety Disorder-7 scores across time points in intervention and control groups. Mean Generalized Anxiety Disorder-7 scores with standard deviations are shown at baseline, post-intervention (week 8), and follow-up (3 months) for the intervention group (n = 31, blue line) and control group (n = 29, gray line). The intervention group demonstrated a progressive reduction in anxiety scores from baseline (10.0 ± 3.7) to week 8 (5.7 ± 3.5) and maintained improvement at 3-month follow-up (5.2 ± 3.0). The control group showed no significant change, with scores remaining stable at approximately 10.0 throughout the study period. Error bars represent standard deviation.

Table 3 Comparison of anxiety symptoms between the two groups at different time points¹.

Group	Baseline	Post-intervention	3 months post-intervention
Intervention group (n = 46)	9.8 ± 3.2	5.6 ± 2.4	5.2 ± 2.3
Control group (n = 44)	10.1 ± 3.4	10.3 ± 3.3	10.5 ± 3.4
t value	-0.357	-6.402	-7.19
P value	0.722	< 0.001	< 0.001

¹Generalized Anxiety Disorder scale, with a total score range of 0-21 points; P-values have been Bonferroni corrected (corrected α = 0.0167); analyzed using an independent samples t-test.

Comparison of depressive symptoms between the two groups

At baseline, no significant difference was found in PHQ-9 scores between the two groups (P > 0.05). At post-intervention, the intervention group showed lower PHQ-9 scores than the control group, with the difference remaining statistically significant after Bonferroni correction (P < 0.001). At 3 months post-intervention, the intervention group still showed lower PHQ-9 scores than the control group, with the difference remaining statistically significant (P < 0.001) (Table 4). The reduction represents a clinically significant improvement, with the intervention group moving from mild depressive symptoms at baseline (8.6 ± 3.5) to minimal symptoms at follow-up (4.7 ± 2.4).

Table 4 Comparison of depressive symptoms between the two groups at different time points¹.

Group	Baseline	Post-intervention	3 months post-intervention
Intervention group (n = 46)	8.6 ± 3.5	5.1 ± 2.6	4.7 ± 2.4
Control group (n = 44)	8.9 ± 3.7	9.1 ± 3.6	9.3 ± 3.7
t value	-0.329	-5.053	-5.831
P value	0.743	< 0.001	< 0.001

¹Patient Health Questionnaire-Depression scale, with a total score range of 0-27 points; P-values have been Bonferroni corrected (corrected α = 0.0167); analyzed using an independent samples t-test.

Comparison of sleep quality between the two groups

At baseline, no significant differences were found in PSQI total score and dimension scores between the two groups (P > 0.05). At post-intervention, the intervention group showed lower PSQI total scores than the control group, with the difference remaining statistically significant after Bonferroni correction (P < 0.001). At 3 months post-intervention, the intervention group still showed lower PSQI total scores than the control group, with the difference remaining statistically significant (P < 0.001) (Table 5). Notably, the PSQI score in the intervention group dropped below the > 7 threshold for poor sleep quality at both post-intervention (6.8 ± 2.1) and follow-up (6.3 ± 2.0), indicating a clinically meaningful improvement in sleep quality.

Table 5 Comparison of sleep quality between the two groups at different time points¹.

Group	Baseline	Post-intervention	3 months post-intervention
Intervention group (n = 46)	9.7 ± 2.4	6.8 ± 2.1	6.3 ± 2.0
Control group (n = 44)	9.9 ± 2.6	10.1 ± 2.5	10.3 ± 2.6
t value	-0.315	-5.627	-6.776
P value	0.754	< 0.001	< 0.001

¹Pittsburgh Sleep Quality Index, with a total score range of 0-21 points, where higher scores indicate poorer sleep quality; P-values have been Bonferroni corrected (corrected α = 0.0167); analyzed using an independent samples t-test.

Comparison of job satisfaction between the two groups

At baseline, no significant differences were found in job satisfaction total score and dimension scores between the two groups (P > 0.05). At post-intervention, the intervention group showed higher job satisfaction total scores than the control group, with the difference remaining statistically significant after Bonferroni correction (P < 0.001). At 3 months post-intervention, the intervention group still showed higher job satisfaction total scores than the control group, with the difference remaining statistically significant (P < 0.001) (Table 6).

Table 6 Comparison of job satisfaction between the two groups at different time points¹.

Group	Baseline	Post-intervention	3 months post-intervention
Intervention group (n = 46)	58.3 ± 9.6	68.5 ± 10.2	70.2 ± 9.8
Control group (n = 44)	57.8 ± 9.8	57.5 ± 9.9	57.1 ± 10.0
t value	0.2	4.383	5.268
P value	0.842	< 0.001	< 0.001

¹Job Satisfaction Scale total score ranges from 20 points to 100 points, with higher scores indicating higher satisfaction; P-values have been Bonferroni corrected (corrected α = 0.0167); analyzed using an independent samples t-test.

Comparison of self-efficacy between the two groups

At baseline, no significant difference was found in GSES scores between the two groups (P > 0.05). At post-intervention, the intervention group showed higher GSES scores than the control group, with the difference remaining statistically significant after Bonferroni correction (P < 0.001). At 3 months post-intervention, the intervention group still showed higher GSES scores than the control group, with the difference remaining statistically significant (P < 0.001) (Table 7).

Table 7 Comparison of self-efficacy between the two groups at different time points¹.

Group	Baseline	Post-intervention	3 months post-intervention
Intervention group (n = 46)	24.6 ± 4.8	29.8 ± 5.1	30.5 ± 4.9
Control group (n = 44)	24.9 ± 4.6	24.7 ± 4.7	24.5 ± 4.8
t value	-0.251	4.1	4.92
P value	0.803	< 0.001	< 0.001

¹General Self-Efficacy Scale, with a total score range of 10-40 points, where higher scores indicate stronger self-efficacy; P-values have been Bonferroni corrected (corrected α = 0.0167); analyzed using an independent samples t-test.

DISCUSSION

This study found that after receiving CBT group intervention, nurses in the intervention group showed significantly reduced emotional exhaustion and depersonalization dimension scores and significantly enhanced professional efficacy, and this effect was maintained at the 3-month follow-up. This is consistent with multiple domestic and international intervention studies on burnout in healthcare workers[8]. Research shows that CBT intervention can reduce emotional exhaustion scores in healthcare workers by an average of 3.5-4.2 points, which is similar to the 6.6-point reduction in emotional exhaustion scores in the intervention group of this study[9]. Other studies have reported that after 8-12 weeks of CBT intervention, nurses’ total burnout scores can decrease by 15%-25%[10]. In this study, the MBI-GS total score in the intervention group decreased from 53.7 points at baseline to 34.0 points at 3 months post-intervention, a reduction of 36.7%, showing more significant effects. This may be related to factors such as the intervention content being customized for the work characteristics of operating room nurses, controlling group size to 8-10 people to ensure adequate interaction, and co-facilitation by professional psychologists and senior nursing managers to enhance professionalism and specificity[11].

The ways in which CBT reduces burnout probably work through several different and synergistic pathways. First, by cognitive restructuring training, nurses can detect and dispute irrational beliefs related to burnout to establish more rational and flexible cognitive appraisal patterns, which reduce emotional exhaustion. The group format proved particularly useful in this regard, as listening to peers articulate similar maladaptive thoughts normalized these experiences and ameliorated the shame and isolation often associated with feelings of inadequacy. Vicarious learning and self-efficacy for cognitive change were greatly enhanced by witnessing other members of the group manage to challenge their own negative cognitions[12]. Secondly, behavioral activation techniques used to create the balance between social and work life for nurses, suitable time management, and coping skills with stress, as well as positive events applied during working hours, have been investigated along with the extent of reducing several aspects connected with depersonalization. The supportive nature of the group enhanced accountability in practicing behavioral changes within and between sessions[13]. Third, the use of relaxation methods, including mindfulness meditation and progressive muscle relaxation, decreases levels of physiological arousal, which depletes physical endurance as well as mental strength while experiencing chronic work stress. The combined practice of these techniques allowed participants to move past their initial awkwardness and skepticism, while group experiences with their effectiveness reinforced ongoing use[14]. Lastly, experience sharing and social support network establishment in group settings reduce loneliness at work, multi-directional coping skills, peer learning, and confidence toward challenges, ultimately achieving professional efficacy[15].

The current study indicated a remarkable improvement in the symptoms of anxiety and depression among nurses in the intervention group at 3 months post-intervention; GAD-7 scores decreased from 9.8 points (baseline) to 5.2 points, while PHQ-9 scores decreased from 8.6 points to 4.7 points, which aligns with previous research where higher levels of symptoms led to similar results[16]. Studies have found that CBT intervention can reduce anxiety symptom scores by 40% to 50% and depressive symptom scores by 35% to 45%[17]. The reductions in this study were within the expected range of 46.9% and 45.3%, respectively[17]. Importantly, despite not meeting criteria for clinical diagnosis, baseline GAD-7 and PHQ-9 scores were at mild symptom levels, indicating that subclinical psychological symptoms are relatively common in operating room nurses and early preventive intervention is certainly warranted[18].

Burnout, anxiety, and depressive symptoms are closely linked in both directions. On the one hand, chronic burnout can initiate anxiety and depression by persistent emotional exhaustion and low professional efficacy; conversely, depression and anxiety may consume the individual’s psychological resources and adaptation ability while making the situation of burnout worse[19]. CBT can interrupt this feedback loop by simultaneously addressing cognitive biases, emotion regulation, and behavioral patterns[20]. The simultaneous improvement in anxiety, depressive symptoms, and burnout found in the present study further corroborates the integrative mechanism of action of CBT.

Our finding indicates that the sleep quality of nurses in the intervention group improved significantly after the 3-month intervention with PSQI total scores from 9.7 points at baseline to 6.3 points at 3 months after the beginning of this program, which is below the cut-off score (7 points) for insomnia disorder[17]. Studies have shown that CBT combined with sleep hygiene education can improve the PSQI scores of nurses by an average of 2.8 points to 3.5 points[21]. The improvement in sleep quality may result from multiple factors: Alleviation of anxiety and depressive symptoms reduces difficulty falling asleep and early awakening; relaxation training directly reduces physiological arousal levels, promoting sleep initiation; cognitive restructuring reduces pre-sleep rumination and worry[22]. Improvement in sleep quality in turn helps improve emotion regulation, cognitive function, and work performance, forming a virtuous cycle[23].

The improvement in job satisfaction and self-efficacy is an important finding of this study. Job satisfaction total scores in the intervention group increased by 11.9 points (20.4%), and self-efficacy scores increased by 5.9 points (24.0%). Research shows that burnout is an important negative predictor of job satisfaction, while self-efficacy is an important protective factor[24]. CBT intervention, by reducing burnout, enhancing coping skills and problem-solving abilities, improved nurses’ sense of control and competence at work, thereby improving job satisfaction[25]. The enhancement of self-efficacy was particularly noteworthy. The group modality was particularly instrumental in this process, as participants gained self-efficacy through multiple sources identified in Bandura’s social cognitive theory: Mastery experiences (successfully implementing CBT techniques and observing improvements in their own symptoms), vicarious experiences (witnessing peers’ successes and realizing “if they can do it, so can I”), social persuasion (receiving encouragement and positive feedback from facilitators and fellow group members), and physiological and emotional states (the anxiety reduction and improved mood resulting from the intervention enhanced participants’ confidence in their capabilities). Moreover, the diverse coping strategies shared among group members expanded each participant’s behavioral repertoire, providing multiple tools for managing occupational challenges. The enhancement of self-efficacy not only helps cope with current work stress but may also enhance individual psychological resilience in facing future challenges, preventing burnout recurrence[26].

The findings from this study lend empirical evidence to the additional benefits of the group format beyond CBT alone. Both CBT techniques and group-specific therapeutic factors likely contributed to the large benefits observed across all measured outcomes. Universality, the understanding that others share in their struggles, directly worked against the isolation and stigma that impede healthcare workers from seeking help for burnout. The finding that observing peers share similar experiences, directly in discussion or indirectly through written means, was often experienced as richly confirming and able to de-blame participants. Interpersonal learning had occurred by seeing how other nurses coped with challenging situations, and hence had a range of coping behaviours to draw on that exceeded what any single person could come up with alone. The instillation of hope of observing others moving forward or achieving change continued attendance, even when individuals encountered a setback in utilizing a new behavior. The altruism component, helping others by relating their own experience and progress, increased participants’ feelings of purpose and decreased the depersonalization aspect of burnout. The data may help to account for why some of our outcomes, notably self-efficacy and professional efficacy, were above effect sizes reported for individual CBT studies. The group context has the added advantage of being more cost-effective since, for a similar investment of time and human resources, more nurses can be reached, making it especially appropriate for dissemination in healthcare institutions[27]. Group size was controlled (8-10 persons) which allowed for sufficient participation and interaction opportunities without sacrificing the group dynamic within the setting of previous research[28].

The innovations and strengths of this study are as follows: Systematically conducting CBT group intervention (a high-risk population for burnout among operating room nurses), thus filling a gap in this research area; the experimental content of the intervention was customized according to work characteristics and stressors, ensuring high specificity; psychologists and nursing managers co-facilitated (co-led) the sessions, combining psychotherapy professionalism with nursing field experience (enhancing clinical applicability); inclusive multiple mental health indicators evaluation encouragingly evaluating effects of CBT intervention over various dimensions including burnout, anxiety depression sleep job satisfaction self-efficacy; 3-month follow-up assessment providing evidence for medium-term effects which is clinically useful.

This study has the following limitations: First, as a retrospective study design, although baseline data between the two groups were comparable, selection bias may still exist, as nurses in the intervention group who voluntarily participated in the CBT project may indicate stronger help-seeking motivation and willingness to change, which may affect the generalizability of the research results; second, the sample size was relatively small (46 in the intervention group, 44 in the control group), which may limit the statistical power of the study; third, the follow-up time was only 3 months, making it impossible to evaluate the long-term effects and relapse prevention effects of CBT intervention. Future studies should extend follow-up time to 6 months or longer; fourth, this study did not use a randomized controlled design, and future randomized controlled trials are needed to further validate the effectiveness of CBT intervention; fifth, the study did not collect adherence data during the intervention process (such as attendance rate and homework completion), making it impossible to analyze the relationship between intervention dose and effects; finally, the study did not explore which characteristics of nurses would benefit more from CBT intervention. Future research could conduct subgroup analysis or moderation effect analysis.

The findings of this study are clinically significant and of practical importance. The study ultimately confirmed that CBT group intervention was effective in improving the burnout and mental health status of operating room nurses, which provided basic evidence for some healthcare institutions to carry out targeted psychological interventions[29]. Implications for public health, as a key measure for burnout prevention and intervention, CBT group intervention should be applied to the nurse mental health service system in healthcare institutions. The structured protocol for the intervention, been designed to last 8 weeks, has high operability and is scalable well, allowing for all healthcare institutions to adapt it as needed in their real-world practices. Third, genetic counseling, which we focus on in the current study using a group intervention model, has advantages for being more cost-effective and can be implemented in resource-limited situations. Fourth, this study highlights the significance of multidisciplinary collaboration; when implementing similar interventions, psychological professionals and nursing managers can combine their advantages to improve the professionalism and specificity of interventions. Finally, the study emphasises the need to pay attention to subclinical psychological symptoms in operating room nurses by early identification of high-risk populations and preventive interventions instead of waiting for severe psychological problems before treatment.

Based on the findings and limitations of this study, future research can proceed in the following directions: First, conduct multicenter, large-sample randomized controlled trials to improve the internal and external validity of research; second, extend follow-up time to 6 months, 12 months, or even longer to evaluate the long-term effects and relapse prevention effects of CBT intervention; third, explore the impact of different intervention doses (such as intervention frequency, duration, booster training, etc.) on effects to optimize intervention protocols; fourth, study which individual characteristics (such as personality traits, baseline burnout levels, social support, etc.) can predict intervention effects to enable precision intervention; fifth, compare the effects and cost-effectiveness of different intervention formats such as group CBT, individual CBT, and online CBT; sixth, explore the neurobiological mechanisms of CBT intervention, such as studying changes in brain function before and after intervention using functional magnetic resonance imaging; finally, conduct implementation science research to explore how to effectively promote and sustainably implement CBT intervention programs in real healthcare environments, including aspects such as training system construction, quality control, and long-term maintenance.

CONCLUSION

The current study validated that the CBT-based group intervention was beneficial for operating room nurses by reducing burnout, anxiety, and depressive symptoms, and improving sleep quality, job satisfaction, and self-efficacy, with follow-up effects of 3 months post-intervention. This study provides empirical evidence for mental health interventions for operating room nurses in clinical practice. Further studies have to be done with larger sample sizes and longer follow-ups for more validation and optimization of CBT intervention protocols, including strategies for promotion and implementation among various health care settings and nurse populations.